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Extermann M, Artz A, Rebollo MA, Klepin HD, Krug U, Loh KP, Mims AS, Neuendorff N, Santini V, Stauder R, Vey N. Treating acute myelogenous leukemia in patients aged 70 and above: Recommendations from the International Society of Geriatric Oncology (SIOG). J Geriatr Oncol 2024; 15:101626. [PMID: 37741771 DOI: 10.1016/j.jgo.2023.101626] [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: 02/23/2023] [Revised: 08/28/2023] [Accepted: 09/06/2023] [Indexed: 09/25/2023]
Abstract
Acute myeloid leukemia (AML) treatment is challenging in older patients. There is a lack of evidence-based recommendations for older patients ≥70, a group largely underrepresented in clinical trials. With new treatment options being available in recent years, recommendations are needed for these patients. As such the International Society of Geriatric Oncology (SIOG) assembled a task force to review the evidence specific to treatment and outcomes in this population of patients ≥70 years. Six questions were selected by the expert panel in domains of (1) baseline assessment, (2) frontline therapy, (3) post-remission therapy, (4) treatment for relapse, (5) targeted therapies, and (6) patient reported outcome/function and enhancing treatment tolerance. Information from current literature was extracted, combining evidence from systematic reviews/meta-analyses, decision models, individual trials targeting these patients, and subgroup data. Accordingly, recommendations were generated using a GRADE approach upon reviewing current evidence by consensus of the whole panel. It is our firm recommendation and hope that direct evidence should be generated for patients aged ≥70 as a distinct group in high need of improvement of their survival outcomes. Such studies should integrate information from a geriatric assessment to optimize external validity and outcomes.
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Affiliation(s)
- Martine Extermann
- Senior Adult Oncology Program, Moffitt Cancer Center, Tampa, FL, USA.
| | - Andrew Artz
- Division of Leukemia, Department of Hematology & Hematopoietic Cell Transplantation, City of Hope, Duarte, CA, USA
| | - Maite Antonio Rebollo
- Institut Català d'Oncologia, Oncohematogeriatrics Unit, L'Hospitalet de Llobregat, Spain
| | - Heidi D Klepin
- Wake Forest University School of Medicine, Department of Internal Medicine, Section on Hematology and Oncology, Winston-Salem, NC, USA
| | - Utz Krug
- Klinikum Leverkusen, Department of Medicine 3, Leverkusen, Germany
| | - Kah Poh Loh
- University of Rochester Medical Center, Department of Medicine, Division of Hematology and Oncology, James P. Wilmot Cancer Institute, Rochester, NY, USA
| | - Alice S Mims
- The Ohio State University Wexner Medical Center, Department of Internal Medicine, Columbus, OH, USA
| | - Nina Neuendorff
- University Hospital Essen, Department of Hematology and Stem-Cell Transplantation, Essen, Germany
| | - Valeria Santini
- MDS Unit, AOUC, Hematology, University of Florence, Florence, Italy
| | - Reinhard Stauder
- Department of Internal Medicine V (Hematology Oncology), Innsbruck Medical University, Innsbruck, Austria
| | - Norbert Vey
- Aix-Marseille University, Institut Paoli-Calmettes, Hematology Department, Marseille, France
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2
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Appelbaum JS, Wei AH, Mandrekar SJ, Tiong IS, Chua CC, Teh TC, Fong CY, Ting SB, Weber D, Benner A, Hill H, Saadati M, Yin J, Stone RM, Garcia-Manero G, Erba HP, Uy GL, Marcucci G, Larson RA, Thomas A, Freeman SD, Almuina NM, Döhner K, Thomas I, Russel NH, Döhner H, Othus M, Estey EH, Walter RB. Clinical evaluation of complete remission (CR) with partial hematologic recovery (CRh) in acute myeloid leukemia: a report of 7235 patients from seven cohorts. Leukemia 2024; 38:389-392. [PMID: 38263433 PMCID: PMC10996038 DOI: 10.1038/s41375-024-02143-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 01/05/2024] [Accepted: 01/08/2024] [Indexed: 01/25/2024]
Affiliation(s)
- Jacob S Appelbaum
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Division of Hematology and Oncology, University of Washington, Seattle, WA, USA
- Seattle Children's Therapeutics, Seattle Children's Hospital, Seattle, WA, USA
| | - Andrew H Wei
- Department of Clinical Haematology, Peter MacCallum Cancer Centre, and Royal Melbourne Hospital, Melbourne, VIC, Australia
- Division of Blood Cells and Blood Cancer, Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia
| | - Sumithra J Mandrekar
- Department of Quantitative Health Sciences, Alliance Statistics and Data Management Center, Mayo Clinic, Rochester, MN, USA
| | - Ing S Tiong
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- The Malignant Haematology, Transplantation and Cellular Therapies Service, Alfred Hospital, Melbourne, VIC, Australia
- Australasia Leukaemia and Lymphoma Group (ALLG), Richmond, VIC, Australia
| | - Chong Chyn Chua
- The Malignant Haematology, Transplantation and Cellular Therapies Service, Alfred Hospital, Melbourne, VIC, Australia
- Australasia Leukaemia and Lymphoma Group (ALLG), Richmond, VIC, Australia
- Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia
- Department of Haematology, Northern Hospital, Melbourne, VIC, Australia
| | - Tse-Chieh Teh
- The Malignant Haematology, Transplantation and Cellular Therapies Service, Alfred Hospital, Melbourne, VIC, Australia
- Department of Haematology, Eastern Health, Box Hill, VIC, Australia
| | | | - Stephen B Ting
- Eastern Health, Box Hill Hospital and Monash University, Melbourne, VIC, Australia
| | - Daniela Weber
- Department of Internal Medicine III, Ulm University Hospital, Ulm, Germany
| | - Axel Benner
- Division of Biostatistics, German Cancer Research Center, Heidelberg, Germany
| | - Hannah Hill
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Maral Saadati
- Freelance Statistician, Saadati Solutions, Ladenburg, Germany
| | - Jun Yin
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, Tampa, FL, USA
| | - Richard M Stone
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | | | | | - Geoffrey L Uy
- Washington University School of Medicine, St. Louis, MO, USA
| | - Guido Marcucci
- City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | | | - Abin Thomas
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Sylvie D Freeman
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | | | - Konstanze Döhner
- Department of Internal Medicine III, Ulm University Hospital, Ulm, Germany
| | - Ian Thomas
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Nigel H Russel
- School of Medicine, Nottingham University, Nottingham, UK
| | - Hartmut Döhner
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Megan Othus
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, WA, USA.
| | | | - Roland B Walter
- Translational Science and Therapeutics Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Department of Medicine, Division of Hematology and Oncology, University of Washington, Seattle, WA, USA
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
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3
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Wijnen NE, Koedijk JB, Klein K, Luesink M, Goemans BF, Zwaan CM, Kaspers GJL. Treating CD33-Positive de novo Acute Myeloid Leukemia in Pediatric Patients: Focus on the Clinical Value of Gemtuzumab Ozogamicin. Onco Targets Ther 2023; 16:297-308. [PMID: 37153641 PMCID: PMC10155714 DOI: 10.2147/ott.s263829] [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: 02/17/2023] [Accepted: 04/20/2023] [Indexed: 05/10/2023] Open
Abstract
Although survival in pediatric acute myeloid leukemia (AML) has increased considerably over the past decades, refractory disease and relapse rates remain high. Refractory and relapsed disease are difficult to treat, with overall survival rates less than 40-50%. Preventing relapse should, therefore, be one of the highest priorities. Current conventional chemotherapy regimens are hard to intensify due to associated toxic complications, hence more effective therapies that do not increase toxicity are needed. A promising targeted agent is the CD33-directed antibody-drug conjugate gemtuzumab ozogamicin (GO). Because CD33 is highly expressed on leukemic cells in the majority of AML patients, GO can be useful for a broad range of patients. Better relapse-free survival (RFS) after therapy including GO has been reported in several pediatric clinical trials; however, ambiguity about the clinical value of GO in newly diagnosed children remains. Treatment with GO in de novo AML patients aged ≥1 month, in combination with standard chemotherapy is approved in the United States, whereas in Europe, GO is only approved for newly diagnosed patients aged ≥15 years. In this review, we aimed to clarify the clinical value of GO for treatment of newly diagnosed pediatric AML patients. Based on current literature, GO seems to have additional value, in terms of RFS, and acceptable toxicity when used in addition to chemotherapy during initial treatment. Moreover, in KMT2A-rearranged patients, the clinical value of GO was even more evident. Also, we addressed predictors of response, being CD33 expression and SNPs, PgP-1 and Annexin A5. The near finalized intent-to-file clinical trial in the MyeChild consortium investigates whether fractionated dosing has additional value for pediatric AML, which may pave the way for a broader application of GO in pediatric AML.
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Affiliation(s)
- Noa E Wijnen
- Pediatric Hemato-Oncology, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Department of Pediatric Oncology, Emma Children’s Hospital, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
- Correspondence: Noa E Wijnen, Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, Utrecht, 3584 CS, the Netherlands, Tel +31(0)889727272, Email
| | - Joost B Koedijk
- Pediatric Hemato-Oncology, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Department of Pediatric Oncology, Erasmus MC-Sophia Children’s Hospital, Rotterdam, the Netherlands
| | - Kim Klein
- Pediatric Hemato-Oncology, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Wilhelmina Children’s Hospital/University Medical Center, Utrecht, the Netherlands
| | - Maaike Luesink
- Pediatric Hemato-Oncology, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Bianca F Goemans
- Pediatric Hemato-Oncology, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - C Michel Zwaan
- Pediatric Hemato-Oncology, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Department of Pediatric Oncology, Erasmus MC-Sophia Children’s Hospital, Rotterdam, the Netherlands
| | - Gertjan J L Kaspers
- Pediatric Hemato-Oncology, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Department of Pediatric Oncology, Emma Children’s Hospital, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
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Dillon R, Maycock S, Jackson A, Fox S, Freeman S, Craddock C, Thomas C, Homer E, Leahy J, Mamwell A, Potter N, Russell N, Wei A, Ommen HB, Hemmaway C, Knapper S, Billingham L. Venetoclax combined with low dose cytarabine compared to standard of care intensive chemotherapy for the treatment of favourable risk adult acute myeloid leukaemia (VICTOR): Study protocol for an international, open-label, multicentre, molecularly-guided randomised, phase II trial. BMC Cancer 2022; 22:1174. [PMID: 36376888 PMCID: PMC9664612 DOI: 10.1186/s12885-022-10221-2] [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: 06/13/2022] [Accepted: 10/24/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND For patients with acute myeloid leukaemia (AML), the only potentially curative treatment is intensive chemotherapy (IC). This is highly toxic, particularly for patients > 60 years, potentially leading to prolonged hospitalisations requiring intensive supportive care, and sometimes treatment-related death. This also results in extensive healthcare costs and negatively impacts quality of life (QoL). Venetoclax with low-dose cytarabine (VEN + LDAC) is a novel, low-intensity treatment for AML patients who cannot receive IC. VEN + LDAC is given as an outpatient and toxicity appears significantly lower than with IC. Analysis of clinical trials performed to date are promising for patients with the genotype NPM1mutFLT3 ITDneg, where remission and survival rates appear comparable to those achieved with IC. METHODS VICTOR is an international, two-arm, open-label, multi-centre, non-inferiority, randomised-controlled phase II trial to assess VEN + LDAC compared to standard of care (IC) as first-line treatment in older patients (initially aged ≥ 60 years) with newly diagnosed AML. The trial will recruit patients with a NPM1mutFLT3 ITDneg genotype; those with a favourable risk in relation to the experimental treatment. University of Birmingham is the UK co-ordinating centre, with national hubs in Aarhus University Hospital, Denmark, and Auckland District Health Board, New Zealand. The primary outcome is molecular event-free survival time where an event is defined as failure to achieve morphological complete response (CR) or CR with incomplete blood count recovery after two cycles of therapy; molecular persistence, progression or relapse requiring treatment change; morphological relapse, or; death. Secondary outcomes include cumulative resource use at 12- and 24-months, and QoL as assessed by EORTCQLQ-C30 and EQ-5D-3L at 3-, 6-, 12-, 18- and 24-months. The trial employs an innovative Bayesian design with target sample size of 156 patients aged > 60 years. DISCUSSION The principle underpinning the VICTOR trial is that the chance of cure for patients in the experimental arm should not be compromised, therefore, an adaptive design with regular checks on accumulating data has been employed, which will allow for a staged expansion of the trial population to include younger patients if, and when, there is sufficient evidence of non-inferiority in older patients. TRIAL REGISTRATION EudraCT: 2020-000,273-24; 21-Aug-2020. ISRCTN 15,567,173; 08-Dec-2020.
