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Zhong S, Kurish H, Walchack R, Li H, Edwards J, Singh A, Advani A. Efficacy and safety of mitoxantrone, etoposide, and cytarabine for treatment of relapsed or refractory acute myeloid leukemia. Leuk Res 2024; 139:107468. [PMID: 38460433 DOI: 10.1016/j.leukres.2024.107468] [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: 10/31/2023] [Revised: 02/20/2024] [Accepted: 02/26/2024] [Indexed: 03/11/2024]
Abstract
BACKGROUND/RATIONALE Most patients with acute myeloid leukemia (AML) develop relapsed or refractory (R/R) disease after receiving initial induction chemotherapy. Salvage chemotherapy followed by allogeneic hematopoietic stem cell transplantation (alloHSCT) is the only curative therapy for R/R AML. Mitoxantrone, etoposide, and cytarabine (MEC) is the current standard of care salvage regimen for R/R AML at Cleveland Clinic. The primary objective was to determine the overall remission rate (ORR: defined as patients achieving complete remission (CR) or complete remission with incomplete hematologic recovery (CRi)) in R/R AML patients who received MEC. METHODS Adult patients with R/R AML treated with MEC between July 1, 2014 and September 30, 2022 were included. ORR and its association with baseline characteristics were determined. Secondary outcomes included overall survival (OS), event-free survival (EFS), relapse-free survival (RFS), and safety. RESULTS Sixty patients were evaluated. The ORR was 51.7% (33.3% CR and 18.3% CRi). The median time from receipt of MEC to CR/CRi was 7.7 weeks. Patients with bone marrow blasts ≤20% and peripheral blood blasts ≤30% at MEC initiation were more than twice as likely to achieve CR/CRi compared to those with a higher blast burden. The median OS was 6.3 months. Twenty-four (40.0%) patients proceeded to alloHSCT. Twenty-one (35.0%) patients were transferred to the intensive care unit (ICU) during their admission. CONCLUSIONS MEC is an effective salvage regimen for patients with R/R AML, especially among those with low disease burden at initiation. Febrile neutropenia, infections, and severe oral mucositis were common with MEC administration.
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Affiliation(s)
- Sharon Zhong
- Department of Pharmacy, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA.
| | - Heena Kurish
- Department of Pharmacy, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA
| | - Robert Walchack
- Department of Pharmacy, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA
| | - Hong Li
- Taussig Cancer Institute, Cleveland Clinic, 10201 Carnegie Ave, Cleveland, OH 44106, USA
| | - Jessi Edwards
- Department of Pharmacy, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA
| | - Abhay Singh
- Taussig Cancer Institute, Cleveland Clinic, 10201 Carnegie Ave, Cleveland, OH 44106, USA
| | - Anjali Advani
- Taussig Cancer Institute, Cleveland Clinic, 10201 Carnegie Ave, Cleveland, OH 44106, USA
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Franco S, Khan T, Dinner S, Karmali R, Melody M. Dosing of 7 + 3 induction chemotherapy in a patient with acute myeloid leukemia (AML) and morbid obesity. J Oncol Pharm Pract 2024:10781552241240444. [PMID: 38509800 DOI: 10.1177/10781552241240444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Abstract
INTRODUCTION Traditional chemotherapy dosing is based on body surface area (BSA) using standard formulas, which can pose challenges in dosing patients at body weight extremes. Studies suggest that chemotherapy dosing according to actual body weight does not increase toxicity in obese patients and current guidelines recommend full weight-based dosing of chemotherapy regardless of body mass index (BMI). However, the dosing of anthracyclines in obese patients can be challenging given limitations in maximum cumulative dosage, particularly in those at very extreme BMI. In this case, we highlight the difficulties of dosing anthracycline-based induction chemotherapy in a patient with newly diagnosed acute myeloid leukemia (AML) and BMI >90 kg/m2. CASE REPORT A 40-year-old female with morbid obesity is diagnosed with AML (nucleophosmin 1 (NPMI) and isocitrate dehydrogenase-2 mutated, FMS-like tyrosine kinase 3-Internal tandem duplication negative). MANAGEMENT AND OUTCOME The patient was initiated on induction therapy with 7 + 3 with dose capping of BSA at 2.75 m2 (cytarabine 200 mg/m2 continuous infusion over 24 h for 7 days, plus daunorubicin 60 mg/m2 slow intravenous push for 3 days), followed by two cycles of high-dose cytarabine consolidation therapy using actual BSA. The patient achieved morphologic complete remission; however, measurable residual disease testing for NPM1 remained positive after induction therapy. DISCUSSION This case suggests that dose capping of anthracyclines in the treatment of newly diagnosed AML may be an effective and safe treatment alternative in those with extreme BMI elevations beyond what has been studied in the literature. Given the increasing incidence of morbid obesity, further studies are needed to confirm appropriate dosing of anthracycline-based regimens at upper BMI extremes (>60 kg/m2).
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Affiliation(s)
- Stephanie Franco
- Department of Internal Medicine, Northwestern Medicine, Chicago, IL, USA
| | - Talha Khan
- Robert H. Lurie Comprehensive Cancer Center, Department of Pharmacy, Chicago, IL, USA
| | - Shira Dinner
- Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Reem Karmali
- Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Megan Melody
- Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Zhang C, Gao D, Wang X, Sun X, Yan Y, Yang Y, Zhang J, Yan J. Effectiveness of chemotherapy using bortezomib combined with homoharringtonine and cytarabine in refractory or relapsed acute myeloid leukemia: a phase II, multicenter, prospective clinical trial. Front Oncol 2023; 13:1142449. [PMID: 37664023 PMCID: PMC10472935 DOI: 10.3389/fonc.2023.1142449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 06/28/2023] [Indexed: 09/05/2023] Open
Abstract
Background Refractory/relapsed acute myeloid leukemia (R/R AML) has unsatisfactory outcomes even after allogeneic hematopoietic stem cell transplantation. Long-term survival is mainly influenced by complete remission (CR) rates after induction therapies. Objectives To investigate CR/CR with incomplete hematologic recovery (CRi) rates and adverse events with a new induction therapy (bortezomib, homoharringtonine, and cytarabine [BHA]) for patients with R/R AML. Methods We enrolled 21 patients with R/R AML (median age, 42 [range, 30-62] years), who received BHA for remission induction (bortezomib, 1.3 mg/m2/day on days 1 and 4; homoharringtonine, 4 mg/m2/day for 5 days, and cytarabine, 1.5 g/m2/day for 5 days). CR and adverse events were assessed. Results After one course of BHA, the CR/CRi and partial remission rates were 38.1% and 14.3%, respectively, with an overall response rate (ORR) of 52.4% in 21 patients. 9 of 21 patients harbored FLT3-ITD or FLT3-TKD mutations, and achieved either CR/CRi or ORR of 66.7% (P=0.03) by comparison with that in R/R AML without FLT3 mutation. After induction therapy, consolidation chemotherapy or allogeneic hematopoietic stem cell transplantation led to a one-year overall survival of 27.8% in all patients. One-year relapse-free survival was 50% in 8 patients who had achieved CR/CRi after one course of BHA. During induction, non-hematologic adverse events (grade 3/4) commonly were infection (90.5%), hypokalemia (14.4%), hypocalcemia (14.3%), and mucositis (9.5%). In patients achieving CR, the median time to neutrophil count >0.5×109/L and time to platelet count >20×109/L were 15 (13-17) days and 13 (13-18) days, respectively. Conclusion BHA chemotherapy regimen was safe and tolerable to serve as an induction therapy for R/R AML, particularly with FLT3 mutation. The higher CR/CRi rate will give a clue to determine a potentialeffectiveness of BHA for AML patients carrying FLT3 mutation in a further investigation. Clinical trial registration https://www.chictr.org.cn/, identifier ChiCTR2000029841.
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Affiliation(s)
- Chengtao Zhang
- Department of Hematology, Liaoning Key Laboratory of Hematopoietic Stem Cell Transplantation and Translational Medicine, Liaoning Medical Center for Hematopoietic Stem Cell Transplantation, The Second Hospital of Dalian Medical University, Dalian, China
| | - Da Gao
- Department of Hematology, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia, China
| | - Xiaohong Wang
- Department of Hematology, The ChaoYang Central Hospital, Liaoning, China
| | - Xiuli Sun
- Department of Hematology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Yan Yan
- Department of Hematology, Bayannur Hospital, Bayannur, Inner Mongolia, China
| | - Yan Yang
- Department of Hematology, Liaoning Key Laboratory of Hematopoietic Stem Cell Transplantation and Translational Medicine, Liaoning Medical Center for Hematopoietic Stem Cell Transplantation, The Second Hospital of Dalian Medical University, Dalian, China
| | - Jingjing Zhang
- Department of Hematology, Liaoning Key Laboratory of Hematopoietic Stem Cell Transplantation and Translational Medicine, Liaoning Medical Center for Hematopoietic Stem Cell Transplantation, The Second Hospital of Dalian Medical University, Dalian, China
| | - Jinsong Yan
- Department of Hematology, Liaoning Key Laboratory of Hematopoietic Stem Cell Transplantation and Translational Medicine, Liaoning Medical Center for Hematopoietic Stem Cell Transplantation, The Second Hospital of Dalian Medical University, Dalian, China
- Blood Stem Cell Transplantation Institute of Dalian Medical University, Dalian, China
- Pediatric Oncology and Hematology Center of the Second Hospital of Dalian Medical University, Dalian, China
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Babakoohi S, Gu SL, Ehsan H, Markova A. Dermatologic complications in transplantation and cellular therapy for acute leukemia. Best Pract Res Clin Haematol 2023; 36:101464. [PMID: 37353285 PMCID: PMC10291442 DOI: 10.1016/j.beha.2023.101464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 03/30/2023] [Indexed: 04/09/2023]
Abstract
Adoptive cellular immunotherapy, mainly hematopoietic stem cell transplant and CAR-T cell therapy have revolutionized treatment of patients with acute leukemia. Indications and inclusion criteria for these treatments have expanded in recent years. While these therapies are associated with significant improvements in disease response and overall survival, patients may experience adverse events from associated chemotherapy conditioning, engraftment, cytokine storm, supportive medications, and post-transplant maintenance targeted therapies. Supportive oncodermatology is a growing specialty to manage cutaneous toxicities resulting from the anti-cancer therapies. In this review, we summarize diagnosis and management of the common cutaneous adverse events including drug eruptions, graft-versus-host disease, neoplastic and paraneoplastic complications in patients undergoing cellular therapies.
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Affiliation(s)
- Shahab Babakoohi
- Levine Cancer Institute, Atrium Health Wake Forest Baptist, Charlotte, NC, USA.
| | - Stephanie L Gu
- Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY, USA
| | - Hamid Ehsan
- Levine Cancer Institute, Atrium Health Wake Forest Baptist, Charlotte, NC, USA
| | - Alina Markova
- Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY, USA.
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Picardi M, Giordano C, Della Pepa R, Pugliese N, Esposito M, Abagnale DP, Giannattasio ML, Lisi D, Lamagna M, Grimaldi F, Muccioli Casadei G, Ciriello M, Persico M, Gargiulo G, Pane F. Intravascular Complications of Central Venous Catheterization by Insertion Site in Acute Leukemia during Remission Induction Chemotherapy Phase: Lower Risk with Peripherally Inserted Catheters in a Single-Center Retrospective Study. Cancers (Basel) 2023; 15:cancers15072147. [PMID: 37046808 PMCID: PMC10093126 DOI: 10.3390/cancers15072147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/29/2023] [Accepted: 03/30/2023] [Indexed: 04/08/2023] Open
Abstract
The basilic/brachial (BBV), internal jugular (IJV), and subclavian veins (SCV) are commonly used as central venous catheter (CVC) sites. A BBV approach [peripherally inserted central catheter (PICC)] is increasingly used for short- to intermediate-term CVCs for acute leukemias undergoing cytotoxic intensive regimens. In this retrospective study, the catheterization of the BBV, IJV, and SCV in patients with previously untreated acute leukemia was assessed. The primary outcome was the composite incidence of catheter-related symptomatic deep-vein thrombosis (sDVT) and bloodstream infection (BSI) from catheterization up to 30 days later. In a 10-year period, 336 CVC were inserted in the BBV (n = 115), IJV (n = 111), and SCV (n = 110) in 336 patients suffering from AML (n = 201) and ALL (n = 135) and undergoing induction chemotherapy. The primary outcome events were 8, 20, and 27 in the BBV, SCV and IJV cohorts (2.6, 6.9, and 9.6 per 1000 catheter-days, respectively; p = 0.002). The primary outcome risk was significantly higher in the IJV-cohort than in the BBV-cohort (HR, 3.6; 95% CI, 1.6 to 7.9; p = 0.001) and in the SCV-cohort than in the BBV-cohort (HR, 2.6; 95% CI, 1.2 to 5.9; p = 0.02). PICC was a valid CVC for the induction chemotherapy of acute leukemia for the lowest risk of sDVT and BSI.
