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Iemura T, Kondo T, Ueda A, Maeda T, Kitawaki T, Arai Y, Kanda J, Ikeda T, Imada K, Ishikawa T, Anzai N, Itoh M, Takeoka T, Akasaka T, Yago K, Yonezawa A, Arima N, Kitano T, Nohgawa M, Watanabe M, Moriguchi T, Yamashita K, Ueda Y, Matsumoto K, Takaori-Kondo A. Effects of combined test dose and therapeutic drug monitoring strategy in exposure-directed busulfan. Ann Hematol 2023; 102:2909-2922. [PMID: 37052663 DOI: 10.1007/s00277-023-05209-2] [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: 11/11/2022] [Accepted: 04/01/2023] [Indexed: 04/14/2023]
Abstract
Although exposure-directed busulfan (BU) dosing can improve allogeneic hematopoietic stem cell transplantation outcomes, there is still large variability in BU exposure with test dose alone due to changes in BU clearance caused by drug interactions. We conducted a single-arm phase II trial using the combined test dose and therapeutic drug monitoring strategy (PK-guided group) and compared the outcomes with an external historical cohort receiving a fixed-dose (fixed-dose group). The first eight and second eight doses were adjusted based on the area under the blood concentration-time curve (AUC) of the test and first doses, respectively, targeting a total AUC of 82.1 mg·h/L. All patients received either BU and cyclophosphamide conditioning (BU/CY) or fludarabine (FLU)-containing conditioning. The BU clearance at the first dose decreased more in patients receiving FLU than in those receiving BU/CY; however, BU clearance also declined over time in patients who received BU/CY. The simulated total AUC (sAUC) with test dose only was significantly higher in patients who received FLU than in those who received BU/CY, but sAUC with the combined strategy was comparable. The 100-day progression-free survival was 85.5% (95% confidence interval [CI]: 71.9-92.8%), and was not inferior to that in the fixed-dose group. For the FLU-containing regimens, the PK-guided group showed decreased relapse (0.0% vs. 26.9%, p = 0.03), and favorable overall survival (75.1% vs. 57.0%, p = 0.07) at 1 year. The combined strategy effectively controlled the BU exposure close to the target levels, potentially improving efficacy, especially in patients receiving the FLU-containing regimen. Clinical evaluation of efficacy of dose-modified intravenous busulfan in allogeneic hematopoietic stem cell transplantation for hematological malignancy (#UMIN000014077, June 15th, 2014).
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Affiliation(s)
- Tomoki Iemura
- Department of Hematology and Oncology, Kyoto University, 54, Shogoin Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Tadakazu Kondo
- Department of Hematology and Oncology, Kyoto University, 54, Shogoin Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan.
| | - Atsushi Ueda
- Department of Hematology, Kurashiki Central Hospital, Okayama, Japan
| | - Takeshi Maeda
- Department of Hematology, Kurashiki Central Hospital, Okayama, Japan
| | - Toshio Kitawaki
- Department of Hematology and Oncology, Kyoto University, 54, Shogoin Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Yasuyuki Arai
- Department of Hematology and Oncology, Kyoto University, 54, Shogoin Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
- Department of Clinical Laboratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Junya Kanda
- Department of Hematology and Oncology, Kyoto University, 54, Shogoin Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Takashi Ikeda
- Division of Hematology and Stem Cell Transplantation, Shizuoka Cancer Center, Shizuoka, Japan
| | - Kazunori Imada
- Department of Hematology, Japanese Red Cross Osaka Hospital, Osaka, Japan
| | - Takayuki Ishikawa
- Department of Hematology, Kobe City Medical Center General Hospital, Hyogo, Japan
| | - Naoyuki Anzai
- Department of Hematology, Takatsuki Red Cross Hospital, Osaka, Japan
| | - Mitsuru Itoh
- Department of Hematology, Kyoto City Hospital, Kyoto, Japan
| | - Tomoharu Takeoka
- Department of Hematology, Japan Red Cross Otsu Hospital, Shiga, Japan
| | | | - Kazuhiro Yago
- Department of Hematology, Shizuoka General Hospital, Shizuoka, Japan
| | - Akihito Yonezawa
- Department of Hematology, Kokura Memorial Hospital, Fukuoka, Japan
| | | | | | - Masaharu Nohgawa
- Department of Hematology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Mitsumasa Watanabe
- Department of Hematology, Hyogo Prefectural Amagasaki General Medical Center, Hyogo, Japan
| | | | - Kouhei Yamashita
- Department of Hematology and Oncology, Kyoto University, 54, Shogoin Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Yasunori Ueda
- Department of Hematology, Kurashiki Central Hospital, Okayama, Japan
| | - Kana Matsumoto
- Department of Clinical Pharmaceutics, Faculty of Pharmaceutical Sciences, Doshisha Women's College of Liberal Arts, Kyoto, Japan
| | - Akifumi Takaori-Kondo
- Department of Hematology and Oncology, Kyoto University, 54, Shogoin Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
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Tomizawa D. Evolution and optimization of therapies for acute lymphoblastic leukemia in infants. Int J Hematol 2023; 117:162-172. [PMID: 36441356 DOI: 10.1007/s12185-022-03502-w] [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: 10/18/2022] [Revised: 11/21/2022] [Accepted: 11/22/2022] [Indexed: 11/29/2022]
Abstract
Acute lymphoblastic leukemia (ALL) in infants accounts for less than 5% of pediatric ALL and is biologically and clinically unique. Approximately 70% to 80% of cases present as an aggressive leukemia with KMT2A gene rearrangement (KMT2A-r), which is one of the most difficult-to-cure forms of pediatric leukemia. Owing to continuing global efforts through multicenter clinical trials since the mid-1990s, a standard of care for infant KMT2A-r ALL, including minimal residual disease-based risk stratifications, "hybrid chemotherapy" incorporating myeloid leukemia-like drugs (e.g., cytarabine) into the ALL chemotherapy backbone, and selective use of allogeneic hematopoietic stem cell transplantation, has now been established. However, there are still many concerns regarding treatment of infants with KMT2A-r ALL, including insufficient efficacy of the current standard therapies, limited pharmacokinetic/pharmacodynamic data on drugs in infants, and management of both acute and late toxicities. Refinements in risk stratification based on leukemia biology, as well as the introduction of emerging novel immunotherapies and molecular-targeted drugs to contemporary therapy, through international collaboration would provide key solutions for further improvement in outcomes.