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Affiliation(s)
- Richard Dillon
- Department of Medical and Molecular Genetics, King's College London, London, UK.
- Department of Clinical Haematology, Guy's and St Thomas' National Health Service (NHS) Foundation Trust, London, UK.
| | - Shanna Maycock
- Cancer Research UK Clinical Trials Unit (CRCTU), University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Aimee Jackson
- Cancer Research UK Clinical Trials Unit (CRCTU), University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Sonia Fox
- Cancer Research UK Clinical Trials Unit (CRCTU), University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Sylvie Freeman
- Clinical Immunology Service, Institute of Immunology and Immunotherapy, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
- Centre for Clinical Haematology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Charles Craddock
- Cancer Research UK Clinical Trials Unit (CRCTU), University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
- Centre for Clinical Haematology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Catherine Thomas
- Cancer Research UK Clinical Trials Unit (CRCTU), University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Emma Homer
- Cancer Research UK Clinical Trials Unit (CRCTU), University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | | | | | - Nicola Potter
- Department of Medical and Molecular Genetics, King's College London, London, UK
| | - Nigel Russell
- School of Medicine, Clinical Sciences Building, The University of Nottingham, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1PB, UK
| | - Andrew Wei
- Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne. VIC 3000, Australia
| | - Hans Beier Ommen
- Department of Hematology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus C, Denmark
| | - Claire Hemmaway
- Department of Haematology, Auckland City Hospital, Auckland, New Zealand
| | - Steve Knapper
- Institute of Cancer and Genetics, School of Medicine, Cardiff University, Cardiff, CF14 4XN, UK
| | - Lucinda Billingham
- Cancer Research UK Clinical Trials Unit (CRCTU), University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
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5
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Tazi Y, Arango-Ossa JE, Zhou Y, Bernard E, Thomas I, Gilkes A, Freeman S, Pradat Y, Johnson SJ, Hills R, Dillon R, Levine MF, Leongamornlert D, Butler A, Ganser A, Bullinger L, Döhner K, Ottmann O, Adams R, Döhner H, Campbell PJ, Burnett AK, Dennis M, Russell NH, Devlin SM, Huntly BJP, Papaemmanuil E. Unified classification and risk-stratification in Acute Myeloid Leukemia. Nat Commun 2022; 13:4622. [PMID: 35941135 PMCID: PMC9360033 DOI: 10.1038/s41467-022-32103-8] [Citation(s) in RCA: 52] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 07/11/2022] [Indexed: 02/02/2023] Open
Abstract
Clinical recommendations for Acute Myeloid Leukemia (AML) classification and risk-stratification remain heavily reliant on cytogenetic findings at diagnosis, which are present in <50% of patients. Using comprehensive molecular profiling data from 3,653 patients we characterize and validate 16 molecular classes describing 100% of AML patients. Each class represents diverse biological AML subgroups, and is associated with distinct clinical presentation, likelihood of response to induction chemotherapy, risk of relapse and death over time. Secondary AML-2, emerges as the second largest class (24%), associates with high-risk disease, poor prognosis irrespective of flow Minimal Residual Disease (MRD) negativity, and derives significant benefit from transplantation. Guided by class membership we derive a 3-tier risk-stratification score that re-stratifies 26% of patients as compared to standard of care. This results in a unified framework for disease classification and risk-stratification in AML that relies on information from cytogenetics and 32 genes. Last, we develop an open-access patient-tailored clinical decision support tool.
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Grants
- MC_PC_17230 Medical Research Council
- BRC-1215-20014 Department of Health
- 203151/Z/16/Z Wellcome Trust
- MR-R009708-1 Medical Research Council
- C18680/A25508 Cancer Research UK
- 29806 Cancer Research UK
- 25350 Cancer Research UK
- P30 CA008748 NCI NIH HHS
- Wellcome Trust
- 25508 Cancer Research UK
- 25643 Cancer Research UK
- MR/R009708/1 Medical Research Council
- C49940/A25117 Cancer Research UK
- 205254/Z/16/Z Wellcome Trust
- E.P. is a Josie Robertson Investigator and is supported by the European Hematology Association, American Society of Hematology, Gabrielle’s Angels Foundation, V Foundation and The Geoffrey Beene Foundation and is a Damon Runyon Rachleff Innovator fellow. Work in the BJPH lab is funded by Cancer Research UK (C18680/A25508), the European Research Council (647685), MRC (MR-R009708-1), the Kay Kendall Leukaemia Fund (KKL1243), the Wellcome Trust (205254/Z/16/Z) and the Cancer Research UK Cambridge Major Centre (C49940/A25117). This research was supported by the NIHR Cambridge Biomedical Research Centre (BRC-1215-20014), and was funded in part, by the Wellcome Trust who supported the Wellcome - MRC Cambridge Stem Cell Institute (203151/Z/16/Z). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. L.B., H.D. and B.J.P.H. are supported by the HARMONY Alliance (IMI Project No. 116026; https://www.harmony-alliance.eu/). The UK-NCRI AML working group trials were supported with research grants from the Medical Research Council (MRC), Cancer Research UK (CRUK), Blood Cancer UK and Cardiff University. We would like to thank all patients and investigators for their participation in the trials and the study.
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Affiliation(s)
- Yanis Tazi
- Computational Oncology Service, Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Center for Hematologic Malignancies, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Tri-Institutional Computational Biology and Medicine PhD Program, Weill Cornell Medicine of Cornell University and Rockefeller University, New York, NY, USA
- The Rockefeller University, New York, NY, USA
| | - Juan E Arango-Ossa
- Computational Oncology Service, Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Center for Hematologic Malignancies, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Yangyu Zhou
- Computational Oncology Service, Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Center for Hematologic Malignancies, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Elsa Bernard
- Computational Oncology Service, Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Center for Hematologic Malignancies, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ian Thomas
- Centre for Trials Research, School of Medicine, Cardiff University, Cardiff, UK
| | - Amanda Gilkes
- Department of Haematology, School of Medicine, Cardiff University, Cardiff, UK
| | - Sylvie Freeman
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Yoann Pradat
- Computational Oncology Service, Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sean J Johnson
- Centre for Trials Research, School of Medicine, Cardiff University, Cardiff, UK
| | - Robert Hills
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Richard Dillon
- Department of Medical and Molecular Genetics, King's College, London, UK
| | - Max F Levine
- Computational Oncology Service, Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daniel Leongamornlert
- Cancer, Ageing and Somatic Mutation Programme, Wellcome Sanger Institute, Hinxton, UK
| | - Adam Butler
- Cancer, Ageing and Somatic Mutation Programme, Wellcome Sanger Institute, Hinxton, UK
| | - Arnold Ganser
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Lars Bullinger
- Department of Hematology, Oncology, and Tumorimmunology, Campus Virchow Klinikum, Berlin, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Konstanze Döhner
- Department of Internal Medicine III, Ulm University, Ulm, Germany
| | - Oliver Ottmann
- Department of Haematology, School of Medicine, Cardiff University, Cardiff, UK
| | - Richard Adams
- Centre for Trials Research, School of Medicine, Cardiff University, Cardiff, UK
| | - Hartmut Döhner
- Department of Internal Medicine III, Ulm University, Ulm, Germany
| | - Peter J Campbell
- Cancer, Ageing and Somatic Mutation Programme, Wellcome Sanger Institute, Hinxton, UK
| | - Alan K Burnett
- Visiting Professor University of Glasgow, formerly Cardiff University, Cardiff, UK
| | | | - Nigel H Russell
- Department of Haematology, Nottingham University Hospital, Nottingham, UK
| | - Sean M Devlin
- Computational Oncology Service, Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Brian J P Huntly
- Department of Haematology and Wellcome Trust-MRC Cambridge Stem Cell Institute, University of Cambridge, Cambridge, UK
| | - Elli Papaemmanuil
- Computational Oncology Service, Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Center for Hematologic Malignancies, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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6
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Thomas X, Elhamri M, Deloire A, Heiblig M. Antibody-based therapy for acute myeloid leukemia: a review of phase 2 and 3 trials. Expert Opin Emerg Drugs 2022; 27:169-185. [PMID: 35749672 DOI: 10.1080/14728214.2022.2094365] [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: 11/04/2022]
Abstract
INTRODUCTION Despite recent advances in the treatment of adult acute myeloid leukemia (AML), the clinical outcome of patients continues to be unsatisfactory especially among older patients, those with a high-risk profile, and in the relapsed/refractory setting. For this reason, recent clinical trials have explored novel therapeutic agents either used alone or in combination with intensive chemotherapy or low-intensity treatments. AREAS COVERED The current paper reviews the clinical development of monoclonal antibody-based therapies in AML, their current status and phases 2 and 3 prospective trials. EXPERT OPINION Monoclonal antibody-based therapies demonstrated efficacy and tolerability in several clinical trials, especially when used in combination either with '3+7' chemotherapy or with low-intensity treatments. Additional studies are needed to determine new antigens for antibody-based therapies that target leukemia stem cells and spare normal hematopoiesis. Phase 2 and 3 additional clinical trial data are needed to assess the promise of first trials, especially regarding chimeric antigen receptor T cells redirected against myeloid antigens and immune checkpoint inhibitor therapies.