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Affiliation(s)
- Marco Picardi
- Hematology Unit, Department of Clinical Medicine and Surgery, Federico II University Medical School, Via Sergio Pansini, 5, 80131 Naples, Italy
| | - Claudia Giordano
- Hematology Unit, Department of Clinical Medicine and Surgery, Federico II University Medical School, Via Sergio Pansini, 5, 80131 Naples, Italy
| | - Roberta Della Pepa
- Hematology Unit, Department of Clinical Medicine and Surgery, Federico II University Medical School, Via Sergio Pansini, 5, 80131 Naples, Italy
| | - Novella Pugliese
- Hematology Unit, Department of Clinical Medicine and Surgery, Federico II University Medical School, Via Sergio Pansini, 5, 80131 Naples, Italy
| | - Maria Esposito
- Hematology Unit, Department of Clinical Medicine and Surgery, Federico II University Medical School, Via Sergio Pansini, 5, 80131 Naples, Italy
| | - Davide Pio Abagnale
- Hematology Unit, Department of Clinical Medicine and Surgery, Federico II University Medical School, Via Sergio Pansini, 5, 80131 Naples, Italy
| | - Maria Luisa Giannattasio
- Hematology Unit, Department of Clinical Medicine and Surgery, Federico II University Medical School, Via Sergio Pansini, 5, 80131 Naples, Italy
| | - Dario Lisi
- Hematology Unit, Department of Clinical Medicine and Surgery, Federico II University Medical School, Via Sergio Pansini, 5, 80131 Naples, Italy
| | - Martina Lamagna
- Hematology Unit, Department of Clinical Medicine and Surgery, Federico II University Medical School, Via Sergio Pansini, 5, 80131 Naples, Italy
| | - Francesco Grimaldi
- Hematology Unit, Department of Clinical Medicine and Surgery, Federico II University Medical School, Via Sergio Pansini, 5, 80131 Naples, Italy
| | - Giada Muccioli Casadei
- Hematology Unit, Department of Clinical Medicine and Surgery, Federico II University Medical School, Via Sergio Pansini, 5, 80131 Naples, Italy
| | - Mauro Ciriello
- Hematology Unit, Department of Clinical Medicine and Surgery, Federico II University Medical School, Via Sergio Pansini, 5, 80131 Naples, Italy
| | - Marcello Persico
- Department of General Surgery, Endocrinology, Orthopaedics, and Rehabilitations, Federico II University Medical School, Via Sergio Pansini, 5, 80131 Naples, Italy
| | - Gianpaolo Gargiulo
- Hematology Unit, Department of Clinical Medicine and Surgery, Federico II University Medical School, Via Sergio Pansini, 5, 80131 Naples, Italy
| | - Fabrizio Pane
- Hematology Unit, Department of Clinical Medicine and Surgery, Federico II University Medical School, Via Sergio Pansini, 5, 80131 Naples, Italy
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Kulkarni U, Arunachalam AK, Palani HK, Nair RR, Balasundaram N, Venkatraman A, Korula A, Selvarajan S, Lionel S, Balasubramanian P, Maddali M, Abraham A, George B, Mathews V. Haploidentical Natural Killer Cell Therapy as an Adjunct to Stem Cell Transplantation for Treatment of Refractory Acute Myeloid Leukemia. Cell Transplant 2023; 32:9636897231198178. [PMID: 37706453 PMCID: PMC10503284 DOI: 10.1177/09636897231198178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 08/02/2023] [Accepted: 08/08/2023] [Indexed: 09/15/2023] Open
Abstract
Refractory acute myeloid leukemia (AML), defined as failure of two cycles of induction therapy at diagnosis or of one cycle at relapse, represents a subgroup with poor outcomes. Haploidentical natural killer cell (NK) therapy is a strategy that is being explored in refractory malignancies. Historically, at our center, patients with refractory AML have been treated with cytoreductive therapy (fludarabine + cytosine + granulocyte colony-stimulating factor ± idarubicin or mitoxantrone + etoposide) followed by 1-week rest and then reduced-intensity transplant with fludarabine + melphalan. We used the same backbone for this trial (CTRI/2019/02/017505) with the addition of CD56-positive cells from a family donor infused 1 day after the completion of chemotherapy. CD56-positive selection was done using a CliniMACS Prodigy system (Miltenyi Biotec, Bergisch Gladbach, Germany) followed by overnight incubation in autologous plasma with 2 micromolar arsenic trioxide and 500 U/mL of interleukin-2. From February 2019, 14 patients with a median age of 29 years (interquartile range [IQR]: 16.5-38.5) were enrolled in this trial. Six were females. Six had primary refractory AML while eight had relapsed refractory AML. The median CD56-cell dose infused was 46.16 × 106/kg (IQR: 25.06-70.36). One patient withdrew consent after NK cell infusion. Of the 13 patients who proceeded to transplant, five died of immediate post-transplant complications while two did not engraft but were in morphologic leukemia-free state (both subsequently died of infective complications after the second transplant). Of the remaining six patients who engrafted and survived beyond 1 month of the transplant, two developed disease relapse and died. The remaining four patients are alive and relapse free at the last follow-up (mean follow-up duration of surviving patients is 24 months). The 2-year estimated overall survival for the cohort was 28.6% ± 12.1% while the treatment-related mortality (TRM) with this approach was 38.5% ± 13.5%. Haploidentical NK cell therapy as an adjunct to transplant is safe and needs further exploration in patients with AML. For refractory AML, post-transplant NK infusion and strategies to reduce TRM while using pre-transplant NK infusion merit exploration.
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Affiliation(s)
- Uday Kulkarni
- Department of Haematology, Christian Medical College Vellore, Ranipet Campus, India
| | | | - Hamenth Kumar Palani
- Department of Haematology, Christian Medical College Vellore, Ranipet Campus, India
| | | | - Nithya Balasundaram
- Department of Haematology, Christian Medical College Vellore, Ranipet Campus, India
| | - Arvind Venkatraman
- Department of Haematology, Christian Medical College Vellore, Ranipet Campus, India
| | - Anu Korula
- Department of Haematology, Christian Medical College Vellore, Ranipet Campus, India
| | - Sushil Selvarajan
- Department of Haematology, Christian Medical College Vellore, Ranipet Campus, India
| | - Sharon Lionel
- Department of Haematology, Christian Medical College Vellore, Ranipet Campus, India
| | | | - Madhavi Maddali
- Department of Haematology, Christian Medical College Vellore, Ranipet Campus, India
| | - Aby Abraham
- Department of Haematology, Christian Medical College Vellore, Ranipet Campus, India
| | - Biju George
- Department of Haematology, Christian Medical College Vellore, Ranipet Campus, India
| | - Vikram Mathews
- Department of Haematology, Christian Medical College Vellore, Ranipet Campus, India
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Lv W, Chen T, Wang S, Li C, Zhang B, Wang L, Xv F, Cao F, Wang J, Chen L, Liao C, Li N, Liu H. Feasibility of high-throughput drug sensitivity screening (HDS)-guided treatment for children with refractory or relapsed acute myeloid leukemia. Front Pediatr 2023; 11:1117988. [PMID: 36873635 PMCID: PMC9982438 DOI: 10.3389/fped.2023.1117988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 01/23/2023] [Indexed: 02/19/2023] Open
Abstract
Relapsed/refractory (rel/ref) acute myeloid leukemia (AML) has a very high mortality rate. At present, hematopoietic stem cell transplantation (HSCT) is the most effective treatment for rel/ref AML. The remission of the primary disease before HSCT is crucial for the transplantation to be effective. Therefore, it is critical to choose a suitable type of chemotherapy before HSCT. Here, we recorded the outcomes of high-throughput drug sensitivity screening (HDS) in children with rel/ref AML. Thirty-seven pediatric rel/ref AML patients who received HDS from September 2017 until July 2021 were analyzed retrospectively. Most of the patients (24 patients, 64.9%) had adverse cytogenetics. Two patients had rel/ref AML with central nervous system leukemia. The complete remission (CR) rate was 67.6%. Eight patients developed IV grade bone marrow suppression. Twenty-three patients (62.2%) underwent HSCT. The 3-year overall survival (OS) and EFS rates were 45.9% and 43.2%, respectively. Infection in the myelosuppression stage was the main cause of death. The outcome of HDS was superior to the commonly reported rates. These results suggest that HDS may be a novel treatment option for pediatric patients with rel/ref AML, and it is a promising transitional regimen prior to HSCT.
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Affiliation(s)
- Wenxiu Lv
- Department of Hematology and Oncology, Anhui Provincial Children's Hospital (Anhui Hospital, Pediatric Hospital of Fudan University), Hefei, Anhui, China.,Department of Pediatrics, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Tianping Chen
- Department of Hematology and Oncology, Anhui Provincial Children's Hospital (Anhui Hospital, Pediatric Hospital of Fudan University), Hefei, Anhui, China
| | - Shen Wang
- Department of Pediatrics, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Chun Li
- Department of Pediatrics, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Bo Zhang
- Department of Pediatrics, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Liang Wang
- Department of Pediatrics, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Fang Xv
- Department of Pediatrics, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Fang Cao
- Department of Pediatrics, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Jing Wang
- Department of Pediatrics, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Li Chen
- Department of Pediatrics, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Chenglin Liao
- Department of Pediatrics, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Na Li
- Department of Pediatrics, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Hongjun Liu
- Department of Hematology and Oncology, Anhui Provincial Children's Hospital (Anhui Hospital, Pediatric Hospital of Fudan University), Hefei, Anhui, China
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[Efficacy and safety of IAC regimen for relapse/refractory acute myeloid leukemia: a prospective randomized controlled study]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2022; 43:287-292. [PMID: 35680626 PMCID: PMC9189487 DOI: 10.3760/cma.j.issn.0253-2727.2022.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Objective: To evaluate the efficacy and toxicity profiles of idarubicin, cytarabine, and cyclophosphamide (IAC) in relapse/refractory acute myeloid leukemia (AML) . Methods: This study was a prospective, randomized controlled clinical trial with the registration number NCT02937662. The patients were randomly divided into two groups. The experimental group was treated with an IAC regimen, and the regimen of the control group was selected by doctors according to medication experience. After salvage chemotherapy, allogeneic hematopoietic stem cell transplantation (allo-HSCT) was conducted as far as possible according to the situation of the patients. We aimed to observe the efficacy, safety, and toxicity of the IAC regimen in relapse/refractory AML and to explore which is the better regimen. Results: Forty-two patients were enrolled in the clinical trial, with a median age of 36 years (IAC group, 22 cases and control groups, 20 cases) . ①The objective response rate was 71.4% in the IAC group and 40.0% in the control group (P=0.062) ; the complete remission (CR) rate was 66.7% in the IAC group and 40.0% in the control group (P=0.121) . The median follow-up time of surviving patients was 10.5 (range:1.7-32.8) months; the median overall survival (OS) was 14.1 (range: 0.6-49.1) months in the IAC group and 9.9 (range: 2.0-53.8) months in the control group (P=0.305) . The 1-year OS was 54.5% (95%CI 33.7%-75.3%) in the IAC group and 48.2% (95%CI 25.9%-70.5%) in the control group (P=0.305) , with no significant difference between these two regimens. ②The main hematologic adverse events (AEs) were anemia, thrombocytopenia, and neutropenia. The incidence of grade 3-4 hematologic AEs in the two groups was 100% (22/22) in the IAC group and 95% (19/20) in the control group. The median time of neutropenia after chemotherapy in the IAC group and control group was 20 (IQR: 8-30) and 14 (IQR: 5-50) days, respectively (P=0.023) . ③The CR rate of the early relapse (relapse within 12 months) group was 46.7% and that of the late relapse (relapse after 12 months) group was 72.7% (P=0.17) . The median OS time of early recurrence was 9.9 (range:1.7-53.8) months, and that of late recurrence patients was 19.3 (range: 0.6-40.8) months (P=0.420) , with no significant differences between the two groups. The 1-year OS rates were 45.3% (95%CI 27.2%-63.3%) and 66.7% (95%CI 40.0%-93.4%) , respectively (P=0.420) . Survival analysis showed that the 1-year OS rates of the hematopoietic stem cell transplantation group and non-hematopoietic stem cell transplantation group were 87.5% (95%CI 71.2%-100%) and 6.3% (95%CI 5.7%-18.3%) , respectively. The OS rate of the hematopoietic stem cell transplantation group was significantly higher than that of the non-hematopoietic stem cell transplantation group (P<0.001) . Conclusion: The IAC regimen is a well-tolerated and effective regimen in relapsed/refractory AML; this regimen had similar efficacy and safety with the regimen selected according to the doctor's experience for treating relapsed/refractory AML. For relapsed/refractory patients with AML, allogeneic hematopoietic stem cell transplantation should be attempted as soon as possible to achieve long-term survival.
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Park S, Kwag D, Kim TY, Lee JH, Lee JY, Min GJ, Park SS, Yahng SA, Jeon YW, Shin SH, Yoon JH, Lee SE, Cho BS, Eom KS, Kim YJ, Lee S, Min CK, Cho SG, Lee JW, Kim HJ. A retrospective comparison of salvage intensive chemotherapy versus venetoclax-combined regimen in patients with relapsed/refractory acute myeloid leukemia (AML). Ther Adv Hematol 2022; 13:20406207221081637. [PMID: 35340720 PMCID: PMC8949776 DOI: 10.1177/20406207221081637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 01/31/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Evidence that a venetoclax (VEN)-combined regimen is effective in relapsed/refractory acute myeloid leukemia (R/R AML) is emerging. However, it is unknown how VEN-combined low intensity treatment compares to intensive chemotherapy (IC) in medically fit patients with R/R AML. Methods: We compared AML patients who received IC (n = 89) to those who received a VEN in combination with hypomethylating agents or low dose cytarabine (VEN combination) (n = 54) as their first- or second-line salvage after failing anthracycline-containing intensive chemotherapy. Results: The median age was 49 years, and significantly more patients in the VEN combination group were in their second salvage and had received prior stem cell transplantation (SCT). Overall response rates including CR, CRi, and MLFS were comparable (44.0% for IC vs. 59.3% for VEN combination, p = 0.081), but VEN combination group compared to IC group tended to show lower treatment related mortality. The rate of bridging to SCT was the same (68.5%), but the percentage of SCT at blast clearance was significantly higher in the VEN-combined group (62.3% vs. 86.5%, p = 0.010). After median follow-up periods of 22.5 (IC) and 11.3 months (VEN combination), the median overall survival was 8.9 (95% CI, 5.4-12.4) and 12.4 months (95% CI, 9.5-15.2) (p = 0.724), respectively. Conclusion: VEN combination provides a comparable anti-leukemic response and survival to salvage IC, and provide a bridge to SCT with better disease control in medically-fit patients with R/R AML.