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Affiliation(s)
- Daisuke Tomizawa
- Division of Leukemia and Lymphoma, Children's Cancer Center, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-Ku, Tokyo, 157-8535, Japan.
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Alatrash G, Saberian C, Bassett R, Thall PF, Ledesma C, Lu Y, Daher M, Valdez BC, Kawedia J, Popat U, Mehta R, Oran B, Nieto Y, Olson A, Anderlini P, Marin D, Hosing C, Alousi AM, Shpall EJ, Rondon G, Chen J, Qazilbash M, Champlin RE, Andersson BS, Kebriaei P. Vorinostat combined with Busulfan, Fludarabine, and Clofarabine Conditioning Regimen for Allogeneic Hematopoietic Stem Cell Transplantation in Patients with Acute Leukemia: Long-term Study Outcomes. Transplant Cell Ther 2022; 28:501.e1-501.e7. [DOI: 10.1016/j.jtct.2022.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 04/15/2022] [Accepted: 05/14/2022] [Indexed: 11/30/2022]
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Takachi T, Arakawa Y, Nakamura H, Watanabe T, Aoki Y, Ohshima J, Takahashi Y, Hirayama M, Miyamura T, Sugita K, Koh K, Horibe K, Ishii E, Mizutani S, Tomizawa D. Personalized pharmacokinetic targeting with busulfan in allogeneic hematopoietic stem cell transplantation in infants with acute lymphoblastic leukemia. Int J Hematol 2019; 110:355-363. [PMID: 31201644 DOI: 10.1007/s12185-019-02684-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 05/29/2019] [Accepted: 05/30/2019] [Indexed: 01/22/2023]
Abstract
Individual busulfan (BU) dosing based on pharmacokinetic (PK) data is preferable for hematopoietic stem cell transplantation (HSCT) conditioning, but information on BU PK in infants is scarce. We report BU PK data on HSCT conditioning for infants with KMT2A-gene-rearrangement-positive acute lymphoblastic leukemia (MLL-r ALL). Infants showed wide variation in BU PK indices, such as clearance (CL) and volume of distribution (Vd) value, which are distributed more widely among those who received oral, rather than intravenous (IV), BU. Because the steady state concentration (Css) fluctuates readily in infants, dose re-adjustment based on PK at the initial administration was important even if the initial dose was determined by a PK test. HSCT can be performed safely within the Css range of 600-900 ng/mL per dose, although it was difficult to fit within the therapeutic index of BU. The clinical outcome of engraftment, graft-versus-host disease, adverse events, including sinusoidal obstruction syndrome, and survival did not correlate with the BU PK data, which paradoxically suggests that remaining within this Css range helped minimize transplant-related toxicities, while securing engraftment in infants with MLL-r ALL.
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Affiliation(s)
- Takayuki Takachi
- Department of Hematology and Oncology, Shizuoka Children's Hospital, Shizuoka, Japan.,Clinical Research Center, National Hospital Organization, Nagoya Medical Center, Nagoya, Japan
| | - Yuki Arakawa
- Department of Hematology and Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Hiroyoshi Nakamura
- Department of Pharmacy, Chiba University Hospital, Chiba, Japan.,International University of Health and Welfare Mita Hospital, Tokyo, Japan
| | - Tomoyuki Watanabe
- Department of Nutrition and Health, Faculty of Psychological and Physical Science, Aichi Gakuin University, Nisshin, Japan
| | - Yuki Aoki
- Department of Pediatric Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Junjiro Ohshima
- Department of Hematology/Oncology for Children and Adolescents, Sapporo Hokuyu Hospital, Sapporo, Japan
| | - Yoshihiro Takahashi
- Department of Pediatrics, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Masahiro Hirayama
- Department of Pediatrics, Mie University Graduate School of Medicine, Tsu, Japan
| | - Takako Miyamura
- Department of Pediatrics, Osaka University Graduate School of Medicine, Suita, Japan
| | - Kanji Sugita
- Department of Pediatrics, Faculty of Medicine, University of Yamanashi, Chuo, Japan
| | - Katsuyoshi Koh
- Department of Hematology and Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Keizo Horibe
- Clinical Research Center, National Hospital Organization, Nagoya Medical Center, Nagoya, Japan
| | - Eiichi Ishii
- Department of Pediatrics, Ehime University Graduate School of Medicine, Toon, Japan
| | - Shuki Mizutani
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Daisuke Tomizawa
- Division of Leukemia and Lymphoma, Children's Cancer Center, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan.