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Affiliation(s)
- Xavier Thomas
- Department of Clinical Hematology, Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Pierre Bénite, France
| | - Mohamed Elhamri
- Department of Clinical Hematology, Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Pierre Bénite, France
| | - Alexandre Deloire
- Department of Clinical Hematology, Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Pierre Bénite, France
| | - Maël Heiblig
- Department of Clinical Hematology, Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Pierre Bénite, France
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7
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Godwin CD, Rodríguez-Arbolí E, Othus M, Halpern AB, Appelbaum JS, Percival MEM, Hendrie PC, Oehler VG, Keel SB, Abkowitz JL, Cooper JP, Cassaday RD, Estey EH, Walter RB. Phase 1/2 Trial of CLAG-M with Dose-Escalated Mitoxantrone in Combination with Fractionated-Dose Gemtuzumab Ozogamicin for Newly Diagnosed Acute Myeloid Leukemia and Other High-Grade Myeloid Neoplasms. Cancers (Basel) 2022; 14:cancers14122934. [PMID: 35740603 PMCID: PMC9221325 DOI: 10.3390/cancers14122934] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 06/10/2022] [Accepted: 06/12/2022] [Indexed: 12/04/2022] Open
Abstract
Simple Summary Several studies have demonstrated that gemtuzumab ozogamicin (GO) improves outcomes with intensive chemotherapy in some adults with acute myeloid leukemia (AML), but it has remained unclear which dosing schedule of GO is best. Here, we conducted a phase 1/2 study in 66 adults with newly diagnosed AML or other high-grade myeloid neoplasm, and found that a fractionated dosing schedule of GO (GO3) can be safely combined with cladribine, high-dose cytarabine, G-CSF, and dose-escalated mitoxantrone (CLAG-M). Fifty-two out of sixty (87%) patients treated with CLAG-M/GO3 achieved a complete remission (CR)/CR with incomplete hematologic recovery (CRi), 45/52 (87%) without flow cytometric measurable residual disease. Six- and twelve-month event-free survival were 73% and 58%; among favorable-risk patients, these estimates were 100% and 95%. Compared to 186 medically matched adults treated with CLAG-M alone, CLAG-M/GO3 was associated with better survival in patients with favorable-risk disease. These data indicate that CLAG-M/GO3 is safe and more efficacious than CLAG-M alone in favorable-risk AML/high-grade myeloid neoplasm. Abstract Gemtuzumab ozogamicin (GO) improves outcomes when added to intensive AML chemotherapy. A meta-analysis suggested the greatest benefit when combining fractionated doses of GO (GO3) with 7 + 3. To test whether GO3 can be safely used with high intensity chemotherapy, we conducted a phase 1/2 study of cladribine, high-dose cytarabine, G-CSF, and dose-escalated mitoxantrone (CLAG-M) in adults with newly diagnosed AML or other high-grade myeloid neoplasm (NCT03531918). Sixty-six patients with a median age of 65 (range: 19–80) years were enrolled. Cohorts of six and twelve patients were treated in phase 1 with one dose of GO or three doses of GO (GO3) at 3 mg/m2 per dose. Since a maximum-tolerated dose was not reached, the recommended phase 2 dose (RP2D) was declared to be GO3. At RP2D, 52/60 (87%) patients achieved a complete remission (CR)/CR with incomplete hematologic recovery (CRi), 45/52 (87%) without flow cytometric measurable residual disease (MRD). Eight-week mortality was 0%. Six- and twelve-month event-free survival (EFS) were 73% and 58%; among favorable-risk patients, these estimates were 100% and 95%. Compared to 186 medically matched adults treated with CLAG-M alone, CLAG-M/GO3 was associated with better survival in patients with favorable-risk disease (EFS: p = 0.007; OS: p = 0.030). These data indicate that CLAG-M/GO3 is safe and leads to superior outcomes than CLAG-M alone in favorable-risk AML/high-grade myeloid neoplasm.
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Affiliation(s)
- Colin D. Godwin
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA 98109, USA; (C.D.G.); (E.R.-A.); (A.B.H.); (J.S.A.); (M.-E.M.P.); (P.C.H.); (V.G.O.); (S.B.K.); (J.L.A.); (J.P.C.); (R.D.C.)
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA 98195, USA
| | - Eduardo Rodríguez-Arbolí
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA 98109, USA; (C.D.G.); (E.R.-A.); (A.B.H.); (J.S.A.); (M.-E.M.P.); (P.C.H.); (V.G.O.); (S.B.K.); (J.L.A.); (J.P.C.); (R.D.C.)
| | - Megan Othus
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, WA 98109, USA;
| | - Anna B. Halpern
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA 98109, USA; (C.D.G.); (E.R.-A.); (A.B.H.); (J.S.A.); (M.-E.M.P.); (P.C.H.); (V.G.O.); (S.B.K.); (J.L.A.); (J.P.C.); (R.D.C.)
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA 98195, USA
| | - Jacob S. Appelbaum
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA 98109, USA; (C.D.G.); (E.R.-A.); (A.B.H.); (J.S.A.); (M.-E.M.P.); (P.C.H.); (V.G.O.); (S.B.K.); (J.L.A.); (J.P.C.); (R.D.C.)
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA 98195, USA
| | - Mary-Elizabeth M. Percival
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA 98109, USA; (C.D.G.); (E.R.-A.); (A.B.H.); (J.S.A.); (M.-E.M.P.); (P.C.H.); (V.G.O.); (S.B.K.); (J.L.A.); (J.P.C.); (R.D.C.)
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA 98195, USA
| | - Paul C. Hendrie
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA 98109, USA; (C.D.G.); (E.R.-A.); (A.B.H.); (J.S.A.); (M.-E.M.P.); (P.C.H.); (V.G.O.); (S.B.K.); (J.L.A.); (J.P.C.); (R.D.C.)
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA 98195, USA
| | - Vivian G. Oehler
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA 98109, USA; (C.D.G.); (E.R.-A.); (A.B.H.); (J.S.A.); (M.-E.M.P.); (P.C.H.); (V.G.O.); (S.B.K.); (J.L.A.); (J.P.C.); (R.D.C.)
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA 98195, USA
| | - Siobán B. Keel
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA 98109, USA; (C.D.G.); (E.R.-A.); (A.B.H.); (J.S.A.); (M.-E.M.P.); (P.C.H.); (V.G.O.); (S.B.K.); (J.L.A.); (J.P.C.); (R.D.C.)
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA 98195, USA
| | - Janis L. Abkowitz
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA 98109, USA; (C.D.G.); (E.R.-A.); (A.B.H.); (J.S.A.); (M.-E.M.P.); (P.C.H.); (V.G.O.); (S.B.K.); (J.L.A.); (J.P.C.); (R.D.C.)
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA 98195, USA
| | - Jason P. Cooper
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA 98109, USA; (C.D.G.); (E.R.-A.); (A.B.H.); (J.S.A.); (M.-E.M.P.); (P.C.H.); (V.G.O.); (S.B.K.); (J.L.A.); (J.P.C.); (R.D.C.)
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA 98195, USA
| | - Ryan D. Cassaday
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA 98109, USA; (C.D.G.); (E.R.-A.); (A.B.H.); (J.S.A.); (M.-E.M.P.); (P.C.H.); (V.G.O.); (S.B.K.); (J.L.A.); (J.P.C.); (R.D.C.)
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA 98195, USA
| | - Elihu H. Estey
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA 98109, USA; (C.D.G.); (E.R.-A.); (A.B.H.); (J.S.A.); (M.-E.M.P.); (P.C.H.); (V.G.O.); (S.B.K.); (J.L.A.); (J.P.C.); (R.D.C.)
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA 98195, USA
| | - Roland B. Walter
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA 98109, USA; (C.D.G.); (E.R.-A.); (A.B.H.); (J.S.A.); (M.-E.M.P.); (P.C.H.); (V.G.O.); (S.B.K.); (J.L.A.); (J.P.C.); (R.D.C.)
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA 98195, USA
- Department of Laboratory Medicine & Pathology, University of Washington, Seattle, WA 98195, USA
- Department of Epidemiology, University of Washington, Seattle, WA 98195, USA
- Correspondence: ; Tel.: +1-206-667-3599
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Colunga-Lozano LE, Kenji Nampo F, Agarwal A, Desai P, Litzow M, Sekeres MA, Guyatt GH, Brignardello-Petersen R. Less intensive antileukemic therapies (monotherapy and/or combination) for older adults with acute myeloid leukemia who are not candidates for intensive antileukemic therapy: A systematic review and meta-analysis. PLoS One 2022; 17:e0263240. [PMID: 35108310 PMCID: PMC8809589 DOI: 10.1371/journal.pone.0263240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 01/17/2022] [Indexed: 01/06/2023] Open
Abstract
Introduction Elderly patients with acute myeloid leukemia not eligible for intensive antileukemic therapy are treated with less intensive therapies, uncertainty remains regarding their relative merits. Objectives To compare the effectiveness and safety of less intensive antileukemic therapies for older adults with newly diagnosed AML not candidates for intensive therapies. Methods We included randomized controlled trials (RCTs) and non-randomized studies (NRS) comparing less intensive therapies in adults over 55 years with newly diagnosed AML. We searched MEDLINE and EMBASE from inception to August 2021. We assessed risk of bias of RCTs with a modified Cochrane Risk of Bias tool, and NRS with the Non-Randomized Studies of Interventions tool (ROBINS-I). We calculated pooled hazard ratios (HRs), risk ratios (RRs), mean differences (MD) and their 95% confidence intervals (CIs) using a random-effects pairwise meta-analyses and assessed the certainty of evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Results We included 27 studies (17 RCTs, 10 NRS; n = 5,698), which reported 9 comparisons. Patients were treated with azacitidine, decitabine, and low-dose cytarabine (LDAC), as monotherapies or in combination with other agents. Moderate certainty of evidence suggests no convincing difference in overall survival of patients who receive azacitidine monotherapy compared to LDAC monotherapy (HR 0.69; 95% CI, 0.31–1.53), fewer febrile neutropenia events occurred between azacitidine monotherapy to azacitidine combination (RR 0.45; 95% CI, 0.31–0.65), and, fewer neutropenia events occurred between LDAC monotherapy to decitabine monotherapy (RR 0.62; 95% CI 0.44–0.86). All other comparisons and outcomes had low or very low certainty of evidence. Conclusion There is no convincing superiority in OS when comparing less intensive therapies. Azacitidine monotherapy is likely to have fewer adverse events than azacitidine combination (febrile neutropenia), and LDAC monotherapy is likely to have fewer adverse events than decitabine monotherapy (neutropenia).