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Affiliation(s)
- Silvia Park
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Daehun Kwag
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Tong Yoon Kim
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Jong Hyuk Lee
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Joon Yeop Lee
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Gi June Min
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Sung Soo Park
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Seung-Ah Yahng
- Department of Hematology, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, South Korea
| | - Young-Woo Jeon
- Department of Hematology, Yeoido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Seung-Hwan Shin
- Department of Hematology, Catholic Hematology Hospital, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Jae-Ho Yoon
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Sung-Eun Lee
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Byung Sik Cho
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Ki-Seong Eom
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Yoo-Jin Kim
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Seok Lee
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Chang-Ki Min
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Seok-Goo Cho
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Jong Wook Lee
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Hee-Je Kim
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
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Webster JA, Luznik L, Gojo I. Treatment of AML Relapse After Allo-HCT. Front Oncol 2022; 11:812207. [PMID: 34976845 PMCID: PMC8716583 DOI: 10.3389/fonc.2021.812207] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 11/25/2021] [Indexed: 01/02/2023] Open
Abstract
With advances in allogeneic hematopoietic stem cell transplant (allo-HCT), disease relapse has replaced transplant-related mortality as the primary cause of treatment failure for patients with acute myeloid leukemia (AML). The efficacy of allo-HCT in AML is a consequence of a graft-versus-leukemia (GVL) effect that is mediated by T lymphocytes, and unique mechanisms of immune evasion underlying post-allo-HCT AML relapses have recently been characterized. Relapsed AML following allo-HCT presents a particularly vexing clinical challenge because transplant-related toxicities, such as graft-versus-host (GVHD) and infections, increase the risk of treatment-related morbidity and mortality. In general, the prognosis of relapsed AML following allo-HCT is poor with most patients failing to achieve a subsequent remission and 2-year survival consistently <15%. The two factors that have been found to predict a better prognosis are a longer duration of post-transplant remission prior to relapse and a lower disease burden at the time of relapse. When considered in combination with a patient's age; co-morbidities; and performance status, these factors can help to inform the appropriate therapy for the treatment of post-transplant relapse. This review discusses the options for the treatment of post-transplant AML relapse with a focus on the options to achieve a subsequent remission and consolidation with cellular immunotherapy, such as a second transplant or donor lymphocyte infusion (DLI). While intensive reinduction therapy and less intensive approaches with hypomethylating agents have long represented the two primary options for the initial treatment of post-transplant relapse, molecularly targeted therapies and immunotherapy are emerging as potential alternative options to achieve remission. Herein, we highlight response and survival outcomes achieved specifically in the post-transplant setting using each of these approaches and discuss how some therapies may overcome the immunologic mechanisms that have been implicated in post-transplant relapse. As long-term survival in post-transplant relapse necessarily involves consolidation with cellular immunotherapy, we present data on the efficacy and toxicity of both DLI and second allo-HCT including when such therapies are integrated with reinduction. Finally, we provide our general approach to the treatment of post-transplant relapse, integrating both novel therapies and our improved understanding of the mechanisms underlying post-transplant relapse.
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Affiliation(s)
- Jonathan A Webster
- Hematologic Malignancies and Bone Marrow Transplantation Program, Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Leo Luznik
- Hematologic Malignancies and Bone Marrow Transplantation Program, Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Ivana Gojo
- Hematologic Malignancies and Bone Marrow Transplantation Program, Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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11
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Wang L, Li C, Xu F, Cao F, Zhang B, Wang J, Wang S, Chen L, Li N, Liao C, Liu H. Analysis of efficacy, safety and prognostic factors of DAC-HAA treatment in Chinese pediatric patients with refractory or relapsed acute myeloid leukemia. Mol Clin Oncol 2021; 15:269. [PMID: 34790353 PMCID: PMC8591692 DOI: 10.3892/mco.2021.2431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 08/19/2021] [Indexed: 11/06/2022] Open
Abstract
Hematopoietic stem cell transplantation (HSCT) is generally considered as the only effective treatment for children with relapsed/refractory (R/R) acute myeloid leukemia (AML). Achieving remission prior to HSCT affects the efficacy of the procedure and patient survival; therefore, induction therapy in children with R/R AML prior to HSCT is very important. The aim of the present study was to evaluate the clinical efficacy, prognosis and safety of 5-aza-2-deoxycytidine (DAC) combined with homoharringtonine + cytarabine + aclarubicin (HAA regimen) in the treatment of pediatric R/R AML. A total of 53 pediatric patients with R/R AML, aged 1-14 years, were treated with DAC-HAA. The overall response rate was 83.1%, with a complete remission rate of 77.4% and a partial remission rate of 5.7%. In conclusion, DAC-HAA therapy for children with R/R AML was found to be associated with a high remission rate, a short period of bone marrow suppression and a good safety profile. Therefore, DAC-HAA may be of value as a transitional regimen prior to HSCT and is worthy of clinical consideration.
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Affiliation(s)
- Liang Wang
- Children's Hematology Oncology, Anhui Provincial Cancer Hospital, Hefei, Anhui 230031, P.R. China
| | - Chun Li
- Department of Pediatrics, The First Affiliated Hospital of University of Science and Technology of China, Hefei, Anhui 230001, P.R. China
| | - Fang Xu
- Children's Hematology Oncology, Anhui Provincial Cancer Hospital, Hefei, Anhui 230031, P.R. China
| | - Fang Cao
- Children's Hematology Oncology, Anhui Provincial Cancer Hospital, Hefei, Anhui 230031, P.R. China
| | - Bo Zhang
- Children's Hematology Oncology, Anhui Provincial Cancer Hospital, Hefei, Anhui 230031, P.R. China
| | - Jing Wang
- Children's Hematology Oncology, Anhui Provincial Cancer Hospital, Hefei, Anhui 230031, P.R. China
| | - Shen Wang
- Children's Hematology Oncology, Anhui Provincial Cancer Hospital, Hefei, Anhui 230031, P.R. China
| | - Li Chen
- Children's Hematology Oncology, Anhui Provincial Cancer Hospital, Hefei, Anhui 230031, P.R. China
| | - Na Li
- Children's Hematology Oncology, Anhui Provincial Cancer Hospital, Hefei, Anhui 230031, P.R. China
| | - Chenglin Liao
- Children's Hematology Oncology, Anhui Provincial Cancer Hospital, Hefei, Anhui 230031, P.R. China
| | - Hongjun Liu
- Department of Pediatrics, The First Affiliated Hospital of University of Science and Technology of China, Hefei, Anhui 230001, P.R. China
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12
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[Efficacy and safety of venetoclax and azacitidine in the treatment of refractory and relapsed acute myeloid leukemia]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2021; 42:861-864. [PMID: 34788928 PMCID: PMC8607025 DOI: 10.3760/cma.j.issn.0253-2727.2021.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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13
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Fajardo-Orduña GR, Ledesma-Martínez E, Aguiñiga-Sánchez I, Mora-García MDL, Weiss-Steider B, Santiago-Osorio E. Inhibitors of Chemoresistance Pathways in Combination with Ara-C to Overcome Multidrug Resistance in AML. A Mini Review. Int J Mol Sci 2021; 22:ijms22094955. [PMID: 34066940 PMCID: PMC8124548 DOI: 10.3390/ijms22094955] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 04/30/2021] [Accepted: 05/03/2021] [Indexed: 12/12/2022] Open
Abstract
Acute myeloid leukemia (AML), the most common type of leukemia in older adults, is a heterogeneous disease that originates from the clonal expansion of undifferentiated hematopoietic progenitor cells. These cells present a remarkable variety of genes and proteins with altered expression and function. Despite significant advances in understanding the molecular panorama of AML and the development of therapies that target mutations, survival has not improved significantly, and the therapy standard is still based on highly toxic chemotherapy, which includes cytarabine (Ara-C) and allogeneic hematopoietic cell transplantation. Approximately 60% of AML patients respond favorably to these treatments and go into complete remission; however, most eventually relapse, develop refractory disease or chemoresistance, and do not survive for more than five years. Therefore, drug resistance that initially occurs in leukemic cells (primary resistance) or that develops during or after treatment (acquired resistance) has become the main obstacle to AML treatment. In this work, the main molecules responsible for generating chemoresistance to Ara-C in AML are discussed, as well as some of the newer strategies to overcome it, such as the inclusion of molecules that can induce synergistic cytotoxicity with Ara-C (MNKI-8e, emodin, metformin and niclosamide), subtoxic concentrations of chemotherapy (PD0332991), and potently antineoplastic treatments that do not damage nonmalignant cells (heteronemin or hydroxyurea + azidothymidine).
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Affiliation(s)
- Guadalupe Rosario Fajardo-Orduña
- Hematopoiesis and Leukemia Laboratory, Research Unit on Cell Differentiation and Cancer, FES Zaragoza, National Autonomous University of Mexico, 09230 Mexico City, Mexico; (G.R.F.-O.); (E.L.-M.); (I.A.-S.); (B.W.-S.)
| | - Edgar Ledesma-Martínez
- Hematopoiesis and Leukemia Laboratory, Research Unit on Cell Differentiation and Cancer, FES Zaragoza, National Autonomous University of Mexico, 09230 Mexico City, Mexico; (G.R.F.-O.); (E.L.-M.); (I.A.-S.); (B.W.-S.)
| | - Itzen Aguiñiga-Sánchez
- Hematopoiesis and Leukemia Laboratory, Research Unit on Cell Differentiation and Cancer, FES Zaragoza, National Autonomous University of Mexico, 09230 Mexico City, Mexico; (G.R.F.-O.); (E.L.-M.); (I.A.-S.); (B.W.-S.)
- Department of Biomedical Sciences, School of Medicine, Faculty of High Studies Zaragoza, National Autonomous University of Mexico, 09230 Mexico City, Mexico
| | - María de Lourdes Mora-García
- Immunobiology Laboratory, Research Unit on Cell Differentiation and Cancer, FES Zaragoza, National Autonomous University of Mexico, 09230 Mexico City, Mexico;
| | - Benny Weiss-Steider
- Hematopoiesis and Leukemia Laboratory, Research Unit on Cell Differentiation and Cancer, FES Zaragoza, National Autonomous University of Mexico, 09230 Mexico City, Mexico; (G.R.F.-O.); (E.L.-M.); (I.A.-S.); (B.W.-S.)
| | - Edelmiro Santiago-Osorio
- Hematopoiesis and Leukemia Laboratory, Research Unit on Cell Differentiation and Cancer, FES Zaragoza, National Autonomous University of Mexico, 09230 Mexico City, Mexico; (G.R.F.-O.); (E.L.-M.); (I.A.-S.); (B.W.-S.)
- Correspondence: ; Tel.: +52-55-57-73-41-08
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14
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Piccini M, Pilerci S, Merlini M, Grieco P, Scappini B, Bencini S, Peruzzi B, Caporale R, Signori L, Pancani F, Vannucchi AM, Gianfaldoni G. Venetoclax-Based Regimens for Relapsed/Refractory Acute Myeloid Leukemia in a Real-Life Setting: A Retrospective Single-Center Experience. J Clin Med 2021; 10:jcm10081684. [PMID: 33919958 PMCID: PMC8070927 DOI: 10.3390/jcm10081684] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 03/31/2021] [Accepted: 04/08/2021] [Indexed: 11/16/2022] Open
Abstract
Relapsed/refractory (R/R) acute myeloid leukemia (AML) is a largely unmet medical need, owing to the lack of standardized, effective treatment approaches, resulting in an overall dismal outcome. The only curative option for R/R AML patients is allogeneic hematopoietic stem cell transplantation (HSCT) which is only applicable in a fraction of patients due to the scarce efficacy and high toxicity of salvage regimens. Recently, a number of targeted agents with relatively favorable toxicity profiles have been explored in clinical trials for R/R AML patients. The Bcl-2 inhibitor venetoclax, in combination with hypomethylating agents or low dose cytarabine, has produced impressive results for newly diagnosed AML, while its role in R/R disease is not well defined yet. We retrospectively analyzed the clinical outcomes of 47 R/R AML patients treated with venetoclax-based regimens between March 2018 and December 2020 at our institution. Overall, we report a composite complete response rate of 55% with an overall acceptable toxicity profile. Outcomes were particularly favorable for NPM1 mutated patients, unlike for FLT3-ITD positive patients irrespective of NPM1 status. For patients treated with intention to transplant, the procedure could be finally performed in 54%. These findings suggest a role for venetoclax-based regimens in R/R AML patients and support the design of prospective studies.
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Affiliation(s)
- Matteo Piccini
- SOD Ematologia, Università degli Studi di Firenze e Azienda Ospedaliera Universitaria Careggi, 50139 Firenze, Italy; (M.P.); (B.S.); (A.M.V.)
| | - Sofia Pilerci
- Scuola di Specializzazione in Ematologia, Università degli Studi di Firenze, 50139 Firenze, Italy; (S.P.); (M.M.)
| | - Marta Merlini
- Scuola di Specializzazione in Ematologia, Università degli Studi di Firenze, 50139 Firenze, Italy; (S.P.); (M.M.)
| | - Pietro Grieco
- SOD Ematologia, Ospedale San Donato, Azienda Usl Toscana Sud-Est, 20121 Milano, Italy;
| | - Barbara Scappini
- SOD Ematologia, Università degli Studi di Firenze e Azienda Ospedaliera Universitaria Careggi, 50139 Firenze, Italy; (M.P.); (B.S.); (A.M.V.)
| | - Sara Bencini
- SOD Centro Diagnostico di Citofluorimetria e Immunoterapia, Azienda Ospedaliera Universitaria Careggi, 50139 Firenze, Italy; (S.B.); (B.P.); (R.C.)
| | - Benedetta Peruzzi
- SOD Centro Diagnostico di Citofluorimetria e Immunoterapia, Azienda Ospedaliera Universitaria Careggi, 50139 Firenze, Italy; (S.B.); (B.P.); (R.C.)
| | - Roberto Caporale
- SOD Centro Diagnostico di Citofluorimetria e Immunoterapia, Azienda Ospedaliera Universitaria Careggi, 50139 Firenze, Italy; (S.B.); (B.P.); (R.C.)
| | - Leonardo Signori
- Centro di Ricerca e Innovazione per le Malattie Mieloproliferative (CRIMM), Università degli Studi e Azienda Ospedaliera Universitaria Careggi, 50139 Firenze, Italy; (L.S.); (F.P.)
| | - Fabiana Pancani
- Centro di Ricerca e Innovazione per le Malattie Mieloproliferative (CRIMM), Università degli Studi e Azienda Ospedaliera Universitaria Careggi, 50139 Firenze, Italy; (L.S.); (F.P.)
| | - Alessandro Maria Vannucchi
- SOD Ematologia, Università degli Studi di Firenze e Azienda Ospedaliera Universitaria Careggi, 50139 Firenze, Italy; (M.P.); (B.S.); (A.M.V.)