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Chevallier P, Peterlin P, Garnier A, Le Bourgeois A, Mahé B, Dubruille V, Blin N, Touzeau C, Gastinne T, Lok A, Le Bris Y, Béné MC, Le Gouill S, Moreau P, Guillaume T. Clofarabine-based reduced intensity conditioning regimen with peripheral blood stem cell graft and post-transplant cyclophosphamide in adults with myeloid malignancies. Oncotarget 2018; 9:33528-33535. [PMID: 30323896 PMCID: PMC6173357 DOI: 10.18632/oncotarget.26083] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 08/04/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The Baltimore reduced-intensity conditioning (RIC) regimen using high-dose post-transplant cyclophosphamide (PTCY) is considered as a standard of care for haploidentical allogeneic stem cell transplantation (allo-SCT). However, it is associated with relatively low survivals and high incidence of relapse, especially when considering myeloid malignancies. RESULTS This retrospective study included 36 adults (males n = 18; median age: 60.5 years old; haplodonors n = 27; matched donors n = 8) with myeloid malignancies transplanted between March 2014 and March 2017 at the University Hospital of Nantes. Very encouraging results were observed with a 18-month overall survival (OS), disease-free survival (DFS) and relapse incidence (RI) of 72% ± 7.5%, 63.8 ± 8%, and 25 ± 6% respectively, and a GVHD relapse-free survival (GRFS) of 52.6 ± 8%. In univariate analysis, there were no differences regarding 18-month survivals between patients allografted: i) for acute myeloid leukemia vs myelodysplastic syndrome (OS 70 ± 11% vs 69.2 ± 13%, p = 0.3; DFS 64.7 ± 11% vs 61.5 ± 13%, p = 0.65), or ii) with haplo-identical vs other donors (OS: 66.2 ± 9% vs 88.8 ± 10.4%, p = 0.16; DFS 59 ± 9.5% vs 77.8%, p = 0.6). CONCLUSION The "Clo-Baltimore regimen" is safe and feasible and provides good survivals for patients with myeloid malignancies and haplo-donors. METHODS Here, we report a variant of the Baltimore regimen, where 1) fludarabine was replaced by clofarabine, 2) bone marrow was replaced by peripheral blood stem cells, and 3) tacrolimus was replaced by cyclosporine, in a "Clo-Baltimore regimen".
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Affiliation(s)
| | | | - Alice Garnier
- Hematology Department, CHU Hotel-Dieu, Nantes, France
| | | | - Beatrice Mahé
- Hematology Department, CHU Hotel-Dieu, Nantes, France
| | | | - Nicolas Blin
- Hematology Department, CHU Hotel-Dieu, Nantes, France
| | | | | | - Anne Lok
- Hematology Department, CHU Hotel-Dieu, Nantes, France
| | - Yannick Le Bris
- Hematology/Biology Laboratory, CHU Hotel-Dieu, Nantes, France
| | - Marie C. Béné
- Hematology/Biology Laboratory, CHU Hotel-Dieu, Nantes, France
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Clofarabine followed by haploidentical stem cell transplant using fludarabine, busulfan, and total-body irradiation with post-transplant cyclophosphamide in non-remission AML. Int J Hematol 2018. [PMID: 29542029 DOI: 10.1007/s12185-018-2431-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Approximately 30-40% of patients with acute myeloid leukemia (AML) experience induction failures. In these patients who do not achieve remission with two cycles of standard induction therapies, the probability of achieving remission with subsequent inductions is very limited. Hematopoietic stem cell transplantation (HSCT) is the only curative option for these patients, but high relapse rate and transplant-related mortality often preclude them to proceed to transplant. Thus, AML not in remission at time of HSCT remains a huge unmet need in current HSCT practice, particularly if the patient does not have an HLA-matched donor identified by the time of two induction failures. We used clofarabine cytoreduction immediately followed by fludarabine (Flu) and busulfan (Bu) × 3 with total-body irradiation (TBI) conditioning (Flu/Bu3/TBI) for haploidentical peripheral blood stem cell transplant with post-transplant cyclophosphamide for two cases of refractory AML with a very high tumor burden at transplant and achieved complete remission by day + 30 in both cases.
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