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Affiliation(s)
- Luis Enrique Colunga-Lozano
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- * E-mail:
| | - Fernando Kenji Nampo
- Department of Latin-American Institute of Life and Nature science, University of Latin-American Integration, Foz Do Iguaçu, Parana, Brazil
| | - Arnav Agarwal
- Department of Medicine, Toronto University, Toronto, Ontario, Canada
| | - Pinkal Desai
- Division of Hematology and Medical Oncology, Weill Cornell Medical Center, New York, New York, United States of America
| | - Mark Litzow
- Division of Hematology, Mayo clinic, Rochester, Minnesota, United states of America
| | - Mikkael A. Sekeres
- Division of Hematology, Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida, United States of America
| | - Gordon H. Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
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9
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Blood Count Recovery Following Induction Therapy for Acute Myeloid Leukemia in Children Does Not Predict Survival. Cancers (Basel) 2022; 14:cancers14030616. [PMID: 35158884 PMCID: PMC8833679 DOI: 10.3390/cancers14030616] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 01/18/2022] [Accepted: 01/21/2022] [Indexed: 12/19/2022] Open
Abstract
Simple Summary International Working Group (IWG) and European LeukemiaNet (ELN) adult response definitions are currently used to evaluate the efficacy of new agents for childhood acute myeloid leukemia (AML); however, the criteria are not consistent with consensus definitions used in pediatric trials or the common practice of intensifying treatment prior to full hematopoietic recovery of ANC ≥ 1000 cells/μL and platelets ≥ 100 cells/μL. This retrospective analysis of the two most recent Phase 3 AML trials in the Children’s Oncology Group assesses the incidence, timing, and prognostic significance of count recovery following induction chemotherapy in children with AML. These data confirm that awaiting count recovery to meet adult criteria does not reflect standard practice in pediatric AML and IWG/ELN-defined CR does not have a significant impact on survival in children. Continuing to use adult IWG/ELN count recovery definitions limits childhood AML drug development by underestimating response, and therefore, updated response criteria are needed for pediatric AML patients. Abstract International Working Group (IWG) and European LeukemiaNet (ELN) response definitions are utilized to evaluate the efficacy of new agents for childhood acute myeloid leukemia (AML) for regulatory purposes. However, these criteria are not consistent with definitions used in pediatric AML trials or with standard pediatric practice to proceed with subsequent therapy cycles prior to IWG/ELN-defined count recovery. We retrospectively analyzed data from the two most recent Phase 3 pediatric AML clinical trials conducted by the Children’s Oncology Group (COG) to assess the incidence, timing, and prognostic significance of count recovery following induction chemotherapy. Of the patients with fewer than 5% bone marrow blasts at the end of first induction, 21.5% of patients proceeded to a second induction cycle prior to achieving ANC ≥ 500 cells/μL and platelets ≥ 50,000 cells/μL, both well below the IWG/ELN thresholds of ANC > 1000 cells/μL and platelets > 100,000 cells/μL. In these two sequential childhood AML Phase 3 trials, neither ANC nor platelet recovery predicted survival. Intensification of treatment through the initiation of subsequent therapy cycles prior to attainment of IWG/ELN-defined CR is common practice in clinical trials for children with AML, suggesting that updated response definitions are needed for pediatric AML.
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10
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Guo Y, Deng L, Qiao Y, Liu B. Efficacy and safety of adding gemtuzumab ozogamicin to conventional chemotherapy for adult acute myeloid leukemia: a systematic review and meta-analysis. Hematology 2021; 27:53-64. [PMID: 34957930 DOI: 10.1080/16078454.2021.2013410] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Introduction: Compared with the 3 + 7 regimen, the addition of gemtuzumab ozogamicin (GO) has improved survival in patients with acute myeloid leukemia (AML). We conducted a systematic review and meta-analysis to examine the overall efficacy and safety of GO in combination with conventional chemotherapy regimens in patients with AML.Methods: We searched several databases (MEDLINE, Embase, Web of Science and Cochrane Library). Hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated for overall survival (OS) and relapse-free survival (RFS); odds ratios (ORs) with 95% CIs were calculated for the other outcomes.Results: Ten records involving 11 randomized controlled trials (RCTs) met the inclusion criteria. GO plus induction chemotherapy significantly increased RFS (HR: 0.84, 95% CI: 0.73-0.98), decreased the incidence of relapse (OR: 0.78, 95% CI: 0.68-0.91) and resistant disease (OR: 0.72, 95% CI: 0.61-0.84), and had no significant effect on the rate of complete remission (CR) with or without incomplete platelet recovery (OR: 1.21, 95% CI: 0.94-1.55), 30-day mortality (OR: 1.25, 95% CI: 0.99-1.57). Subgroup analysis showed significant OS benefits for patients with favorable cytogenetic (HR: 0.50, 95% CI: 0.28-0.89) or given GO at induction stage (HR: 0.91, 95% CI: 0.84-1.00). Compared with other dosing schedule groups, 3 mg/m2 fractionated schedule had a greater RFS benefit (HR: 0.52, 95% CI: 0.36-0.76) and lower relapse risk (OR: 0.48, 95% CI: 0.28-0.84).Conclusions: Adding low-dose GO to induction or both induction and post-remission chemotherapy has considerable efficacy and unequivocal safety for newly diagnosed adult AML.
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Affiliation(s)
- Yuancheng Guo
- The First Clinical Medical College, Lanzhou University, Lanzhou, People's Republic of China
| | - Lijuan Deng
- Shaanxi Provincial People's Hospital, Shaanxi, People's Republic of China
| | - Yanhong Qiao
- Xi'an Central Hospital, Xi'an, People's Republic of China
| | - Bei Liu
- The First Clinical Medical College, Lanzhou University, Lanzhou, People's Republic of China.,Department of Hematology, The First Affiliated Hospital, Lanzhou University, Lanzhou, People's Republic of China
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11
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Liu Y, Wang S, Schubert ML, Lauk A, Yao H, Blank MF, Cui C, Janssen M, Schmidt C, Göllner S, Kleist C, Zhou F, Rahfeld JU, Sauer T, Schmitt M, Müller-Tidow C. CD33-directed immunotherapy with third-generation chimeric antigen receptor T cells and gemtuzumab ozogamicin in intact and CD33-edited acute myeloid leukemia and hematopoietic stem and progenitor cells. Int J Cancer 2021; 150:1141-1155. [PMID: 34766343 DOI: 10.1002/ijc.33865] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 10/18/2021] [Accepted: 10/18/2021] [Indexed: 12/17/2022]
Abstract
Immunotherapies, such as chimeric antigen receptor (CAR) modified T cells and antibody-drug conjugates (ADCs), have revolutionized the treatment of cancer, especially of lymphoid malignancies. The application of targeted immunotherapy to patients with acute myeloid leukemia (AML) has been limited in particular by the lack of a tumor-specific target antigen. Gemtuzumab ozogamicin (GO), an ADC targeting CD33, is the only approved immunotherapeutic agent in AML. In our study, we introduce a CD33-directed third-generation CAR T-cell product (3G.CAR33-T) for the treatment of patients with AML. 3G.CAR33-T cells could be expanded up to the end-of-culture, that is, 17 days after transduction, and displayed significant cytokine secretion and robust cytotoxic activity when incubated with CD33-positive cells including cell lines, drug-resistant cells, primary blasts as well as normal hematopoietic stem and progenitor cells (HSPCs). When compared to second-generation CAR33-T cells, 3G.CAR33-T cells exhibited higher viability, increased proliferation and stronger cytotoxicity. Also, GO exerted strong antileukemia activity against CD33-positive AML cells. Upon genomic deletion of CD33 in HSPCs, 3G.CAR33-T cells and GO preferentially killed wildtype leukemia cells, while sparing CD33-deficient HSPCs. Our data provide evidence for the applicability of CD33-targeted immunotherapies in AML and its potential implementation in CD33 genome-edited stem cell transplantation approaches.
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Affiliation(s)
- Yi Liu
- Department of Medicine V, Heidelberg University Hospital, Heidelberg, Germany.,Molecular Medicine Partnership Unit (MMPU), European Molecular Biology Laboratory (EMBL) and Heidelberg University Hospital, Heidelberg, Germany
| | - Sanmei Wang
- Department of Medicine V, Heidelberg University Hospital, Heidelberg, Germany.,Department of Hematology, First Affiliated Hospital of Nanjing Medical University, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, China
| | | | - Annika Lauk
- Department of Medicine V, Heidelberg University Hospital, Heidelberg, Germany
| | - Hao Yao
- Department of Medicine V, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Chunhong Cui
- Department of Medicine V, Heidelberg University Hospital, Heidelberg, Germany.,Shanghai University of Medicine and Health Sciences, Shanghai, China
| | - Maike Janssen
- Department of Medicine V, Heidelberg University Hospital, Heidelberg, Germany
| | - Christina Schmidt
- Department of Medicine V, Heidelberg University Hospital, Heidelberg, Germany
| | - Stefanie Göllner
- Department of Medicine V, Heidelberg University Hospital, Heidelberg, Germany
| | - Christian Kleist
- Department of Nuclear Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Fengbiao Zhou
- Department of Medicine V, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Tim Sauer
- Department of Medicine V, Heidelberg University Hospital, Heidelberg, Germany
| | - Michael Schmitt
- Department of Medicine V, Heidelberg University Hospital, Heidelberg, Germany
| | - Carsten Müller-Tidow
- Department of Medicine V, Heidelberg University Hospital, Heidelberg, Germany.,Molecular Medicine Partnership Unit (MMPU), European Molecular Biology Laboratory (EMBL) and Heidelberg University Hospital, Heidelberg, Germany
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12
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Hepatotoxicity is the risk factor with gemtuzumab ozogamicin treatment in acute myelogenous leukaemia patients. Clin Res Hepatol Gastroenterol 2021; 45:101443. [PMID: 32448587 DOI: 10.1016/j.clinre.2020.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 04/27/2020] [Indexed: 02/04/2023]
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13
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Adjunctive Volasertib in Patients With Acute Myeloid Leukemia not Eligible for Standard Induction Therapy: A Randomized, Phase 3 Trial. Hemasphere 2021; 5:e617. [PMID: 34350385 PMCID: PMC8328241 DOI: 10.1097/hs9.0000000000000617] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 06/09/2021] [Indexed: 12/13/2022] Open
Abstract
In this phase 3 trial, older patients with acute myeloid leukemia ineligible for intensive chemotherapy were randomized 2:1 to receive the polo-like kinase inhibitor, volasertib (V; 350 mg intravenous on days 1 and 15 in 4-wk cycles), combined with low-dose cytarabine (LDAC; 20 mg subcutaneous, twice daily, days 1–10; n = 444), or LDAC plus placebo (P; n = 222). Primary endpoint was objective response rate (ORR); key secondary endpoint was overall survival (OS). Primary ORR analysis at recruitment completion included patients randomized ≥5 months beforehand; ORR was 25.2% for V+LDAC and 16.8% for P+LDAC (n = 371; odds ratio 1.66 [95% confidence interval (CI), 0.95–2.89]; P = 0.071). At final analysis (≥574 OS events), median OS was 5.6 months for V+LDAC and 6.5 months for P+LDAC (n = 666; hazard ratio 0.97 [95% CI, 0.8–1.2]; P = 0.757). The most common adverse events (AEs) were infections/infestations (grouped term; V+LDAC, 81.3%; P+LDAC, 63.5%) and febrile neutropenia (V+LDAC, 60.4%; P+LDAC, 29.3%). Fatal AEs occurred in 31.2% with V+LDAC versus 18.0% with P+LDAC, most commonly infections/infestations (V+LDAC, 17.1%; P+LDAC, 6.3%). Lack of OS benefit with V+LDAC versus P+LDAC may reflect increased early mortality with V+LDAC from myelosuppression and infections.
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14
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Dennis M, Burnett A, Hills R, Thomas I, Ariti C, Severinsen MT, Hemmaway C, Greaves P, Clark RE, Copland M, Russell N. A randomised evaluation of low-dose cytosine arabinoside (ara-C) plus tosedostat versus low-dose ara-C in older patients with acute myeloid leukaemia: results of the LI-1 trial. Br J Haematol 2021; 194:298-308. [PMID: 33961292 DOI: 10.1111/bjh.17501] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 03/29/2021] [Accepted: 04/01/2021] [Indexed: 11/26/2022]
Abstract
Older patients with acute myeloid leukaemia (AML) account for nearly half of those with the disease. Because they are perceived to be unfit for, unwilling to receive, or unlikely to benefit from conventional chemotherapy they represent an important unmet need. Tosedostat is a selective oral aminopeptidase inhibitor, which in phase I/II trials showed acceptable toxicity and encouraging efficacy. We report the only randomised study of low-dose cytosine arabinoside (LDAC) combined with tosedostat (LDAC-T) versus LDAC in untreated older patients not suitable for intensive treatment. A total of 243 patients were randomised 1:1 as part of the 'Pick-a-Winner' LI-1 trial. There was a statistically non-significant increase in the complete remission (CR) rate with the addition of tosedostat, LDAC-T 19% versus LDAC 12% [odds ratio (OR) 0·61, 95% confidence interval (CI) 0·30-1·23; P = 0·17]. For overall response (CR+CR with incomplete recovery of counts), there was little evidence of a benefit to the addition of tosedostat (25% vs. 18%; OR 0·68, 95% CI 0·37-1·27; P = 0·22). However, overall survival (OS) showed no difference (2-year OS 16% vs. 12%, hazard ratio 0·97, 95% CI 0·73-1·28; P = 0·8). Exploratory analyses failed to identify any subgroup benefitting from tosedostat. Despite promising pre-clinical, early non-randomised clinical data with acceptable toxicity and an improvement in response, we did not find evidence that the addition of tosedostat to LDAC produced a survival benefit in this group of patients with AML. International Standard Randomised Controlled Trial Number: ISRCTN40571019.