- Centro di Ricerca e Innovazione per le Malattie Mieloproliferative (CRIMM), Università degli Studi e Azienda Ospedaliera Universitaria Careggi, 50139 Firenze, Italy; (L.S.); (F.P.)
| | - Giacomo Gianfaldoni
- SOD Ematologia, Università degli Studi di Firenze e Azienda Ospedaliera Universitaria Careggi, 50139 Firenze, Italy; (M.P.); (B.S.); (A.M.V.)
- Correspondence:
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15
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Tenold ME, Moskoff BN, Krishnan R, Rosenberg AS, Hoeg RT, Abedi M, Tuscano JM, Jonas BA. Retrospective Analysis of Adult Patients With Relapsed/Refractory Acute Myeloid Leukemia Treated with FLAG at a Comprehensive Cancer Center. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 21:e611-e618. [PMID: 33811007 DOI: 10.1016/j.clml.2021.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/02/2021] [Accepted: 02/12/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND FLAG ± Ida (fludarabine, cytarabine, granulocyte colony-stimulating factor, and idarubicin), is a salvage chemotherapy regimen for relapsed or refractory (R/R) acute myeloid leukemia (AML), with complete remission (CR) rates historically ranging from 52% to 63%. We review the outcomes for patients with R/R AML treated with FLAG ± Ida at the University of California Davis Comprehensive Cancer Center. PATIENTS AND METHODS Adult patients (≥ 18 years) with R/R AML who received FLAG or FLAG + Ida from January 1, 2012 to October 31, 2016 were identified via chart review. Outcomes evaluated were CR, CR with incomplete hematologic recovery (CRi), overall response rate, overall survival (OS), relapse-free survival, and adverse events. RESULTS Forty-two patients were included. The median age was 52 years (range, 23-73 years), and 57% were male. Sixteen (38.1%) patients had relapsed disease, and 26 (61.9%) had refractory disease. Most (n = 35; 83.3%) patients had European LeukemiaNet intermediate-risk AML. Responses were CR in 20 (47.6%) and CRi in 6 (14.3%). The median OS was 10 months (range, 0.8-51 months), and the median relapse-free survival was 12 months (range, 1-51 months) for responders. The median OS for patients who achieved CR was not reached, and the estimated 48-month survival rate was 56%. The median OS after CRi or no response was 3.47 and 2.17 months, respectively. The median OS was not significantly different when censored for stem cell transplant following chemotherapy, nor with use/deferral of idarubicin. The most common adverse effects were pancytopenia and infection. CONCLUSION Patient outcomes after treatment with FLAG ± Ida for R/R AML remain similar to prior reports, confirming its role as a salvage regimen for these patients.
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Affiliation(s)
- Matthew E Tenold
- Division of Hematology and Oncology, Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, CA
| | - Benjamin N Moskoff
- Pharmacy Department, University of California Davis School of Medicine, Sacramento, CA
| | - Rajeev Krishnan
- Department of Hematology/Oncology, Kaiser Permanente Northwest, Portland, OR
| | - Aaron S Rosenberg
- Division of Hematology and Oncology, Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, CA
| | - Rasmus T Hoeg
- Division of Hematology and Oncology, Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, CA
| | - Mehrdad Abedi
- Division of Hematology and Oncology, Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, CA
| | - Joseph M Tuscano
- Division of Hematology and Oncology, Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, CA; Veterans Administration Northern California Healthcare System, Sacramento, CA
| | - Brian A Jonas
- Division of Hematology and Oncology, Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, CA; Veterans Administration Northern California Healthcare System, Sacramento, CA.
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16
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Abbasi AM, Shaikh U, Ali N, Haider MN. Fludarabine-based salvage therapy for refractory/relapsed acute leukemias: A single center experience. Leuk Res Rep 2021; 15:100235. [PMID: 33598399 PMCID: PMC7869002 DOI: 10.1016/j.lrr.2021.100235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 01/23/2021] [Accepted: 01/24/2021] [Indexed: 12/02/2022] Open
Affiliation(s)
| | - Usman Shaikh
- Department of Pathology and Laboratory Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Natasha Ali
- Department of Pathology and Laboratory Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Mohammad Nadir Haider
- Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, United States
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17
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Pandya BJ, Yang H, Schmeichel C, Qi CZ, Shah MV. A budget impact analysis of gilteritinib for the treatment of relapsed or refractory FLT3 mut+ acute myeloid leukemia in a US health plan. J Med Econ 2021; 24:19-28. [PMID: 33280474 DOI: 10.1080/13696998.2020.1851698] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
AIMS To estimate the economic impact of the introduction of gilteritinib for the treatment of relapsed/refractory (R/R) FLT3 mutation-positive (FLT3 mut+) acute myeloid leukemia (AML) from a US payer's perspective. METHODS A budget impact model (BIM) was developed to evaluate the 3-year total budgetary impact of treating adults with R/R FLT3 mut+ AML eligible for gilteritinib in a hypothetical US health plan. Total costs (drugs/administration, hospitalization, monitoring, adverse events, transfusions, subsequent hematopoietic stem cell transplantation, post-progression, and FLT3 testing) were estimated before and after gilteritinib entry. The budget impact was the total cost difference between the two scenarios. The target population size and cost inputs were based on public data or published literature, drug market share was informed by market research data, and the model included recommended treatments for R/R FLT3 mut+ AML per clinical guidelines. Deterministic sensitivity analyses (DSAs) and scenario analyses varying key model inputs and assumptions were conducted to test for robustness. RESULTS In a hypothetical health plan with 1 million members, 20.9 adults with R/R FLT3 mut+ AML were estimated to be eligible for gilteritinib. Of these, it was assumed 30.0% would be treated with gilteritinib in Year 1 following gilteritinib entry, increasing the total plan budget by $663,795 and the per-member-per-month (PMPM) cost by $0.055. In Years 2-3, the market share of gilteritinib increased to 45.0%, increasing the total plan budget impact by $1,078,371 and $1,087,230, and the PMPM cost by $0.090 and $0.091, respectively. The model results remained robust in DSAs and scenario analyses, with the largest impact observed when the projected uptake of gilteritinib was changed. LIMITATIONS The results of this BIM are contingent upon the model's assumptions and inputs. CONCLUSIONS Adding gilteritinib to the formulary for the treatment of adults with R/R FLT3 mut+ AML had a minimal budget impact from a US payer's perspective.
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Affiliation(s)
- Bhavik J Pandya
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
| | | | | | | | - Manasee V Shah
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
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18
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Mushtaq MU, Harrington AM, Chaudhary SG, Michaelis LC, Carlson KSB, Abedin S, Runass L, Callander NS, Fallon MJ, Juckett M, Hall AC, Hematti P, Mattison RJ, Atallah EL, Guru Murthy GS. Comparison of salvage chemotherapy regimens and prognostic significance of minimal residual disease in relapsed/refractory acute myeloid leukemia. Leuk Lymphoma 2020; 62:158-166. [PMID: 32951486 DOI: 10.1080/10428194.2020.1821009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
We compared the outcomes of salvage chemotherapy in 146 patients with relapsed (57.5%) or refractory (42.5%) AML who received CLAG-M (51%), MEC (39%) or CLAG (10%). Minimal residual disease (MRD) was assessed by flow cytometry. Bivariate, Kaplan-Meier, and Cox regression analyses were conducted. Complete remission (CR) rate of 46% (CLAG-M 54% versus MEC/CLAG 40%, p = .045) was observed with MRD-negative CR of 33% (CLAG-M 39% versus MEC/CLAG 22%, p = .042). Median overall survival (OS) was 9.7 months; the longest OS occurred with CLAG-M (13.3, 95%CI 2.4-24.3) versus MEC (6.9, 95%CI 2.9-10.9) or CLAG (6.2, 95%CI 2.4-12.6) (p = .025). When adjusted for age, gender, relapsed/refractory AML, poor risk AML, MRD, chemotherapy and transplant, CLAG-M (HR 0.63, 95% CI 0.40-0.98, p = .042), MRD-negativity (HR 0.15, 95% CI 0.07-0.30, p < .001) and transplant (HR 0.22, 95% CI 0.13-0.39, p < .001) were associated with higher OS. Our findings confirm that CLAG-M is a reasonable salvage regimen for RR-AML followed by transplant.
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Affiliation(s)
- Muhammad Umair Mushtaq
- Division of Hematology/Oncology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.,University of Wisconsin Carbone Cancer Center, Madison, WI, USA
| | | | - Sibgha Gull Chaudhary
- Division of Hematology/Oncology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.,University of Wisconsin Carbone Cancer Center, Madison, WI, USA
| | - Laura C Michaelis
- Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Karen-Sue B Carlson
- Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Sameem Abedin
- Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Lyndsey Runass
- Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Natalie S Callander
- Division of Hematology/Oncology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.,University of Wisconsin Carbone Cancer Center, Madison, WI, USA
| | | | - Mark Juckett
- Division of Hematology/Oncology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.,University of Wisconsin Carbone Cancer Center, Madison, WI, USA
| | - Aric C Hall
- Division of Hematology/Oncology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.,University of Wisconsin Carbone Cancer Center, Madison, WI, USA
| | - Peiman Hematti
- Division of Hematology/Oncology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.,University of Wisconsin Carbone Cancer Center, Madison, WI, USA
| | - Ryan J Mattison
- Division of Hematology/Oncology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.,University of Wisconsin Carbone Cancer Center, Madison, WI, USA
| | - Ehab L Atallah
- Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
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19
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Byrne M, Danielson N, Sengsayadeth S, Rasche A, Culos K, Gatwood K, Wyatt H, Chinratanalab W, Dholaria B, Ferrell PB, Fogo K, Goodman S, Jagasia M, Jayani R, Kassim A, Mohan SR, Savani BN, Strickland SA, Engelhardt BG, Savona M. The use of venetoclax-based salvage therapy for post-hematopoietic cell transplantation relapse of acute myeloid leukemia. Am J Hematol 2020; 95:1006-1014. [PMID: 32390196 DOI: 10.1002/ajh.25859] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 04/26/2020] [Accepted: 05/04/2020] [Indexed: 12/19/2022]
Abstract
For patients with high risk myeloid disease, allogeneic hematopoietic cell transplantation (HCT) is the only potentially curative therapy. Unfortunately, many of these patients relapse after HCT and have a limited survival. The recent approval of venetoclax, an orally bioavailable BCL-2 inhibitor, resulted in significant responses in treatment naïve acute myeloid leukemia (AML), and off-label use in the relapsed/refractory setting is increasing. We report the outcomes of 21 patients who underwent allogeneic HCT for myeloid disease, relapsed with AML, and were treated with venetoclax. Several patients had poor risk features including antecedent hematologic malignancy (6/21), complex karyotype (6/21), and TP53 mutations (5/21). The median age was 64.5 years and time from HCT to relapse was 5.7 months (range: 0.9 to 44.9 months). Of the 19 patients who were assessed for response, there were meaningful treatment responses seen in eight patients: five CR, three CRi, zero PR, for an ORR of 42.1%. Treatment effect was seen in six additional patients, including four in the morphologic leukemia-free state. Nine patients maintained their response for ≥3 months and eight were receiving therapy at data cut. Post-HCT AML relapse has an exceedingly poor outcome, and venetoclax-based therapy is a potent therapy option that should be studied prospectively in this setting.
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Affiliation(s)
- Michael Byrne
- Department of Medicine Vanderbilt University School of Medicine Nashville Tennessee USA
- Vanderbilt‐Ingram Cancer Center Nashville Tennessee USA
| | | | - Salyka Sengsayadeth
- Department of Medicine Vanderbilt University School of Medicine Nashville Tennessee USA
- Tennessee Valley Healthcare System Nashville Tennessee USA
| | - Adrianne Rasche
- Department of Nursing Vanderbilt University Medical Center Nashville Tennessee USA
| | - Katie Culos
- Department of Pharmacy Vanderbilt University Medical Center Nashville Tennessee USA
| | - Katie Gatwood
- Department of Pharmacy Vanderbilt University Medical Center Nashville Tennessee USA
| | - Houston Wyatt
- Department of Pharmacy Vanderbilt University Medical Center Nashville Tennessee USA
| | - Wichai Chinratanalab
- Department of Medicine Vanderbilt University School of Medicine Nashville Tennessee USA
- Tennessee Valley Healthcare System Nashville Tennessee USA
| | - Bhagirathbhai Dholaria
- Department of Medicine Vanderbilt University School of Medicine Nashville Tennessee USA
- Vanderbilt‐Ingram Cancer Center Nashville Tennessee USA
| | - P. Brent Ferrell
- Department of Medicine Vanderbilt University School of Medicine Nashville Tennessee USA
- Vanderbilt‐Ingram Cancer Center Nashville Tennessee USA
| | - Kristin Fogo
- Department of Nursing Vanderbilt University Medical Center Nashville Tennessee USA
| | - Stacey Goodman
- Department of Medicine Vanderbilt University School of Medicine Nashville Tennessee USA
- Tennessee Valley Healthcare System Nashville Tennessee USA
| | - Madan Jagasia
- Department of Medicine Vanderbilt University School of Medicine Nashville Tennessee USA
- Vanderbilt‐Ingram Cancer Center Nashville Tennessee USA
| | - Reena Jayani
- Department of Medicine Vanderbilt University School of Medicine Nashville Tennessee USA
- Vanderbilt‐Ingram Cancer Center Nashville Tennessee USA
| | - Adetola Kassim
- Department of Medicine Vanderbilt University School of Medicine Nashville Tennessee USA
- Vanderbilt‐Ingram Cancer Center Nashville Tennessee USA
| | - Sanjay R. Mohan
- Department of Medicine Vanderbilt University School of Medicine Nashville Tennessee USA
- Vanderbilt‐Ingram Cancer Center Nashville Tennessee USA
| | - Bipin N. Savani
- Department of Medicine Vanderbilt University School of Medicine Nashville Tennessee USA
- Vanderbilt‐Ingram Cancer Center Nashville Tennessee USA
| | - Stephen A. Strickland
- Department of Medicine Vanderbilt University School of Medicine Nashville Tennessee USA
- Vanderbilt‐Ingram Cancer Center Nashville Tennessee USA
| | - Brian G. Engelhardt
- Department of Medicine Vanderbilt University School of Medicine Nashville Tennessee USA
- Vanderbilt‐Ingram Cancer Center Nashville Tennessee USA
| | - Michael Savona
- Department of Medicine Vanderbilt University School of Medicine Nashville Tennessee USA
- Vanderbilt‐Ingram Cancer Center Nashville Tennessee USA
- Program in Cancer Biology Vanderbilt University Nashville Tennessee USA
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20
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Abstract
Relapse is still a common scenario in acute myeloid leukemia (AML) treatment and occurs in 40–50% of younger and the great majority of elderly patients. The prognosis in relapsed AML patients is generally poor but depends largely on the timing of relapse (early versus late) and the possibility of allogeneic hematopoietic stem cell transplantation (HSCT). At the time of relapse, we again perform a mutational screening and cytogenetic analysis in all AML patients as clonal evolution of disease is frequent. Clinical trials should be first priority in all relapsed patients. In fit patients without prior transplant, we aim to perform HSCT after salvage therapy. In AML patients relapsing after HSCT and good performance status, intensive therapy can be considered with subsequent cellular therapy such as donor lymphocyte infusion (DLI) or a second HSCT. However, less than 20% of these patients are alive after 5 years. For those patients that are unfit, the therapeutic aim is to prolong life with acceptable quality of life. Here, hypomethylating agents (HMA), low-dose AraC (LDAC), and solely cytoreductive therapy with hydroxurea are options depending on first-line therapy. For those patients that have not been treated with venetoclax in first line, the combination therapy of venetoclax with demethylating agents achieves encouraging response rates. Venetoclax is currently also studied in combination with intensive salvage therapy. Importantly, for patients with isocitrate dehydrogenase (IDH) 1/2–mutated AML, ivosidenib, an IDH1 inhibitor, and enasidenib, an IDH2 inhibitor, present well-tolerated options in the setting of refractory or relapsed (r/r) disease even in elderly and heavily pre-treated patients with response rates of 30–40%. Both substances have been approved by the U.S. Food and Drug Administration (FDA) for r/r AML patients with IDH1/2 mutations (but not yet by the European Medicines Agency (EMA)). For patients with FMS-like tyrosine kinase 3 (FLT3) mutations, treatment with the selective FLT3 inhibitor gilteritinib is well tolerated and leads to improved outcome compared with standard salvage therapy. The approval has been granted by the FDA and the EMA. Generally, we would recommend targeted therapy for IDH1/2- and FLT3-mutated AML if available. In order to improve outcome in relapsed AML, it will be important to intelligently combine novel substances with each other as well as chemotherapy in prospective clinical trials. The development of therapies with bispecific antibodies or chimeric antigen receptor T cells (CAR-T) are still in early development.
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21
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Mayer K, Hahn-Ast C, Schwab K, Schmidt-Wolf IGH, Brossart P, Glasmacher A, von Lilienfeld-Toal M. Long-term follow-up of Cladribine, high-dose Cytarabine, and Idarubicin as salvage treatment for relapsed acute myeloid leukemia and literature review. Eur J Haematol 2020; 104:538-545. [PMID: 32049382 DOI: 10.1111/ejh.13395] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 02/07/2020] [Accepted: 02/07/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE Outcome for relapsed acute myeloid leukemia (AML) is poor. Cladribine has activity in AML, and an enhancing effect on other cytostatic drugs thus may help overcome resistance. Here, we present the final analysis of our phase II trial evaluating safety and efficacy of cladribine, cytarabine, and idarubicin (CAI) in relapsed AML. METHODS Patients with relapsed AML after at least 6 months remission received two courses of CAI. After 9 patients, prolonged neutropenia prompted protocol change (omission of idarubicin in 2nd course and dose-reduction of cytarabine). Primary endpoints were remission rate and safety. RESULTS Twenty patients received treatment, fourteen one, and six two courses CAI/CA. After first course, complete remission (CR/CRi) was achieved in 60%. Most frequent toxicity was infection. Median OS was 8.8 months in all patients and 21.1 months in those with CR. Nine patients (48%) proceeded to allogeneic stem cell transplantation (allo-SCT), four of those are still alive and in CR, accounting for a 5-year survival rate of 55% of transplanted patients. CONCLUSION Cladribine, cytarabine, and idarubicin in relapsed AML is feasible and induces good response rates. As expected, infections are the most important complication. However, combined with allo-SCT, long-term survival can be achieved in a substantial number of patients.
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Affiliation(s)
- Karin Mayer
- Medizinische Klinik III, Hämatologie/Onkologie/Rheumatologie, Universitätsklinikum Bonn, Bonn, Germany
| | - Corinna Hahn-Ast
- Medizinische Klinik III, Hämatologie/Onkologie/Rheumatologie, Universitätsklinikum Bonn, Bonn, Germany
| | - Katjana Schwab
- Medizinische Klinik III, Hämatologie/Onkologie/Rheumatologie, Universitätsklinikum Bonn, Bonn, Germany
| | | | - Peter Brossart
- Medizinische Klinik III, Hämatologie/Onkologie/Rheumatologie, Universitätsklinikum Bonn, Bonn, Germany
| | - Axel Glasmacher
- Medizinische Klinik III, Hämatologie/Onkologie/Rheumatologie, Universitätsklinikum Bonn, Bonn, Germany
| | - Marie von Lilienfeld-Toal
- Klinik für Innere Medizin II, Abteilung für Hämatologie und Onkologie, Universitätsklinikum Jena, Jena, Germany.,Leibniz-Institut für Naturstoff-Forschung und Infektionsbiologie, Hans-Knöll Institut, Jena, Germany.,Center for Sepsis Control and Care (CSCC), Universitätsklinikum Jena, Jena, Germany
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22
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Çiftçiler R, Sevindik ÖG, Tekgündüz AİE, Erkurt MA, Vural F, Turgut B, Kaynar L, Payzın B, Doğu MH, Karakuş V, Altuntaş F, Büyükaşık Y, Demirkan F. Acute Lymphoblastic Leukemia in Routine Practice: A Turkish Multicenter Study. Turk J Haematol 2019; 36:169-177. [PMID: 31131598 PMCID: PMC6682776 DOI: 10.4274/tjh.galenos.2019.2019.0008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Objective: Significant developments occurred in the clinical management of acute lymphoblastic leukemia (ALL) in adults in recent decades. However, treatment results are still not satisfactory, especially in routine practice. The objective of this study was to evaluate the general clinical features, treatment details, and outcomes of a large group of patients followed in multiple centers in Turkey with a diagnosis of ALL. Materials and Methods: A retrospective analysis of the data of patients with ALL was made, the patients having been diagnosed and treated between January 2003 and June 2017 by different protocols in the hematology clinics of ten different centers. A total of 288 patients, aged between 17 and 76 years old, were included in the study. In this retrospective multicenter analysis of patients with ALL, classification of patients was performed based on treatment period, Philadelphia chromosome positivity, treatment regimen, and administration of allogeneic hematopoietic stem cell transplantation (allo-HSCT). Results: The majority of cases were B-cell in origin, while 224 patients had B-ALL and 64 of the patients had T-ALL. Median follow-up duration for all patients was 18.2 months (range: 0.03-161 months). Philadelphia chromosome positivity was determined in 49 patients (21.9%), and 54 patients (18.8%) were receiving allo-HSCT. After induction chemotherapy, 219 patients (76.0%) achieved complete remission, 32 patients (11.2%) were evaluated as treatment refractory, and 37 patients (12.8%) were deceased. Median overall survival was 47.7 months (95% confidence interval: 36.1-59.2) and median disease-free survival was 23.4 months (95% confidence interval: 6.7-40.0) for all patients. Conclusion: Multicenter studies are extremely important for defining the specific clinical features of a particular disease. The results of this study will make a significant contribution to the literature as they reflect real-life data providing valuable information about the Turkish ALL patient profile.
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Affiliation(s)
- Rafiye Çiftçiler
- Hacettepe University Faculty of Medicine, Department of Hematology, Ankara, Turkey
| | | | | | - Mehmet Ali Erkurt
- İnönü University Faculty of Medicine, Department of Hematology, Malatya, Turkey
| | - Filiz Vural
- Ege University Faculty of Medicine, Department of Hematology, İzmir, Turkey
| | - Burhan Turgut
- Namık Kemal University Faculty of Medicine, Department of Hematology, Tekirdağ, Turkey
| | - Leylagül Kaynar
- Erciyes University Faculty of Medicine, Department of Hematology, Kayseri, Turkey
| | - Bahriye Payzın
- İzmir Atatürk Training and Research Hospital, Clinic of Hematology, İzmir, Turkey
| | - Mehmet Hilmi Doğu
- İstanbul Training and Research Hospital, Clinic of Hematology, İstanbul, Turkey
| | - Volkan Karakuş
- Muğla Sıtkı Koçman University Faculty of Medicine, Department of Hematology, Muğla, Turkey
| | - Fevzi Altuntaş
- Ankara Oncology Training and Research Hospital, Clinic of Hematology, Ankara, Turkey
| | - Yahya Büyükaşık
- Hacettepe University Faculty of Medicine, Department of Hematology, Ankara, Turkey
| | - Fatih Demirkan
- Dokuz Eylül University Faculty of Medicine, Department of Hematology, İzmir, Turkey
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23
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Hatsumi N, Miyawaki S, Yamauchi T, Takeshita A, Komatsu N, Usui N, Arai Y, Ishida F, Morii T, Kano Y, Ogura M, Machida S, Nishii K, Honda S, Ohnishi K, Naoe T. Phase II study of FLAGM (fludarabine + high-dose cytarabine + granulocyte colony-stimulating factor + mitoxantrone) for relapsed or refractory acute myeloid leukemia. Int J Hematol 2019; 109:418-425. [PMID: 30725360 DOI: 10.1007/s12185-019-02606-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 01/22/2019] [Accepted: 01/22/2019] [Indexed: 10/27/2022]
Abstract
Given the poor prognosis of patients with relapsed/refractory acute myeloid leukemia (AML), better therapy is needed. Fludarabine enhances the efficacy of Ara-C (cytarabine) by increasing intracellular Ara-C-triphosphate. The FLAG (fludarabine, high-dose Ara-C, supported with granulocyte colony-stimulating factor) regimen has been tested for use in AML patients by other investigators. In the phase II study reported here, we evaluated the efficacy and toxicity of FLAGM therapy (FLAG with mitoxantrone), further intensified by adding mitoxantrone, based on the results of a phase I study by our group. The major endpoints were complete remission (CR) rate and early death. From June 2004 to February 2008, 41 patients (median age 52 years; range 18-64 years) were enrolled. Thirty (73% 95% CI 58-84%) patients achieved CR, which met the primary endpoint; there was a single case of early death from pneumonia. Two-year overall survival was 39.4% (95% CI 25.2-55.6%). Of those who achieved CR, 27 underwent allogeneic stem cell transplantation (SCT), and 12 SCT recipients showed long-term survival. Grade 3/4 non-hematological adverse events included infection (59%), nausea/vomiting (15%), diarrhea (7%), and elevated liver enzymes (7%). In conclusion, FLAGM is an effective and safe salvage therapy for patients with relapsed/refractory AML, and facilitated SCT for a large proportion of patients.
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Affiliation(s)
- Nahoko Hatsumi
- Leukemia Research Center, Saiseikai Maebashi Hospital, Maebashi, Japan
| | - Shuichi Miyawaki
- Leukemia Research Center, Saiseikai Maebashi Hospital, Maebashi, Japan. .,Division of Hematology, Tokyo Metropolitan Ohtsuka Hospital, 2-8-1 Minamiohtsuka Toshima-ku, Tokyo, 170-8476, Japan.
| | - Takahiro Yamauchi
- First Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Akihiro Takeshita
- Department of Medicine III, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Norio Komatsu
- Division of Hematology, Jichi Medical University, Shimotsuke, Japan
| | - Noriko Usui
- Division of Clinical Oncology and Hematology, Department of Internal Medicine, Jikei University School of Medicine, Tokyo, Japan
| | - Yukihiro Arai
- Department of Hematology, Dokkyo University School of Medicine, Mibu, Japan
| | - Fumihiro Ishida
- Department of Internal Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Takeshi Morii
- The Second Department of Internal Medicine, Nara Medical University, Nara, Japan
| | - Yasuhiko Kano
- Division of Hematology, Tochigi Cancer Center, Utsunomiya, Japan
| | - Michinori Ogura
- Department of Hematology and Oncology, Nagoya Daini Red Cross Hospital, Nagoya, Japan.,Department of Hematology and Oncology, Kasugai Municipal Hospital, Kasugai, Japan
| | - Shinichiro Machida
- Department of Hematology and Oncology, Tokai University School of Medicine, Isehara, Japan
| | - Kazuhiro Nishii
- Hematology and Oncology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Sumihisa Honda
- Department of Public Health, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Kazunori Ohnishi
- Oncology Center, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Tomoki Naoe
- Oncology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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24
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Zhang J, Geng H, Liu L, Zhang H. Synergistic cytotoxicity of homoharringtonine and etoposide in acute myeloid leukemia cells involves disrupted antioxidant defense. Cancer Manag Res 2019; 11:1023-1032. [PMID: 30774430 PMCID: PMC6349074 DOI: 10.2147/cmar.s187597] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Background/Aims Cytotoxicity induced by reactive oxygen species (ROS) is critical for the effectiveness of chemotherapeutic drugs used in the treatment of acute myeloid leukemia (AML). This study aimed to investigate whether ROS contributes to cytotoxicity in AML cells when treated with homoharringtonine (HHT) and etoposide (ETP) in combination. Methods AML cell lines THP1 and HL60 and primary AML cells from patients were treated with HHT and ETP alone or in combination, and cell viability was determined by trypan blue exclusion test, and apoptosis was analyzed by annexin-V/propidium iodide double staining as well as Western blot for measuring expression of cleaved caspase-9 and cleaved caspase-3. Intracellular ROS level was detected by DCFH-DA fluorescence assay, and N-Acetyl-L-cysteine (NAC) was used to scavenge intracellular ROS. Retroviral infection was applied to mediate stable overexpression in AML cells. Results We show that HHT and ETP exhibit synergistic cytotoxicity in AML cell lines and primary AML cells in vitro, and meanwhile, HHT causes elevated ROS generation in ETP-treated AML cells. We next reveal that the elevated ROS is a critical factor for the synergistic cytotoxicity, since ROS scavenge by NAC remarkably diminishes this effect. Mechanistically, we demonstrate that HHT causes elevated ROS generation by disabling thioredoxin-mediated antioxidant defense. Finally, similar to HHT treatment, depletion of thioredoxin sensitizes AML to ETP treatment. Conclusion These results provide the foundation for augmenting the efficacy of ETP in treating AML with HHT, and also highlight the importance of targeting ROS in improving treatment outcome in AML.