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Affiliation(s)
- Mike Dennis
- Department of Haematology, Christie Hospital NHS Trust, Manchester, UK
| | - Alan Burnett
- Paul O'Gorman Leukaemia Centre, Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Robert Hills
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Ian Thomas
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Cono Ariti
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Marianne T Severinsen
- Department of Haematology, Clinical Cancer Research Centre, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Claire Hemmaway
- Department of Haematology, Auckland City Hospital, Auckland, New Zealand
| | - Paul Greaves
- Department of Haematology, Queen's Hospital, Romford, UK
| | - Richard E Clark
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK
| | - Mhairi Copland
- Paul O'Gorman Leukaemia Centre, Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Nigel Russell
- Department of Haematology, Nottingham University Hospitals, Nottingham, UK
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15
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Pollard JA, Guest E, Alonzo TA, Gerbing RB, Loken MR, Brodersen LE, Kolb EA, Aplenc R, Meshinchi S, Raimondi SC, Hirsch B, Gamis AS. Gemtuzumab Ozogamicin Improves Event-Free Survival and Reduces Relapse in Pediatric KMT2A-Rearranged AML: Results From the Phase III Children's Oncology Group Trial AAML0531. J Clin Oncol 2021; 39:3149-3160. [PMID: 34048275 DOI: 10.1200/jco.20.03048] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
PURPOSE We investigated the impact of the CD33-targeted agent gemtuzumab ozogamicin (GO) on survival in pediatric patients with KMT2A-rearranged (KMT2A-r) acute myeloid leukemia (AML) enrolled in the Children's Oncology Group trial AAML0531 (NCT01407757). METHODS Patients with KMT2A-r AML were identified and clinical characteristics described. Five-year overall survival (OS), event-free survival (EFS), disease-free survival (DFS), and relapse risk (RR) were determined overall and for higher-risk versus not high-risk translocation partners. GO's impact on response was determined and outcomes based on consolidation approach (hematopoietic stem cell transplant [HSCT] v chemotherapy) described. RESULTS Two hundred fifteen (21%) of 1,022 patients enrolled had KMT2A-r AML. Five-year EFS and OS from study entry were 38% and 58%, respectively. EFS was superior with GO treatment (EFS 48% with GO v 29% without, P = .003), although OS was comparable (63% v 53%, P = .054). For patients with KMT2A-r AML who achieved complete remission, GO was associated with lower RR (40% GO v 66% patients who did not receive GO [No-GO], P = .001) and improved 5-year DFS (GO 57% v No-GO 33%, P = .002). GO benefit was observed in both higher-risk and not high-risk KMT2A-r subsets. For patients who underwent HSCT, prior GO exposure was associated with decreased relapse (5-year RR: 28% GO and HSCT v 73% No-GO and HSCT, P = .006). In multivariable analysis, GO was independently associated with improved EFS, improved DFS, and reduced RR. CONCLUSION GO added to conventional chemotherapy improved outcomes for KMT2A-r AML; consolidation with HSCT may further enhance outcomes. Future clinical trials should study CD33-targeted agents in combination with HSCT for pediatric KMT2A-r AML.
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Affiliation(s)
- Jessica A Pollard
- Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA.,Department of Pediatrics, Harvard Medical School, Boston, MA
| | | | - Todd A Alonzo
- University of Southern California Keck School of Medicine, Los Angeles, CA.,Children's Oncology Group, Monrovia, CA
| | | | | | | | | | | | - Soheil Meshinchi
- Fred Hutchinson Cancer Research Center, Seattle, WA.,University of Washington School of Medicine, Seattle, WA
| | | | - Betsy Hirsch
- University of Minnesota Cancer Center, Minneapolis, MN
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16
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Cortes JE, Mehta P. Determination of fitness and therapeutic options in older patients with acute myeloid leukemia. Am J Hematol 2021; 96:493-507. [PMID: 33368536 PMCID: PMC7986910 DOI: 10.1002/ajh.26079] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 12/15/2020] [Accepted: 12/20/2020] [Indexed: 12/11/2022]
Abstract
Treatment of older patients with AML remains challenging. Although age, performance status, and comorbidities are commonly employed to determine fitness for intensive treatment, several studies have demonstrated improved outcomes with treatment in older and classically unfit patients, highlighting the importance of other disease-related and patient-related factors that have prognostic value for treatment outcome in AML. However, consistent and objective assessments for fitness are lacking. Multi-parameter geriatric assessment tools offer more comprehensive evaluation, but are limited by the required resources and lack of standardization and consensus regarding prognostic value. These assessments are particularly important considering the emerging new AML therapies that represent a spectrum of intensities. Patients should therefore be evaluated holistically for fitness to receive a specific treatment, with the aim of providing individualized care, and such definitions of fitness should also consistently be applied to clinical trials. This review will examine evolving criteria for the determination of fitness among AML patients and discuss treatment options for older and/or unfit patients with AML.
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Affiliation(s)
- Jorge E. Cortes
- Georgia Cancer Center Augusta University Augusta Georgia USA
| | - Priyanka Mehta
- Department of Haematology University Hospitals Bristol, NHS Foundation Trust Bristol UK
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17
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Othus M, Garcia-Manero G, Godwin J, Weick J, Stirewalt D, Appelbaum F, Erba H, Estey E. Associations between complete remission and 2- to 3-year survival following 7 + 3 induction for acute myeloid leukemia. Leuk Lymphoma 2021; 62:1967-1972. [PMID: 33719833 DOI: 10.1080/10428194.2021.1885663] [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: 10/21/2022]
Abstract
Among acute myeloid leukemia (AML) patients treated with 7 + 3 induction, we evaluate the association between complete morphologic remission (CR) and long-term overall survival (OS) over four decades. We analyzed 1247 patients age ≤65 randomized to 7 + 3 arms from five SWOG studies. OS has improved over the four decades. Hazards for death in the two most recent studies fell after year 2. In multivariable models, decade of therapy was the most important variable with respect to long-term survival and CR by day 100 the second most important variable. Protocol/decade, which captures many factors not included in our multivariable model, was the most important predictor of being alive at year 2 or 3. The next most important factor was achievement of first CR by day 100.
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Affiliation(s)
- Megan Othus
- SWOG Statistical Center, Seattle, WA, USA.,Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | | | - John Godwin
- Providence Onc/Hem Care Clinic, Portland, OR, USA
| | - James Weick
- VA Medical Center, North Palm Beach, FL, USA
| | | | | | - Harry Erba
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Elihu Estey
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
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18
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Shallis RM, Pollyea DA, Zeidan AM. The complete story of less than complete responses: The evolution and application of acute myeloid leukemia clinical responses. Blood Rev 2021; 48:100806. [PMID: 33531169 DOI: 10.1016/j.blre.2021.100806] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 11/13/2020] [Accepted: 12/17/2020] [Indexed: 10/22/2022]
Abstract
Complete remission (CR) has long been the critical therapeutic response in acute myeloid leukemia (AML). However, "less than CR" responses have been and continue to be proposed to define clinically meaningful post-therapy outcomes. These responses include CR with incomplete recovery (CRi), CR with incomplete platelet recovery (CRp) and, most recently, CR with partial hematologic recovery (CRh), which has been introduced and subsequently used for regulatory approval. However, the clinical benefits associated with "less than CR" responses have primarily been evaluated in the context of intensive therapies. In an era with sophisticated measurable residual disease (MRD) assessments, including flow-based, cytogenetic and molecular techniques, and an increase in "targeted", non-intensive therapies, the clinical value of responses that are "less than CR" must be reevaluated. Improvements in the rate of CR has not always led to improvements in OS among older patients. As such, MRD techniques might help define a more stringent response criterion (MRD-negative CR) that might better correlate with OS and should be incorporated in future clinical trials. Here we discuss the evolution of CR and "less than CR" responses, data regarding their clinical benefits, and considerations relevant to response assessments with newer therapies.
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Affiliation(s)
- Rory M Shallis
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA; Yale Cancer Center, New Haven, CT, USA
| | - Daniel A Pollyea
- Division of Hematology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Amer M Zeidan
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA; Yale Cancer Center, New Haven, CT, USA.
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19
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Barrière S, Gastaud L. [European approvals: Glasdegib for Acute myeloid leukemia]. Bull Cancer 2020; 107:1206-1207. [PMID: 33070952 DOI: 10.1016/j.bulcan.2020.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 09/13/2020] [Accepted: 09/15/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Sabrina Barrière
- CHU de Clermont-Ferrand, service thérapie cellulaire et hématologie clinique, 1, rue Lucie-Aubrac, 63100 Clermont-Ferrand, France.
| | - Lauris Gastaud
- Centre Lacassagne, département d'oncologie médicale, 33, avenue Valombrose, 06189 Nice cedex 2, France
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20
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Goldenson BH, Goodman AM, Ball ED. Gemtuzumab ozogamicin for the treatment of acute myeloid leukemia in adults. Expert Opin Biol Ther 2020; 21:849-862. [PMID: 32990476 DOI: 10.1080/14712598.2021.1825678] [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: 01/27/2023]
Abstract
INTRODUCTION Treatment of acute myeloid leukemia (AML) has changed dramatically in the past ten years with the approval of targeted agents, the first of which was the anti-CD33 antibody-drug conjugate gemtuzumab ozogamicin (GO). Despite withdrawal from the market after accelerated approval, GO was reapproved and now has a well-established role in treating select AML patients. CD33 has proven to be an important target for drug development in AML as evidenced by the improvement in survival with GO treatment. AREAS COVERED The review summarizes the development of GO, its mechanism of action, initial studies and approval, withdrawal from the market, and subsequent reapproval after the results of several large randomized studies became available. We also provide an overview of its current role in the treatment landscape of AML. EXPERT OPINION Multiple phase 3 trials with GO have established a significant benefit with GO in induction therapy for favorable risk AML. Additional studies support the use of GO in relapsed/refractory AML and APL. Despite the withdrawal of GO from the market after initial approval, GO has proven to improve survival of select AML patients when added to induction chemotherapy and in relapsed disease.