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Affiliation(s)
- Jingjing Zhang
- Department of Hematology, Affiliated Hospital of Jining Medical University, Jining 272029, Shandong Province, China,
| | - Huayun Geng
- Department of Hematology, Dongchangfu People's Hospital of Liaocheng, Liaocheng 252000, Shandong Province, China
| | - Ling Liu
- Department of Hematology, Affiliated Hospital of Jining Medical University, Jining 272029, Shandong Province, China,
| | - Hao Zhang
- Department of Hematology, Affiliated Hospital of Jining Medical University, Jining 272029, Shandong Province, China,
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25
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Efficacy and Feasibility of Allogeneic Hematopoietic Stem-Cell Transplantation in the Treatment of Refractory Acute Myeloid Leukemia. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2019; 19:177-182. [PMID: 30616990 DOI: 10.1016/j.clml.2018.11.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 11/06/2018] [Accepted: 11/15/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND Refractory acute myeloid leukemia (AML) includes AML includes failure of disease to respond to standard induction chemotherapy, relapse within 6 months after first CR, and 2 or more relapses. The outcome of these patients is usually very poor; only a small proportion can be rescued by allogenic hematopoietic stem-cell transplantation (allo-HSCT). The aim of this study was to evaluate the efficacy and feasibility of allo-HSCT in patients with refractory AML. PATIENTS AND METHODS We retrospectively analyzed the clinical outcome of 91 patients who were diagnosed with treatment-refractory AML at Hacettepe University Hospital between January 2002 and June 2018. Patients' disease status included refractory AML, defined as failure to respond to standard induction chemotherapy and relapse within 6 months after first complete remission. RESULTS The median follow-up was 12 months (range, 0.5-184 months) for the entire group. Kaplan-Meier estimates of the 3-year overall survival for patients who underwent allo-HSCT and patients who received only salvage chemotherapy were 67% and 12%, respectively. Additionally, the Kaplan-Meier estimates of 5-year overall survival for patients who underwent allo-HSCT and patients who received only salvage chemotherapy were 44% and 4%, respectively (P < .001). Complete remission was obtained in 25 patients (83.3%) who underwent allo-HSCT; however, the disease of only 3 patients (3.8%) exhibited complete response after salvage chemotherapy. CONCLUSION Allo-HSCT is still the best-known treatment option with curative potential in patients with treatment-refractory AML. Therefore, all efforts should be made in an attempt to find a suitable matched donor in order to perform allo-HSCT.
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26
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Identifying Prognostic Factors That Influence Outcome of Childhood Acute Myeloid Leukemia in First Relapse in Saudi Arabia: Results of the Multicenter SAPHOS Study. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2018; 18:773-780. [DOI: 10.1016/j.clml.2018.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 08/28/2018] [Accepted: 09/04/2018] [Indexed: 01/17/2023]
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27
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Westhus J, Noppeney R, Dührsen U, Hanoun M. FLAG salvage therapy combined with idarubicin in relapsed/refractory acute myeloid leukemia. Leuk Lymphoma 2018; 60:1014-1022. [PMID: 30277107 DOI: 10.1080/10428194.2018.1508670] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Acute myeloid leukemia (AML) is characterized by a high failure rate to achieve complete remission as well as high relapse rates that cause an emergent need for efficient and tolerable salvage therapies. The combination of FLAG with idarubicin (FLAG-Ida) is a widely used protocol. However, its efficacy has been analyzed in only a limited number of studies with majorly small patient cohorts. Here, we analyzed 132 patients with largely primary refractory or first-time relapsed AML treated according to the FLAG-Ida protocol. The overall complete remission rate (CR + CRi) was 56% with a median overall survival of 15 months (95% CI, 5.7-25.1). The median disease-free survival for CR/CRi-patients was not reached. The mortality rate on day 30 was 9% and increased on day 60 to 16%. Our results show in relapsed/refractory AML patients a high efficacy and compatibility for the FLAG-Ida regimen.
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Affiliation(s)
- Jonas Westhus
- a Department of Hematology , University Hospital, University of Duisburg-Essen , Essen , Germany
| | - Richard Noppeney
- a Department of Hematology , University Hospital, University of Duisburg-Essen , Essen , Germany
| | - Ulrich Dührsen
- a Department of Hematology , University Hospital, University of Duisburg-Essen , Essen , Germany
| | - Maher Hanoun
- a Department of Hematology , University Hospital, University of Duisburg-Essen , Essen , Germany
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28
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Arellano M, Carlisle JW. How I treat older patients with acute myeloid leukemia. Cancer 2018; 124:2472-2483. [DOI: 10.1002/cncr.31347] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 11/30/2017] [Accepted: 01/04/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Martha Arellano
- Department of Hematology and Medical Oncology, Winship Cancer Institute; Emory University; Atlanta Georgia
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29
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Megías-Vericat JE, Martínez-Cuadrón D, Sanz MÁ, Montesinos P. Salvage regimens using conventional chemotherapy agents for relapsed/refractory adult AML patients: a systematic literature review. Ann Hematol 2018; 97:1115-1153. [DOI: 10.1007/s00277-018-3304-y] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 03/12/2018] [Indexed: 12/26/2022]
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30
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Rashidi A, Weisdorf DJ, Bejanyan N. Treatment of relapsed/refractory acute myeloid leukaemia in adults. Br J Haematol 2018; 181:27-37. [PMID: 29318584 DOI: 10.1111/bjh.15077] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The prognosis of relapsed acute myeloid leukaemia (AML) is poor and treatment is challenging. While the most potent treatment modality for patients who achieve a complete remission after relapse is still allogeneic haematopoietic cell transplantation (allo-HCT), both transplant-related mortality and relapse rates are high and many patients are not candidates for this approach. After a few decades of relative stasis in this field, a large number of novel approaches have become available to tackle this highly fatal disease. This is mostly due to our improved understanding of disease pathogenesis (including targetable mutations) and the anti-leukaemia potential of the immune system. Several small-molecule inhibitors and immunotherapeutic options are being explored in clinical trials and many more are in pre-clinical phase. Future studies will focus on novel and mechanistically driven combinations, sequential treatments, and low-toxicity maintenance strategies. While cure of relapsed/refractory AML without allo-HCT is currently unlikely, treatments are becoming less toxic and remissions are lasting longer.
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Affiliation(s)
- Armin Rashidi
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Daniel J Weisdorf
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Nelli Bejanyan
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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31
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Delia M, Pastore D, Carluccio P, Pasciolla C, Ricco A, Rossi AR, Casieri P, Mestice A, Albano F, Specchia G. FLAG-Ida Regimen as Bridge Therapy to Allotransplantation in Refractory/Relapsed Acute Myeloid Leukemia Patients. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2017; 17:767-773. [DOI: 10.1016/j.clml.2017.06.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Revised: 06/09/2017] [Accepted: 06/09/2017] [Indexed: 12/19/2022]
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32
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Dima D, Oprita L, Rosu AM, Trifa A, Selicean C, Moisoiu V, Frinc I, Zdrenghea M, Tomuleasa C. Adult acute megakaryoblastic leukemia: rare association with cytopenias of undetermined significance and p210 and p190 BCR- ABL transcripts. Onco Targets Ther 2017; 10:5047-5051. [PMID: 29089774 PMCID: PMC5656356 DOI: 10.2147/ott.s146973] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Acute megakaryocytic leukemia (M7-AML) is a rare form of acute myeloid leukemia (AML), which is associated with poor prognosis. The case presented in the current report is a statement for the difficult diagnosis and clinical management of M7-AML in the context of a previous hematologic disorder of undetermined significance and associated genetic abnormalities. Probably, following the complete hematologic remission and further with induction chemotherapy plus tyrosine kinase inhibitor therapy, the clinical management of this case will be followed by a allogeneic bone marrow transplantation, the only proven therapy to improve overall survival.
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Affiliation(s)
- Delia Dima
- Department of Hematology, Ion Chiricuta Oncology Institute
| | | | - Ana-Maria Rosu
- Research Center for Functional Genomics and Translational Medicine
| | | | | | - Vlad Moisoiu
- Research Center for Functional Genomics and Translational Medicine
| | - Ioana Frinc
- Department of Hematology, Ion Chiricuta Oncology Institute
| | - Mihnea Zdrenghea
- Department of Hematology, Ion Chiricuta Oncology Institute.,Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Ciprian Tomuleasa
- Department of Hematology, Ion Chiricuta Oncology Institute.,Research Center for Functional Genomics and Translational Medicine.,Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
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33
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Nakayama H, Tomizawa D, Tanaka S, Iwamoto S, Shimada A, Saito AM, Yamashita Y, Moritake H, Terui K, Taga T, Matsuo H, Kosaka Y, Koh K, Hosoi H, Kurosawa H, Isoyama K, Horibe K, Mizutani S, Adachi S. Fludarabine, cytarabine, granulocyte colony-stimulating factor and idarubicin for relapsed childhood acute myeloid leukemia. Pediatr Int 2017; 59:1046-1052. [PMID: 28771903 DOI: 10.1111/ped.13378] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 06/21/2017] [Accepted: 07/05/2017] [Indexed: 01/03/2023]
Abstract
BACKGROUND The combination of fludarabine (Flu), high-dose cytarabine (Ara-C) and granulocyte colony-stimulating factor (G-CSF; FLAG), with anthracyclines has become standard chemotherapy for refractory acute myeloid leukemia (AML) in European children and adults. To clarify the efficacy and the safety of FLAG-idarubicin (IDA) for children prospectively, we planned a multicenter phase II study (AML-R11) by the Japanese Pediatric Leukemia/Lymphoma Study Group. METHODS Patients with AML aged between 2 and 20 years old, who had the first bone marrow (BM) relapse or induction failure, were enrolled. The FLAG-IDA regimen consisted of Flu 30 mg/m2 for 5 days, Ara-C 2 g/m2 for 5 days, G-CSF (lenograstim) 5 μg/kg for 6 days and IDA 10 mg/m2 for 3 days. The primary endpoint was remission rate after therapy. RESULTS Due to drug supply issues, the trial was suspended after the inclusion of seven eligible patients. There were six cases of early relapse within 1 year of the first remission. All seven patients completed the therapy and no early death was observed. Hematological toxicity was common, and one patient developed grade 4 non-hematological toxicity of bacterial meningitis. Although only one patient with late relapse achieved complete remission, minimal residual disease was positive on both flow cytometry and Wilms' tumor 1 mRNA. Two patients were alive in remission following hematopoietic stem cell transplantation, whereas the other five patients died of either the disease or treatment-related causes. CONCLUSION FLAG-IDA might be tolerable for children with refractory AML although the efficacy should be further investigated.
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Affiliation(s)
- Hideki Nakayama
- Department of Pediatrics, National Hospital Organization Kyushu Cancer Center, Fukuoka, Japan.,Department of Pediatrics, National Hospital Organization Fukuoka-Higashi Medical Center, Fukuoka, Japan.,Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Daisuke Tomizawa
- Division of Leukemia and Lymphoma, Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
| | - Shiro Tanaka
- Department of Clinical Biostatistics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shotaro Iwamoto
- Department of Pediatrics, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Akira Shimada
- Department of Pediatrics, Okayama University, Okayama, Japan
| | - Akiko M Saito
- Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Yuka Yamashita
- Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Hiroshi Moritake
- Department of Pediatrics, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Kiminori Terui
- Department of Pediatrics, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Takashi Taga
- Department of Pediatrics, Shiga University of Medical Science, Ohtsu, Japan
| | - Hidemasa Matsuo
- School of Human Health Science, Faculty of Medicine, Kyoto University, Kyoto, Japan
| | - Yoshiyuki Kosaka
- Department of Pediatric Hematology/Oncology, Hyougo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Katsuyoshi Koh
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Hajime Hosoi
- Department of Pediatrics, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | | | - Keiichi Isoyama
- Department of Pediatrics, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Keizo Horibe
- Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Shuki Mizutani
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Souichi Adachi
- School of Human Health Science, Faculty of Medicine, Kyoto University, Kyoto, Japan
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34
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Treated secondary acute myeloid leukemia: a distinct high-risk subset of AML with adverse prognosis. Blood Adv 2017; 1:1312-1323. [PMID: 29296774 DOI: 10.1182/bloodadvances.2017008227] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 06/14/2017] [Indexed: 12/20/2022] Open
Abstract
Secondary acute myeloid leukemia (s-AML) includes therapy-related AML and AML evolving from antecedent hematological disorder (AHD). s-AML arising after treating AHD likely represents a prognostically distinct, high-risk disease category. In this study, treated s-AML (ts-AML) was defined by: (1) prior diagnosis of myelodysplasia, myeloproliferative neoplasm, or aplastic anemia and (2) at least 1 therapy for that diagnosis. ts-AML was categorized by age (< or ≥60 years), and each cohort assessed for response rates and overall survival (OS) on various treatment regimens. Survival outcomes were compared against other high-risk prognostic subsets. Results showed that complete response and 8-week mortality rates were 32% and 27% in the younger, and 24% and 19% in the older age groups, respectively. There was a significant OS difference within s-AML based on prior treatment of AHD (ie, ts-AML vs s-AML with untreated AHD, 4.2 vs 9.2 months; P < .001). Survival in ts-AML was poor across both cohorts (younger and older, 5 and 4.7 months, respectively). In younger AML, survival was significantly inferior in ts-AML when compared with deletion 5/7, TP53, 3q abnormality, and therapy-related AML groups (median, 5 vs 7.9, 7.8, 7.9, and 11.2 months, respectively; P < .01). Additional adverse karyotype within ts-AML was associated with even worse outcomes (OS range, 1.6-2.8 months). ts-AML represents a very high-risk category, even in younger AML patients. s-AML should be further classified to describe ts-AML, an entity less responsive to currently applied treatment approaches. Future AML trial designs should accommodate ts-AML as a distinct subgroup.
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35
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Molteni A, Riva M, Ravano E, Marbello L, Mancini V, Grillo G, Zucchetti E, Greco R, Cairoli R. Clofarabine-based chemotherapy as a bridge to transplant in the setting of refractory or relapsed acute myeloid leukemia, after at least one previous unsuccessful salvage treatment containing fludarabine: a single institution experience. Int J Hematol 2017; 105:769-776. [PMID: 28220349 DOI: 10.1007/s12185-017-2198-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Revised: 02/05/2017] [Accepted: 02/06/2017] [Indexed: 11/25/2022]
Abstract
For refractory or relapsed acute myeloid leukemia patients, allogeneic hematopoietic stem cell transplantation is the only curative treatment option, but the disease must be in remission before this can be attempted. "Salvage" therapy regimens containing high-dose cytarabine plus fludarabine or cladribine with or without anthracyclines or plus mitoxantrone and etoposide fail in 30-50% of cases. We report the outcome of 14 patients treated with a clofarabine-based treatment administered after at least one failed fludarabine-based "salvage" attempt in a "real life" (outside a clinical trial) context. No death related to the clofarabine-based treatment was observed. Four of the 14 patients (29%) reached complete remission and one (7%) achieved a reduction of marrow blasts to fewer than 10%. Three of these five patients were successfully transplanted and have shown a long-term survival. The small number of this group of patients does not permit the identification of clinical features clearly related to a favorable outcome, but we note that all the three long-term survivals were FLT3 wild type. Clofarabine-based "salvage therapy" in patients with very poor expectancy is feasible even after a fludarabine-based salvage attempt, albeit with success only in a small percentage of cases (3/14 = 21%).
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Affiliation(s)
- Alfredo Molteni
- Hematology, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy.
| | - Marta Riva
- Hematology, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
| | - Emanuele Ravano
- Hematology, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
| | - Laura Marbello
- Hematology, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
| | - Valentina Mancini
- Hematology, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
| | - Giovanni Grillo
- Hematology, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
| | - Elisa Zucchetti
- Hematology, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
| | - Rosa Greco
- Hematology, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
| | - Roberto Cairoli
- Hematology, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
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36
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Law KB, Chang KM, Hamzah NA, Ng KH, Ong TC. Fludarabine, High Dose Cytarabine and Granulocyte Colony-Stimulating Factor (FLAG) as Consolidation Chemotherapy in Older Patients with Acute Myeloid Leukemia: A Retrospective Cohort Study. Indian J Hematol Blood Transfus 2017; 33:483-491. [PMID: 29075058 DOI: 10.1007/s12288-017-0790-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 02/06/2017] [Indexed: 11/30/2022] Open
Abstract
The study aimed to investigate the effect of consolidation treatment with fludarabine, high-dose cytarabine and granulocyte colony-stimulating factor or FLAG in older AML patients. The study included 41 eligible patients above 54 years old, who received both induction and consolidation chemotherapy for AML from 2008 to 2013. The study cohort had a minimum 24 months follow-up period. Survival analysis was carried out to assess patients' overall survival and disease free survival based on types of consolidation regimens. The consolidation treatment with FLAG exerted a protective effect to both overall survival and disease free survival in older patients. Patients who were consolidated with FLAG regimen had a significant longer overall survival (log-rank, p = 0.0025) and disease free survival (log-rank, p = 0.0026). The median overall survival was longer (18.70 months) with the use of FLAG when compared to non-FLAG group (8.09 months). The median disease free survival was also longer (13.84 months) with use of FLAG when compared to the non-FLAG group (4.44 months). Regression analysis with Cox model yielded hazard ratio of 0.245 (p = 0.0094) in overall survival and 0.217 (p = 0.0068) in disease free survival. The use of FLAG as consolidation treatment was associated with approximately 60-80% reduction in hazard rates. The result was adjusted for age, race and gender in regression analysis. Older AML patients had longer remission and survival when consolidated with FLAG regimen after the induction chemotherapy.
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Affiliation(s)
- Kian Boon Law
- Clinical Trial Unit, Level 7, Hospital Ampang, Jalan Mewah Utara, Pandan Mewah, 68000 Ampang, Selangor Malaysia.,Institute of Mathematical Sciences, Faculty of Science, University of Malaya, Kuala Lumpur, 50603 Malaysia
| | - Kian Meng Chang
- Department of Hematology, Hospital Ampang, Jalan Mewah Utara, Pandan Mewah, 68000 Ampang, Selangor Malaysia
| | - Nor Aishah Hamzah
- Institute of Mathematical Sciences, Faculty of Science, University of Malaya, Kuala Lumpur, 50603 Malaysia
| | - Kok Haur Ng
- Institute of Mathematical Sciences, Faculty of Science, University of Malaya, Kuala Lumpur, 50603 Malaysia
| | - Tee Chuan Ong
- Department of Hematology, Hospital Ampang, Jalan Mewah Utara, Pandan Mewah, 68000 Ampang, Selangor Malaysia
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Park H, Youk J, Kim I, Yoon SS, Park S, Lee JO, Bang SM, Koh Y. Comparison of cladribine- and fludarabine-based induction chemotherapy in relapsed or refractory acute myeloid leukaemia. Ann Hematol 2016; 95:1777-86. [PMID: 27539617 DOI: 10.1007/s00277-016-2774-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 07/29/2016] [Indexed: 01/09/2023]
Abstract
Induction regimens integrating cladribine or fludarabine have shown promising outcomes in relapsed or refractory (R/R) acute myeloid leukaemia (AML). We compared the outcome of a cladribine- versus a fludarabine-based regimen as induction chemotherapy for R/R-AML. We included patients with R/R-AML who were treated with a cladribine- or fludarabine-based chemotherapy between 2006 and 2015. We analysed 120 patients, 65 treated with cladribine and 55 treated with fludarabine. The CR rates were 62.7 and 61.4 % for the cladribine group and fludarabine group, respectively (p = 0.890). Poor prognostic factors included older age, secondary AML, poor cytogenetic risk group, prior induction failure, and short first CR duration. No significant overall survival (OS) or relapse-free survival (RFS) differences were found between the groups (OS, p = 0.213; RFS, p = 0.143). However, in a certain subset, survival outcomes were better with cladribine than with fludarabine, including de novo AML, CR at first induction therapy, and not-poor cytogenetic risk group inclusion without overt chemotherapy-refractoriness. By contrast, secondary AML patients had improved survival outcomes when treated with the fludarabine regimen. After CR, better outcomes were observed when allogeneic stem cell transplantation (SCT) was given as consolidation. In R/R-AML, cladribine- and fludarabine-based combination induction chemotherapy had differential survival outcomes according to disease characteristics. Allogeneic SCT after CR with a purine analogue-based regimen improved long-term outcome in these patients.
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Affiliation(s)
- Hyunkyung Park
- Department of Internal Medicine, Seoul National University Hospital, 101 Daehag-ro, Jongno-gu, Seoul, 110-744, Republic of Korea
| | - Jeonghwan Youk
- Department of Internal Medicine, Seoul National University Hospital, 101 Daehag-ro, Jongno-gu, Seoul, 110-744, Republic of Korea
| | - Inho Kim
- Department of Internal Medicine, Seoul National University Hospital, 101 Daehag-ro, Jongno-gu, Seoul, 110-744, Republic of Korea.,Cancer Research Institute, College of Medicine, Seoul National University, Seoul, Republic of Korea.,Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sung-Soo Yoon
- Department of Internal Medicine, Seoul National University Hospital, 101 Daehag-ro, Jongno-gu, Seoul, 110-744, Republic of Korea.,Cancer Research Institute, College of Medicine, Seoul National University, Seoul, Republic of Korea.,Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
| | - Seonyang Park
- Department of Internal Medicine, Seoul National University Hospital, 101 Daehag-ro, Jongno-gu, Seoul, 110-744, Republic of Korea.,Cancer Research Institute, College of Medicine, Seoul National University, Seoul, Republic of Korea.,Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jeong-Ok Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Soo-Mee Bang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Youngil Koh
- Department of Internal Medicine, Seoul National University Hospital, 101 Daehag-ro, Jongno-gu, Seoul, 110-744, Republic of Korea. .,Cancer Research Institute, College of Medicine, Seoul National University, Seoul, Republic of Korea. .,Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea.
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38
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Bergua JM, Montesinos P, Martinez-Cuadrón D, Fernández-Abellán P, Serrano J, Sayas MJ, Prieto-Fernandez J, García R, García-Huerta AJ, Barrios M, Benavente C, Pérez-Encinas M, Simiele A, Rodríguez-Macias G, Herrera-Puente P, Rodríguez-Veiga R, Martínez-Sánchez MP, Amador-Barciela ML, Riaza-Grau R, Sanz MA. A prognostic model for survival after salvage treatment with FLAG-Ida +/− gemtuzumab-ozogamicine in adult patients with refractory/relapsed acute myeloid leukaemia. Br J Haematol 2016; 174:700-10. [DOI: 10.1111/bjh.14107] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Accepted: 02/29/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Juan M. Bergua
- Department of Haematology; Hospital San Pedro de Alcántara; Cáceres Spain
| | - Pau Montesinos
- Department of Haematology; University Hospital La Fe; Valencia Spain
| | | | | | | | - María J. Sayas
- Department of Haematology; Hospital Doctor Peset; Valencia Spain
| | | | - Raimundo García
- Department of Haematology; General Hospital Castellón; Castellón Spain
| | | | - Manuel Barrios
- Department of Haematology; Hospital Carlos Haya; Málaga Spain
| | | | | | | | | | | | | | | | | | | | - Miguel A. Sanz
- Department of Haematology; University Hospital La Fe; Valencia Spain
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39
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Hütter-Krönke ML, Benner A, Döhner K, Krauter J, Weber D, Moessner M, Köhne CH, Horst HA, Schmidt-Wolf IGH, Rummel M, Götze K, Koller E, Petzer AL, Salwender H, Fiedler W, Kirchen H, Haase D, Kremers S, Theobald M, Matzdorff AC, Ganser A, Döhner H, Schlenk RF. Salvage therapy with high-dose cytarabine and mitoxantrone in combination with all-trans retinoic acid and gemtuzumab ozogamicin in acute myeloid leukemia refractory to first induction therapy. Haematologica 2016; 101:839-45. [PMID: 27036160 DOI: 10.3324/haematol.2015.141622] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2015] [Accepted: 03/24/2016] [Indexed: 12/29/2022] Open
Abstract
Outcome of patients with primary refractory acute myeloid leukemia remains unsatisfactory. We conducted a prospective phase II clinical trial with gemtuzumab ozogamicin (3 mg/m(2) intravenously on day 1), all-trans retinoic acid (45 mg/m(2) orally on days 4-6 and 15 mg/m(2) orally on days 7-28), high-dose cytarabine (3 g/m(2)/12 h intravenously on days 1-3) and mitoxantrone (12 mg/m(2) intravenously on days 2-3) in 93 patients aged 18-60 years refractory to one cycle of induction therapy. Primary end point of the study was response to therapy; secondary end points included evaluation of toxicities, in particular, rate of sinusoidal obstruction syndrome after allogeneic hematopoietic cell transplantation. Complete remission or complete remission with incomplete blood count recovery was achieved in 47 (51%) and partial remission in 10 (11%) patients resulting in an overall response rate of 61.5%; 33 (35.5%) patients had refractory disease and 3 patients (3%) died. Allogeneic hematopoietic cell transplantation was performed in 71 (76%) patients; 6 of the 71 (8.5%) patients developed moderate or severe sinusoidal obstruction syndrome after transplantation. Four-year overall survival rate was 32% (95% confidence interval 24%-43%). Patients responding to salvage therapy and undergoing allogeneic hematopoietic cell transplantation (n=51) had a 4-year survival rate of 49% (95% confidence intervaI 37%-64%). Patients with fms-like tyrosine kinase internal tandem duplication positive acute myeloid leukemia had a poor outcome despite transplantation. In conclusion, the described regimen is an effective and tolerable salvage therapy for patients who are primary refractory to one cycle of conventional intensive induction therapy. (clinicaltrials.gov identifier: 00143975).