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Affiliation(s)
- Benjamin H Goldenson
- Department of Medicine, Division of Hematology/Oncology, University of California, San Diego, La Jolla, California, USA
| | - Aaron M Goodman
- Department of Medicine, Division of Blood and Marrow Transplantation, University of California, San Diego, La Jolla, California, USA
| | - Edward D Ball
- Department of Medicine, Division of Blood and Marrow Transplantation, University of California, San Diego, La Jolla, California, USA
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21
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Sekeres MA, Guyatt G, Abel G, Alibhai S, Altman JK, Buckstein R, Choe H, Desai P, Erba H, Hourigan CS, LeBlanc TW, Litzow M, MacEachern J, Michaelis LC, Mukherjee S, O'Dwyer K, Rosko A, Stone R, Agarwal A, Colunga-Lozano LE, Chang Y, Hao Q, Brignardello-Petersen R. American Society of Hematology 2020 guidelines for treating newly diagnosed acute myeloid leukemia in older adults. Blood Adv 2020; 4:3528-3549. [PMID: 32761235 PMCID: PMC7422124 DOI: 10.1182/bloodadvances.2020001920] [Citation(s) in RCA: 109] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 05/08/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Older adults with acute myeloid leukemia (AML) represent a vulnerable population in whom disease-based and clinical risk factors, patient goals, prognosis, and practitioner- and patient-perceived treatment risks and benefits influence treatment recommendations. OBJECTIVE These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in their decisions about management of AML in older adults. METHODS ASH formed a multidisciplinary guideline panel that included specialists in myeloid leukemia, geriatric oncology, patient-reported outcomes and decision-making, frailty, epidemiology, and methodology, as well as patients. The McMaster Grading of Recommendations Assessment, Development and Evaluation (GRADE) Centre supported the guideline-development process, including performing systematic evidence reviews (up to 24 May 2019). The panel prioritized clinical questions and outcomes according to their importance to patients, as judged by the panel. The panel used the GRADE approach, including GRADE's Evidence-to-Decision frameworks, to assess evidence and make recommendations, which were subject to public comment. RESULTS The panel agreed on 6 critical questions in managing older adults with AML, mirroring real-time practitioner-patient conversations: the decision to pursue antileukemic treatment vs best supportive management, the intensity of therapy, the role and duration of postremission therapy, combination vs monotherapy for induction and beyond, duration of less-intensive therapy, and the role of transfusion support for patients no longer receiving antileukemic therapy. CONCLUSIONS Treatment is recommended over best supportive management. More-intensive therapy is recommended over less-intensive therapy when deemed tolerable. However, these recommendations are guided by the principle that throughout a patient's disease course, optimal care involves ongoing discussions between clinicians and patients, continuously addressing goals of care and the relative risk-benefit balance of treatment.
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Affiliation(s)
- Mikkael A Sekeres
- Leukemia Program, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Gregory Abel
- Leukemia Division, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Shabbir Alibhai
- Institute of Medical Sciences, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Jessica K Altman
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Rena Buckstein
- Odette Cancer Centre, Division of Medical Oncology and Hematology, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Hannah Choe
- Division of Hematology, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Pinkal Desai
- Division of Hematology and Medical Oncology, Weill Cornell Medicine, New York, NY
| | - Harry Erba
- Department of Medicine, School of Medicine, Duke University, Durham, NC
| | | | - Thomas W LeBlanc
- Department of Medicine, School of Medicine, Duke University, Durham, NC
| | - Mark Litzow
- Division of Hematology, Mayo Clinic, Rochester, MN
| | | | - Laura C Michaelis
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Sudipto Mukherjee
- Leukemia Program, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH
| | - Kristen O'Dwyer
- Division of Hematology/Oncology, Department of Medicine, University of Rochester, Rochester, NY
| | - Ashley Rosko
- Division of Hematology, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Richard Stone
- Leukemia Division, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Arnav Agarwal
- Department of Internal Medicine, University of Toronto, Toronto, ON, Canada
| | - L E Colunga-Lozano
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Health Science Center, Department of Clinical Medicine, Universidad de Guadalajara, Guadalajara, Mexico; and
| | - Yaping Chang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - QiuKui Hao
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- The Center of Gerontology and Geriatrics/National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
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22
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Abdallah M, Xie Z, Ready A, Manogna D, Mendler JH, Loh KP. Management of Acute Myeloid Leukemia (AML) in Older Patients. Curr Oncol Rep 2020; 22:103. [PMID: 32725515 DOI: 10.1007/s11912-020-00964-1] [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: 12/16/2022]
Abstract
PURPOSE OF REVIEW The acute myeloid leukemia (AML) treatment landscape has rapidly evolved over the past few years. These changes have several implications for the care of older adults (≥ 60 years), who have inferior clinical outcomes. We review decision-making in older adults, focusing on patient- and disease-related factors. We then summarize current treatment options, including multiple recently approved therapies, based on hypothetical clinical scenarios. RECENT FINDINGS In lieu of using chronological age to determine fitness, we highlight the importance of standardized fitness assessments using geriatric assessments. Next, we review intensive and lower-intensity treatment options in the upfront setting. We focus on multiple newly approved medications, including venetoclax, midostaurin, CPX-351, gemtuzumab, glasdegib, enasidenib, and ivosidenib, and their specific indications. Lastly, we briefly discuss supportive care of older adults with AML. Outcomes of older adults with AML remain poor; fortunately, there are many new promising treatment options. Personalized treatment plans based on patient- and disease-specific factors are essential to the care of older adults with AML.
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Affiliation(s)
- Maya Abdallah
- Sections of Hematology/Oncology & Geriatrics, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Zhuoer Xie
- Depatment of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Audrey Ready
- Department of Medicine, University of Massachusetts - Baystate Medical Center, Springfield, MA, USA
| | - Dharmini Manogna
- Department of Medicine, Rochester General Hospital, Rochester, NY, USA
| | - Jason H Mendler
- Division of Hematology/Oncology, University of Rochester Medical Center, James P. Wilmot Cancer Center, 601 Elmwood Avenue, Box 704, Rochester, NY, 14642, USA
| | - Kah Poh Loh
- Division of Hematology/Oncology, University of Rochester Medical Center, James P. Wilmot Cancer Center, 601 Elmwood Avenue, Box 704, Rochester, NY, 14642, USA.
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23
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Evaluation of event-free survival as a robust end point in untreated acute myeloid leukemia (Alliance A151614). Blood Adv 2020; 3:1714-1721. [PMID: 31171508 DOI: 10.1182/bloodadvances.2018026112] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 03/15/2019] [Indexed: 12/18/2022] Open
Abstract
Event-free survival (EFS) is controversial as an end point for speeding approvals in newly diagnosed acute myeloid leukemia (AML). We aimed to examine the robustness of EFS, specifically timing of complete remission (CR) in defining induction failure and impact of hematopoietic cell transplantation (HCT). The study included 1884 untreated AML patients enrolled across 5 trials conducted through Alliance for Clinical Trials in Oncology using anthracycline and cytarabine induction chemotherapy. EFS was defined as time from randomization/registration to induction failure, relapse, or death. Three definitions of induction failure were evaluated: failure to achieve CR by 60 days after randomization/registration, failure to achieve CR by the end of all protocol-defined induction courses, and failure to achieve CR by the end of all protocol-defined treatment. We considered either censoring or no censoring at time of non-protocol-mandated HCT. Although relapse and death are firm end points, the determination of induction failure was not consistent across studies. There was minimal impact of censoring at HCT on EFS estimates; however, median EFS estimates differed considerably based on the timing of CR in defining induction failure, with the magnitude of difference being large enough in most cases to lead to incorrect conclusions about efficacy in a single-arm trial, if the trial definition was not consistent with the definition used for the historical control. Timing of CR should be carefully examined in the historical control data used to guide the design of single-arm trials using EFS as the primary end point. Trials were registered at www.clinicaltrials.gov as #NCT00085124, #NCT00416598, # NCT00651261, #NCT01238211, and #NCT01253070.
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24
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Yilmaz M, Kadia T, Ravandi F. Identifying effective drug combinations for patients with acute myeloid leukemia. Expert Rev Anticancer Ther 2020; 20:591-601. [DOI: 10.1080/14737140.2020.1782749] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Musa Yilmaz
- Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA
| | - Tapan Kadia
- Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA
| | - Farhad Ravandi
- Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA
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25
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Lyon-University Hospital Experience with Gemtuzumab Ozogamicin Therapy in Acute Myeloid Leukemia: a 'Real-Life' Study. Mediterr J Hematol Infect Dis 2020; 12:e2020020. [PMID: 32395209 PMCID: PMC7202336 DOI: 10.4084/mjhid.2020.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 03/17/2020] [Indexed: 11/14/2022] Open
Abstract
Ninety-four adults with newly diagnosed or relapsed/refractory acute myeloid leukemia (AML) were treated with fractionated doses of gemtuzumab ozogamicin (GO) at one-single French center over ten years. We attempted to define predictive factors for response and survival. The overall response rate was 70% (86% in newly diagnosed and 65% in relapsed/refractory AML). Mortality during induction was 6%. Disease-free survival (DFS) and overall survival at three years after GO treatment was 36% and 31%, respectively. Median DFS in relapsed/refractory patients was eight months with a 3-year DFS at 34%. Among remitters, allogeneic hematopoietic stem cell transplantation (HSCT) can be performed in 28 cases (42%), including two patients in first-line therapy and 26 in further line. In relapsed/refractory patients undergoing allogeneic HSCT after responding to GO therapy, the median DFS was not reached. Incidences of transplant-related mortality, grade ≥ 3 acute graft-versus-host (GvH) disease, and extensive chronic GvH disease were 11%, 14%, and 25%, respectively. No sinusoidal obstruction syndromes were reported among allografted patients as among the other patients in the studied cohort. GO-based chemotherapy is a viable option for the treatment of relapsed/refractory AML patients and is a feasible schedule as a bridge to allogeneic transplant.
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Thomas X, Elhamri M, Heiblig M. Emerging pharmacotherapies for elderly acute myeloid leukemia patients. Expert Rev Hematol 2020; 13:619-643. [PMID: 32311298 DOI: 10.1080/17474086.2020.1758058] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Acute myeloid leukemia (AML) is a disease mainly seen in the elderly, for which treatment is undergoing rapid changes. Although recent studies have supported the survival benefit of induction chemotherapy in fit patients and that of hypomethylating agents (HMAs) in non-induction candidates, treatment of this patient age population remains a significant challenge for the treating oncologist. AREAS COVERED In this review, we will examine effectiveness and safety outcomes of upcoming novel treatment strategies in elderly (≥60 years old) patients with AML, highlight the current literature and ongoing trials able to maximize therapeutic options in this heterogeneous patient population. EXPERT OPINION Current developments including new chemotherapeutic strategies and combinations of HMAs with novel drugs targeting epigenetic or immunomodulatory pathways are underway to improve patient survival and quality of life.
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Affiliation(s)
- Xavier Thomas
- Hospices Civils de Lyon, Hematology Department, Lyon-Sud University Hospital , Pierre Bénite, France
| | - Mohamed Elhamri
- Hospices Civils de Lyon, Hematology Department, Lyon-Sud University Hospital , Pierre Bénite, France
| | - Maël Heiblig
- Hospices Civils de Lyon, Hematology Department, Lyon-Sud University Hospital , Pierre Bénite, France
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27
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Vey N. Low-intensity regimens versus standard-intensity induction strategies in acute myeloid leukemia. Ther Adv Hematol 2020; 11:2040620720913010. [PMID: 32215195 PMCID: PMC7081460 DOI: 10.1177/2040620720913010] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 02/12/2020] [Indexed: 12/11/2022] Open
Abstract
Treatment options for elderly patients with acute myeloid leukemia (AML) remain limited. In this age group, AML is frequently associated with poor-risk features, while patients’ present comorbidities and reduced functional reserves. As such, intensive chemotherapy (ICT) is frequently too toxic or ineffective in elderly patients and is restricted to a select minority, though it is standard therapy for the youngest and fittest patients or for those belonging to either the favorable or intermediate-risk groups. The use of hypomethylating agents represent an effective alternative for patients who are unfit for ICT, yet the results remain unsatisfactory. In recent years, prognostic scores were developed that include geriatric assessment tools and improved risk-stratification. In addition, several effective new drugs have emerged. The combination of these drugs with hypomethylating agents or low-dose cytarabine has produced encouraging preliminary results that may change standard practices and offer an alternative to the dilemma of ICT versus low-intensity therapies.
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Affiliation(s)
- Norbert Vey
- Institut Paoli-Calmettes, 232 Boulevard de Sainte Marguerite, Marseille, 13009, France
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28
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Updates on DNA methylation modifiers in acute myeloid leukemia. Ann Hematol 2020; 99:693-701. [DOI: 10.1007/s00277-020-03938-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 01/24/2020] [Indexed: 12/14/2022]
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Stein EM, DiNardo CD, Pollyea DA, Schuh AC. Response Kinetics and Clinical Benefits of Nonintensive AML Therapies in the Absence of Morphologic Response. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 20:e66-e75. [DOI: 10.1016/j.clml.2019.11.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 11/05/2019] [Accepted: 11/19/2019] [Indexed: 02/06/2023]
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30
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Recent drug approvals for newly diagnosed acute myeloid leukemia: gifts or a Trojan horse? Leukemia 2020; 34:671-681. [PMID: 31915366 DOI: 10.1038/s41375-019-0704-5] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 11/26/2019] [Accepted: 12/24/2019] [Indexed: 01/04/2023]
Abstract
Since 2017 the US Food and Drug Administration (FDA) has approved glasdegib, venetoclax, ivosidenib, midostaurin, CPX- 351, and gemtuzumab ozogamicin (GO) to treat persons with newly diagnosed acute myeloid leukemia. The European Medicines Agency (EMA) has done likewise for midostaurin, CPX-351, and GO. While increasing options for persons, particularly older ones, for whom current therapy is unsatisfactory, or simply not given, these approvals raise several concerns. Although the venetoclax and glasdegib approvals were for persons considered "unfit" for intensive induction, the criteria for fitness were not well defined (age ≥75 per se being insufficient) and are frequently subjective, making it likely that many subjects in the venetoclax and glasdegib registration trials were fit for intensive induction; for example, none had performance status 3-4. Fitness must be assessed together with the potential efficacy of a proposed therapy. We note the modest complete remission rates and durations in the venetoclax + hypomethylating agent trial. Although these formed the basis for FDA approval, it is unclear that better results might not have obtained with more intense induction, as several studies, with considerably longer-follow up, have suggested. Hence, we question the venetoclax (and glasdegib) approvals absent randomized comparisons with intense induction. Given the uncertain relation in older individuals between survival and complete remission (CR), much less responses less than CR, we are skeptical of the sole use of these responses in the ivosidenib and venetoclax approvals; we also question the use of survival, without event-free survival, in the glasdegib approval. Noting the midostaurin and CPX-351 approvals included populations not participating in the registration studies we suggest means to address this issue as well as those involving fitness, randomization, and endpoints.
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Pongudom S, Phinyo P, Chinthammitr Y, Charoenprasert K, Kasyanan H, Wongyai K, Purattanamal J, Panoi N, Surawong A. Efficacy and Safety of Metronomic Chemotherapy Versus Palliative Hydroxyurea in Unfit Acute Myeloid Leukemia Patients: A Multicenter, Open-Label Randomized Controlled Trial. Asian Pac J Cancer Prev 2020; 21:147-155. [PMID: 31983177 PMCID: PMC7294042 DOI: 10.31557/apjcp.2020.21.1.147] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Indexed: 01/04/2023] Open
Abstract
Background: Management of unfit AML patients is a therapeutic challenge. Most hematologists tend to avoid aggressive treatment leaving patients with a choice of best supportive care. We hypothesized that metronomic chemotherapy could be an alternative treatment for unfit AML patients. Methods: A multi-center randomized controlled trial was conducted in seven university-affiliated hospitals in Thailand. Unfit AML patients were recruited and followed up from December 2014 to December 2017. Patients were randomly assigned to receive either metronomic chemotherapy or palliative hydroxyurea. Overall survival rates were compared using Cox’s proportional hazard survival analysis. Results: A total of 81 eligible patients were randomly allocated and included for ITT analysis. The OS rate was higher in group receiving metronomic chemotherapy than in group receiving palliative treatment at 6 and 12 months with borderline significance (6 months HR 0.60; 95%CI 0.36, 1.02; p-value 0.060; 12 months: HR 0.66; 95%CI 0.41, 1.08; p-value 0.097). Conclusion: Metronomic chemotherapy could prolong survival time of unfit AML patients, especially in the first 12 months after diagnosis without increasing treatment-associated adverse events.
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Affiliation(s)
- Saranya Pongudom
- Division of Hematology, Department of Internal Medicine, Udon Thani Hospital, Udon Thani, Thailand
| | - Phichayut Phinyo
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Yingyong Chinthammitr
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
| | - Kanyaporn Charoenprasert
- Division of Hematology, Department of Internal Medicine, Si Sa Ket Hospital, Si Sa Ket, Thailand
| | - Harutaya Kasyanan
- Division of Hematology, Department of Internal Medicine, Buddhachinaraj, Hospital, Phitsanulok,Thailand
| | - Klaijith Wongyai
- Division of Hematology, Department of Internal Medicine, Sawanpracharak Hospital, Nakhon Sawan,Thailand
| | - Jittiporn Purattanamal
- Division of Hematology, Department of Internal Medicine, Maharaj Nakhon Si Thammarat Hospital, Nakhon Si Thammarat,Thailand
| | - Naiyana Panoi
- Division of Hematology, Department of Internal Medicine, Chonburi Hospital, Chon Buri, Thailand
| | - Anoree Surawong
- Division of Hematology, Department of Internal Medicine, Sanprasithiprasong Hospital, Ubon Ratchathani, Thailand
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Richard-Carpentier G, DiNardo CD. Single-agent and combination biologics in acute myeloid leukemia. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2019; 2019:548-556. [PMID: 31808888 PMCID: PMC6913489 DOI: 10.1182/hematology.2019000059] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Acute myeloid leukemia (AML) is a heterogeneous malignancy characterized by recurrent genetic, epigenetic, and metabolic abnormalities. As a result of our increasing knowledge of the underlying biology of AML leading to rational drug development, several new targeted agents have been recently added to our therapeutic arsenal. The BCL2 inhibitor venetoclax in combination with low-dose cytarabine (LDAC) or hypomethylating agents (HMAs) is safe and effective in older patients with newly diagnosed AML ineligible for intensive chemotherapy. Glasdegib, a hedgehog pathway inhibitor, may be used in combination with LDAC for the same indication and improves survival compared with LDAC alone. In newly diagnosed, fit, older patients with therapy-related AML or AML with myelodysplasia-related changes, the liposome-encapsulated combination of daunorubicin and cytarabine (CPX-351) has shown superiority over the 7 + 3 regimen. The presence of an IDH1 or IDH2 mutation can be effectively targeted by ivosidenib or enasidenib, respectively. Gemtuzumab ozogamicin improves event-free survival in CD33+ patients with favorable or intermediate-risk cytogenetics. With new targeted agents available, comprehensive genomic characterization of AML at diagnosis and relapse is increasingly necessary to select optimal treatment. Herein, we review the new single-agent and combination biologics (omitting FLT3 inhibitors, which are discussed separately) and provide recommendations on how to best use and manage patients on these regimens in clinical practice.
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Affiliation(s)
| | - Courtney D DiNardo
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, TX
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Richard-Carpentier G, DiNardo CD. Venetoclax for the treatment of newly diagnosed acute myeloid leukemia in patients who are ineligible for intensive chemotherapy. Ther Adv Hematol 2019; 10:2040620719882822. [PMID: 31692757 PMCID: PMC6811760 DOI: 10.1177/2040620719882822] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 09/25/2019] [Indexed: 12/21/2022] Open
Abstract
Acute myeloid leukemia (AML) is an aggressive hematological malignancy with a
globally poor outcome, especially in patients ineligible for intensive
chemotherapy. Until recently, therapeutic options for these patients included
low-dose cytarabine (LDAC) or the hypomethylating agents (HMA) azacitidine and
decitabine, which have historically provided only short-lived and modest
benefits. The oral B-cell lymphoma 2 inhibitor, venetoclax, Venetoclax, an oral
B-cell lymphoma 2 (BCL2) inhibitor, is now approved by the USA Food and Drug
Administration (FDA) in combination with LDAC or HMA in older AML patients
ineligible for intensive chemotherapy. Is now approved by the US Food and Drug
Administration for this indication. In the pivotal clinical trials evaluating
venetoclax either in combination with LDAC or with HMA, the rates of complete
remission (CR) plus CR with incomplete hematological recovery were 54% and 67%,
respectively and the median overall survival (OS) was 10.4 months and
17.5 months, respectively, comparing favorably with outcomes in clinical trials
evaluating single-agent LDAC or HMA. The most common adverse events with
venetoclax combinations are gastrointestinal symptoms, which are primarily low
grade and easily manageable, and myelosuppression, which may require delays
between cycles, granulocyte colony-stimulating factor (G-CSF) administration, or
decreased duration of venetoclax administration per cycle. A bone marrow
assessment after the first cycle of treatment is critical to determine dosing
and timing of subsequent cycles, as most patients will achieve their best
response after one cycle. Appropriate prophylactic measures can reduce the risk
of venetoclax-induced tumor lysis syndrome. In this review, we present clinical
data from the pivotal trials evaluating venetoclax-based combinations in older
patients ineligible for intensive chemotherapy, and provide practical
recommendations for the prevention and management of adverse events associated
with venetoclax.