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Affiliation(s)
| | - Axel Benner
- Division of Biostatistics, German Cancer Research Center, Heidelberg, Germany
| | - Konstanze Döhner
- Department of Internal Medicine III, University Hospital Ulm, Germany
| | - Jürgen Krauter
- Department of Oncology and Hematology, Klinikum Braunschweig, Germany Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Germany
| | - Daniela Weber
- Department of Internal Medicine III, University Hospital Ulm, Germany
| | - Margit Moessner
- Department of Internal Medicine III, University Hospital Ulm, Germany
| | | | - Heinz A Horst
- Department of Internal Medicine II, University Hospital Schleswig-Holstein Campus Kiel, Germany
| | | | - Mathias Rummel
- Department of Hematology/Oncology, University-hospital Giessen, Germany
| | - Katharina Götze
- Department of Internal Medicine III, Technical University of Munich, Germany
| | - Elisabeth Koller
- Department of Hematology/Oncology, Hanuschkrankenhaus, Wien, Austria
| | - Andreas L Petzer
- Department of Medical Oncology and Hematology, Krankenhaus der Barmherzigen Schwestern, Linz, Austria
| | - Hans Salwender
- Department of Hematology/Oncology, Asklepios Klinik Altona, Hamburg, Germany
| | - Walter Fiedler
- Department of Internal Medicine II, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Heinz Kirchen
- Department of Hematology/Oncology, Krankenhaus der Barmherzigen Brüder, Trier, Germany
| | - Detlef Haase
- Department of Hematology and Oncology, Georg-August-University Hospital of Göttingen, Germany
| | - Stephan Kremers
- Department of Hematology/Oncology, Caritas-Krankenhaus, Lebach, Germany
| | - Matthias Theobald
- Department of Medicine III, Johannes Gutenberg-University Mainz, Germany
| | - Axel C Matzdorff
- Department of Hematology/Oncology, Caritas-Krankenhaus, Saarbrücken, Germany
| | - Arnold Ganser
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Germany
| | - Hartmut Döhner
- Department of Internal Medicine III, University Hospital Ulm, Germany
| | - Richard F Schlenk
- Department of Internal Medicine III, University Hospital Ulm, Germany
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40
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How I treat refractory and early relapsed acute myeloid leukemia. Blood 2015; 126:319-27. [DOI: 10.1182/blood-2014-10-551911] [Citation(s) in RCA: 196] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Accepted: 04/02/2015] [Indexed: 12/19/2022] Open
Abstract
AbstractBetween 10% and 40% of newly diagnosed patients with acute myeloid leukemia (AML) do not achieve complete remission with intensive induction therapy and are therefore categorized as primary refractory or resistant. Few of these patients can be cured with conventional salvage therapy. They need to be evaluated regarding eligibility for allogeneic hematopoietic stem cell transplantation (HSCT) as this is currently the treatment with the highest probability of cure. To reduce the leukemia burden prior to transplantation, salvage chemotherapy regimens need to be employed. Whenever possible, refractory/relapsed patients should be enrolled in clinical trials as we do not have highly effective and standardized treatments for this situation. Novel therapies include tyrosine kinase inhibitors, small-molecule inhibitors (eg, for Polo-like kinase 1 and aminopeptidase), inhibitors of mutated isocitrate dehydrogenase (IDH) 1 and IDH2, antibody-based therapies, and cell-based therapies. Although the majority of these therapies are still under evaluation, they are likely to enter clinical practice rapidly as a bridge to transplant and/or in older, unfit patients who are not candidates for allogeneic HSCT. In this review, we describe our approach to refractory/early relapsed AML, and we discuss treatment options for patients with regard to different clinical conditions and molecular profiles.
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Hotinski AK, Lewis ID, Ross DM. Vosaroxin is a novel topoisomerase-II inhibitor with efficacy in relapsed and refractory acute myeloid leukaemia. Expert Opin Pharmacother 2015; 16:1395-402. [PMID: 25958926 DOI: 10.1517/14656566.2015.1044437] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Vosaroxin is a first-in-class anti-cancer quinolone that inhibits topoisomerase-II leading to cell cycle arrest and apoptosis. It has shown efficacy in a range of solid organ and haematopoietic tumours in vitro, and several clinical trials are underway or completed in the field of Acute Myeloid Leukaemia (AML). The treatment of relapsed and refractory AML is a clinical challenge, where long-term survival is rare without allogeneic haematopoietic stem cell transplantation. AREAS COVERED We review the data from the published clinical trials of vosaroxin, including the recently presented Phase III VALOR study. In combination with intermediate dose cytarabine, vosaroxin almost doubled complete response (CR) rates in relapsed and refractory AML compared with cytarabine alone, and prolonged median survival by 1.4 months. EXPERT OPINION Vosaroxin is a promising new agent in the treatment of AML, with the potential to improve CR rates in a high-risk group of patients with relapsed and refractory AML. However, higher CR rates have been associated with higher rates of treatment-related morbidity and mortality, especially in elderly/unfit patients. Maximising the potential of vosaroxin will therefore require the identification of patients most likely to benefit from vosaroxin-containing combination regimens.
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Affiliation(s)
- Anya K Hotinski
- Royal Adelaide Hospital, Leukaemia Fellow, SA Pathology , Adelaide, SA 5000 , Australia
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Fathi AT, Chen YB. Treatment of relapse of acute myeloid leukemia after allogeneic hematopoietic stem cell transplantation. Curr Hematol Malig Rep 2015; 9:186-92. [PMID: 24643311 DOI: 10.1007/s11899-014-0209-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Disease relapse remains a major cause of mortality for patients with acute myeloid leukemia (AML) undergoing allogeneic hematopoietic stem cell transplantation (HSCT). Historically, patients who experience disease relapse after HSCT have a dismal prognosis with very few long-term survivors. There is no standard treatment for patients in this situation given the variability in patient characteristics, disease biology, complications such as graft-vs.-host disease (GVHD) and infections, donor availability, and patient choice. Here, we discuss the current options for treatment of relapsed AML after HSCT including conventional chemotherapy, novel agents, donor leukocyte infusion, second allogeneic HSCT, and emerging therapies.
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Affiliation(s)
- Amir T Fathi
- Center for Leukemia, Massachusetts General Hospital, Zero Emerson Place, Suite 118, Boston, MA, 02114, USA,
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Schnetzke U, Fix P, Spies-Weisshart B, Schrenk K, Glaser A, Fricke HJ, La Rosée P, Hochhaus A, Scholl S. Efficacy and feasibility of cyclophosphamide combined with intermediate- dose or high-dose cytarabine for relapsed and refractory acute myeloid leukemia (AML). J Cancer Res Clin Oncol 2014; 140:1391-7. [PMID: 24728467 DOI: 10.1007/s00432-014-1666-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Accepted: 03/28/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Approximately, 70 % of adult patients with de novo acute myeloid leukemia (AML) achieve a complete remission (CR) while 10-20 % of AML are refractory to induction chemotherapy. Furthermore, a significant proportion of AML patients in CR will relapse during or after consolidation treatment. There is no evidence for a standard salvage regimen and most centers use a combination of an anthracycline and cytarabine (AraC). The aim of this study was to investigate the impact of two age-adjusted regimens containing AraC and cyclophosphamide applied for the treatment of relapsed or refractory AML. PATIENTS AND METHODS We retrospectively analyzed 60 patients (24 male, 36 female; median age 56 years) with relapsed or refractory AML who were treated with a combination of AraC and cyclophosphamide monocentrically between October 2000 and January 2013. Two different protocols containing either high-dose (hAC) or intermediate-dose cytarabin (iAC) have been applied dependent on age and performance status. RESULTS We demonstrate an overall response rate (CR + PR) induced by hAC and iAC of 56.7 %. Importantly, a complete remission rate (CR + CRp) of 52.2 % was found in patients who received the hAC regimen while only 8.8 % of patients achieved a CR following the iAC protocol (p < 0.001). The rate of refractory disease was 26.1 and 47.1 %, respectively. High-risk cytogenetics, i.e., a complex aberrant or monosomal karyotype had no effect on achievement of CR after hAC. In addition, there was no impact of activating FLT3 mutations on response to treatment according to the hAC regimen. In the cohort of patients treated with the iAC protocol, treatment-related mortality of 11.8 % within 60 days was observed but none of the patients who received the hAC regimen died within the first 2 months following chemotherapy. The toxicity profile was acceptable at both cytarabine dose levels. Importantly, 19 patients (82.6 %) of the hAC cohort underwent allogeneic hematopoietic stem cell transplantation (HSCT) as consecutive treatment. CONCLUSION The hAC regimen represents a promising therapeutic approach to induce a second CR in younger patients with relapsed or refractory AML prior to HSCT without using anthracyclines.
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Affiliation(s)
- Ulf Schnetzke
- Abteilung Hämatologie und Internistische Onkologie, Klinik für Innere Medizin II, Universitätsklinikum Jena, Erlanger Allee 101, 07747, Jena, Germany
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Chemomodulation of sequential high-dose cytarabine by fludarabine in relapsed or refractory acute myeloid leukemia: a randomized trial of the AMLCG. Leukemia 2013; 28:1001-7. [DOI: 10.1038/leu.2013.297] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Revised: 09/27/2013] [Accepted: 10/03/2013] [Indexed: 11/08/2022]
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El Rassi F, Arellano M. Update on optimal management of acute myeloid leukemia. CLINICAL MEDICINE INSIGHTS-ONCOLOGY 2013; 7:181-97. [PMID: 23997579 PMCID: PMC3748090 DOI: 10.4137/cmo.s8528] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Acute myeloid leukemia (AML) represents a malignant accumulation of immature myeloid cells in the marrow, presenting with impaired hematopoiesis and its attendant complications, including bleeding, infection, and organ infiltration. Chromosomal abnormalities remain the most powerful predictors of AML prognosis and help to identify a subgroup with favorable prognosis. However, the majority of AML patients who are not in the favorable category succumb to the disease. Therefore, better efforts to identify those patients who may benefit from more aggressive and investigational therapeutic approaches are needed. Newer molecular markers aim at better characterizing the large group of intermediate-risk patients and to identify newer targets for therapy. A group that has seen little improvement over the years is the older AML group, usually defined as age ≥ 60. Efforts to develop less intensive but equally efficacious therapy for this vulnerable population are underway.
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Affiliation(s)
- Fuad El Rassi
- Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
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Yu W, Mao L, Qian J, Qian W, Meng H, Mai W, Tong H, Tong Y, Jin J. Homoharringtonine in combination with cytarabine and aclarubicin in the treatment of refractory/relapsed acute myeloid leukemia: a single-center experience. Ann Hematol 2013; 92:1091-100. [PMID: 23595277 DOI: 10.1007/s00277-013-1758-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Accepted: 04/05/2013] [Indexed: 10/27/2022]
Abstract
To assess the efficacy and toxicity of HAA regimen (Homoharringtonine 4 mg/m(2)/day, days 1-3; cytarabine 150 mg/m(2)/day, days 1-7; aclarubicin 12 mg/m(2)/day, days 1-7) as a salvage therapy in the treatment of refractory and/or relapsed acute myeloid leukemia (AML), 46 patients with refractory and/or relapsed AML, median age 37 (16-65) years, participated in this clinical study. The median follow-up was 41 (10-86) months. Eighty percent of patients achieved complete remission (CR), and the first single course of re-induction HAA regimen resulted in CR rate of 76.1 %. The study protocol allowed two courses of induction. The CR rates of patients with favorable, intermediate and unfavorable cytogenetics were 90 %, 88.9 %, and 37.5 %, respectively. For all patients, the estimated 3-year overall survival (OS) rate was 42 %, and the estimated relapse free survival (RFS) at 3 years for the 36 CR cases was 49 %. The toxicities associated with HAA regimen were acceptable. HAA is a good choice in cases with refractory/relapsing AML for salvage chemotherapy, preferably with a high-efficacy and low-toxicity profile.
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Affiliation(s)
- Wenjuan Yu
- Department of Hematology, the First Affiliated Hospital, Zhejiang University College of Medicine, No. 79 Qingchun Road, Hangzhou, Zhejiang, People's Republic of China
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Mangan JK, Luger SM. Salvage therapy for relapsed or refractory acute myeloid leukemia. Ther Adv Hematol 2013; 2:73-82. [PMID: 23556078 DOI: 10.1177/2040620711402533] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
There are a significant number of patients diagnosed with acute leukemia who either fail to achieve remission or who relapse thereafter. Challenges in treating this patient population include accurately assessing prognosis of disease and whether remission can be achieved; assessing the ability of patients to tolerate aggressive salvage therapies; choosing a salvage therapy that is most likely to succeed; and identifying suitable patients for hematopoietic stem cell transplantation. Despite the development of a variety of new investigational therapies, relapsed or refractory acute myeloid Leukemia remains a difficult clinical problem. Clinicians will need to consider all currently available approaches, including cytotoxic chemotherapy, targeted agents, and allogeneic stem cell transplantation, to optimize outcomes.
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Affiliation(s)
- James K Mangan
- Division of Hematology-Oncology, Department of Internal Medicine, and Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Luo S, Cai F, Jiang L, Zhang S, Shen Z, Sun L, Gao S. Clinical study of Mito-FLAG regimen in treatment of relapsed acute myeloid leukemia. Exp Ther Med 2013; 5:982-986. [PMID: 23407597 PMCID: PMC3570250 DOI: 10.3892/etm.2013.917] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2012] [Accepted: 01/18/2013] [Indexed: 11/21/2022] Open
Abstract
Patients with relapsed acute myeloid leukemia (AML) have unfavorable prognosis and require innovative therapeutic approaches. In this study we used fludarabine combined with a middle dose of cytosine arabinoside (Ara-C), mitoxantrone and granulocyte-colony stimulating factor (G-CSF) as a salvage therapy for patients with relapsed AML in China. Forty-five patients with relapsed AML were treated with the Mito-FLAG regimen consisting of mitoxantrone (7 mg/m2, day 1, 3 and 5), fludarabine (30 mg/m2, days 1–5), Ara-C (1 g/m2, over 3 h every 12 h, days 1–5) and G-CSF [5 μg/kg/day subcutaneously from day 0 until the white blood count (WBC) was >20×109/l]. Patients with a partial response (PR) received another course of the same regimen. Patients with a suitable donor and aged <50 years received allogeneic stem cell transplantation (allo-SCT). Twenty-three patients (51%) and 3 patients (7%) achieved complete remission (CR) and PR, respectively, following one or two courses of Mito-FLAG, and the overall response (OR) rate was 58%. Nine patients (20%) received allo-SCT and 4 patients (9%) succumbed early. Hematological toxicity and infections were the most prominent toxicities of this regimen. Other toxicities included nausea, vomiting, bleeding, hyperbilirubinemia, renal toxicity and arrhythmia. The probability of overall survival (OS) at 4 years was 19% (95% CI, 11–26%) and the probability of 4-year disease-free survival (DFS) was 29% for all 23 patients in CR (95% CI, 18–41%). Our data suggest that Mito-FLAG is a highly effective and well-tolerated salvage regimen for relapsed AML.
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Affiliation(s)
- Sheng Luo
- Department of Hematology, The First Affiliated Hospital of Wenzhou Medical College, Wenzhou, Zhejiang 325000, P.R. China
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