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Affiliation(s)
| | - Courtney D DiNardo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Box 428, Houston TX 77030, USA
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Keiffer G, Palmisiano N. Acute Myeloid Leukemia: Update on Upfront Therapy in Elderly Patients. Curr Oncol Rep 2019; 21:71. [DOI: 10.1007/s11912-019-0823-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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35
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Chauhan L, Shin M, Wang YC, Loken M, Pollard J, Aplenc R, Hirsch BA, Raimondi S, Ries RE, Bernstein ID, Gamis AS, Alonzo TA, Meshinchi S, Lamba JK. CD33_PGx6_Score Predicts Gemtuzumab Ozogamicin Response in Childhood Acute Myeloid Leukemia: A Report From the Children's Oncology Group. JCO Precis Oncol 2019; 3:1800387. [PMID: 32914031 DOI: 10.1200/po.18.00387] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2019] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The US Food and Drug Administration recently announced reapproval of gemtuzumab ozogamicin (GO) for treatment of CD33-positive acute myeloid leukemia (AML), thus opening up opportunities to develop strategies for effective use of GO. In light of our recent report showing prognostic significance of CD33 splicing single nucleotide polymorphisms (SNPs), the objective of this study was to comprehensively evaluate CD33 SNPs for accurate prediction of patients with AML who are more or less likely to respond to GO. PATIENTS AND METHODS We investigated the five new CD33 SNPs (rs2455069, rs35112940, rs61736475, rs1803254, and rs201074739) for association with CD33 leukemic cell surface expression and clinical response in pediatric patients with AML enrolled in the Children's Oncology Group AAML0531 trial. We further developed a composite CD33 pharmacogenetics (PGx) score using six CD33 SNPs (CD33_PGx6_score) for association with clinical outcome. RESULTS Four CD33 SNPs were associated with cell surface CD33 levels and clinical response in the GO versus no-GO arms. Therefore, the CD33_PGx6_score was built using directional genotype scores for the previously reported splicing SNP and five new SNPs. Patients with a CD33_PGx6_score of 0 or higher had higher CD33 expression levels compared with patients with a score of less than 0 (P < .001). In addition, patients with a score of 0 or higher demonstrated an improved disease-free survival in the GO versus no-GO arms (62.5% ± 7.8% v 46.8% ± 8.3%, respectively; P = .008) and a reduced risk of relapse (28.3% ± 7.2% v 49.9% ± 8.4%, respectively; P < .001). No improvement from GO was observed in patients with a CD33-PGx6_score of less than 0. Consistent results were observed across the risk groups. CONCLUSION In this study, we report a composite CD33_PGx6_score using directional genotype scores of CD33 SNPs. Once validated, our findings hold promise for use of the CD33_PGx6_score to guide efficient use of GO in patients with AML. In addition, because the CD33_PGx6_score considers SNPs with varying abundance in different ethnic groups, it has potential for global application.
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Affiliation(s)
| | | | | | | | - Jessica Pollard
- Maine Medical Center, Portland, ME.,Tufts University, Boston, MA
| | | | | | | | - Rhonda E Ries
- Fred Hutchinson Cancer Research Center, Seattle, WA.,University of Washington, Seattle, WA
| | - Irwin D Bernstein
- Fred Hutchinson Cancer Research Center, Seattle, WA.,University of Washington, Seattle, WA
| | - Alan S Gamis
- Children's Mercy Hospitals and Clinics, Kansas City, MO
| | | | - Soheil Meshinchi
- Fred Hutchinson Cancer Research Center, Seattle, WA.,University of Washington, Seattle, WA
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Rafiee R, Chauhan L, Alonzo TA, Wang YC, Elmasry A, Loken MR, Pollard J, Aplenc R, Raimondi S, Hirsch BA, Bernstein ID, Gamis AS, Meshinchi S, Lamba JK. ABCB1 SNP predicts outcome in patients with acute myeloid leukemia treated with Gemtuzumab ozogamicin: a report from Children's Oncology Group AAML0531 Trial. Blood Cancer J 2019; 9:51. [PMID: 31113932 PMCID: PMC6529443 DOI: 10.1038/s41408-019-0211-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 04/15/2019] [Indexed: 12/25/2022] Open
Abstract
Gemtuzumab-ozogamicin (GO), a humanized-anti-CD33 antibody linked with the toxin-calicheamicin-γ is a reemerging and promising drug for AML. Calicheamicin a key element of GO, induces DNA-damage and cell-death once the linked CD33-antibody facilitates its uptake. Calicheamicin efflux by the drug-transporter PgP-1 have been implicated in GO response thus in this study, we evaluated impact of ABCB1-SNPs on GO response. Genomic-DNA samples from 942 patients randomized to receive standard therapy with or without addition of GO (COG-AAML0531) were genotyped for ABCB1-SNPs. Our most interesting results show that for rs1045642, patients with minor-T-allele (CT/TT) had better outcome as compared to patients with CC genotype in GO-arm (Event-free survival-EFS: p = 0.022; and risk of relapse-RR, p = 0.007). In contrast, no difference between genotypes was observed for any of the clinical endpoints within No-GO arm (all p > 0.05). Consistent results were obtained when genotype groups were compared by GO and No-GO arms. The in vitro evaluation using HL60-cells further demonstrated consistent impact of rs1045642-T-allele on calicheamicin induced DNA-damage and cell-viability. Our results show the significance of ABCB1 SNPs on GO response in AML and warrants the need to investigate this in other cohorts. Once validated, ABCB1-SNPs in conjunction with CD33-SNPs can open up opportunities to personalize GO-therapy.
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Affiliation(s)
- Roya Rafiee
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Lata Chauhan
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Todd A Alonzo
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | | | | | | | - Jessica Pollard
- Dana-Farber/Boston Children's Cancer Center and Blood Disorders Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Richard Aplenc
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Susana Raimondi
- Department of Pathology, St. Jude Children's Hospital, Memphis, TN, USA
| | - Betsy A Hirsch
- Children's Hospitals and Clinic of Minnesota, University of Minnesota, Minneapolis, MN, USA
| | - Irwin D Bernstein
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Alan S Gamis
- Division of Hematology/Oncology/Bone Marrow Transplantation, Children's Mercy Hospitals and Clinics, Kansas City, MO, USA
| | - Soheil Meshinchi
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Jatinder K Lamba
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, FL, USA.
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New study-designs to address the clinical complexity of acute myeloid leukemia. Leukemia 2019; 33:567-569. [DOI: 10.1038/s41375-018-0363-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 12/11/2018] [Indexed: 02/06/2023]
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Abstract
PURPOSE OF REVIEW Precious few drugs were successfully developed for acute myeloid leukemia (AML) over the past decades, despite a dramatic expansion of our understanding of its molecular underpinnings during this time. Then in 2017, a wave of new drugs suddenly became approved. This review serves to introduce the newly available drugs, discuss their impact upon therapy, and highlight additional novel agents that are waiting in the wings. RECENT FINDINGS Newly approved agents in AML include a tyrosine kinase inhibitor for patients with FMS-like tyrosine kinase 3 (FLT3) mutations, an inhibitor of mutant isocitrate dehydrogenase (IDH2), and two novel agents using antibody-delivered or liposome-delivered cytotoxics. All of these new agents have demonstrable activity in AML and several have improved survival in randomized studies. In addition to these agents, promising data from other inhibitors of FLT3, IDH1, and B-cell lymphoma 2 (BCL2) will be discussed. SUMMARY Response, survival, and symptom burden of AML therapy are all improving through novel agents. As many of the newly approved drugs benefit-specific genetic subsets, a new priority has emerged to increase the speed of diagnostic genomic studies as a means to guide frontline therapy. This will ensure patients are optimally categorized and treated with to the most rational agents.
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Cortes JE, Heidel FH, Hellmann A, Fiedler W, Smith BD, Robak T, Montesinos P, Pollyea DA, DesJardins P, Ottmann O, Ma WW, Shaik MN, Laird AD, Zeremski M, O'Connell A, Chan G, Heuser M. Randomized comparison of low dose cytarabine with or without glasdegib in patients with newly diagnosed acute myeloid leukemia or high-risk myelodysplastic syndrome. Leukemia 2018; 33:379-389. [PMID: 30555165 PMCID: PMC6365492 DOI: 10.1038/s41375-018-0312-9] [Citation(s) in RCA: 349] [Impact Index Per Article: 58.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 11/02/2018] [Indexed: 01/19/2023]
Abstract
Glasdegib is a Hedgehog pathway inhibitor. This phase II, randomized, open-label, multicenter study (ClinicalTrials.gov, NCT01546038) evaluated the efficacy of glasdegib plus low-dose cytarabine (LDAC) in patients with acute myeloid leukemia (AML) or high-risk myelodysplastic syndrome unsuitable for intensive chemotherapy. Glasdegib 100 mg (oral, QD) was administered continuously in 28-day cycles; LDAC 20 mg (subcutaneous, BID) was administered for 10 per 28 days. Patients (stratified by cytogenetic risk) were randomized (2:1) to receive glasdegib/LDAC or LDAC. The primary endpoint was overall survival. Eighty-eight and 44 patients were randomized to glasdegib/LDAC and LDAC, respectively. Median (80% confidence interval [CI]) overall survival was 8.8 (6.9–9.9) months with glasdegib/LDAC and 4.9 (3.5–6.0) months with LDAC (hazard ratio, 0.51; 80% CI, 0.39–0.67, P = 0.0004). Fifteen (17.0%) and 1 (2.3%) patients in the glasdegib/LDAC and LDAC arms, respectively, achieved complete remission (P < 0.05). Nonhematologic grade 3/4 all-causality adverse events included pneumonia (16.7%) and fatigue (14.3%) with glasdegib/LDAC and pneumonia (14.6%) with LDAC. Clinical efficacy was evident across patients with diverse mutational profiles. Glasdegib plus LDAC has a favorable benefit–risk profile and may be a promising option for AML patients unsuitable for intensive chemotherapy.
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Affiliation(s)
- Jorge E Cortes
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, TX, USA.
| | - Florian H Heidel
- Otto-von-Guericke University Medical Center, Magdeburg, Germany.,Internal Medicine II, University Hospital Jena, Jena, Germany
| | - Andrzej Hellmann
- Department of Haematology and Transplantology, Medical University of Gdańsk, Gdańsk, Poland
| | - Walter Fiedler
- Department of Hematology and Oncology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - B Douglas Smith
- Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - Tadeusz Robak
- Department of Hematology, Medical University of Lodz, Lodz, Poland
| | - Pau Montesinos
- Hospital Universitari i Politècnic La Fe, Valencia, Spain.,CIBERONC, Instituto Carlos III, Madrid, Spain
| | - Daniel A Pollyea
- Division of Hematology, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Oliver Ottmann
- Division of Cancer and Genetics, School of Medicine, Cardiff University, Cardiff, UK
| | | | | | | | | | | | | | - Michael Heuser
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
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Gbadamosi M, Meshinchi S, Lamba JK. Gemtuzumab ozogamicin for treatment of newly diagnosed CD33-positive acute myeloid leukemia. Future Oncol 2018; 14:3199-3213. [PMID: 30039981 PMCID: PMC6331698 DOI: 10.2217/fon-2018-0325] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 06/25/2018] [Indexed: 12/17/2022] Open
Abstract
In September 2017, the US FDA announced re-approval of gemtuzumab ozogamicin (GO), a CD33-targeting immunoconjugate, for treatment of newly diagnosed and relapsed/refractory acute myeloid leukemia (AML). This is a very significant step toward defining new treatment regimens in AML, as the treatment has essentially stayed unchanged with the '7 + 3 induction regimen' (7 days cytarabine and 3 days of anthracycline) since 1973. GO is the first antibody-drug conjugate to receive FDA approval for treating cancer. This review article discusses the challenges faced and lessons learned during the journey of GO for AML treatment. Selected trials that have made significant contribution in our understanding of the most efficacious and safe use of GO for treating AML patients as well as factors influencing GO response are highlighted in this article.
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MESH Headings
- Age Factors
- Aminoglycosides/administration & dosage
- Aminoglycosides/adverse effects
- Aminoglycosides/therapeutic use
- Antibodies, Monoclonal, Humanized/administration & dosage
- Antibodies, Monoclonal, Humanized/adverse effects
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antineoplastic Agents, Immunological/administration & dosage
- Antineoplastic Agents, Immunological/adverse effects
- Antineoplastic Agents, Immunological/therapeutic use
- Biomarkers, Tumor
- Drug Discovery
- France
- Gemtuzumab
- Humans
- Leukemia, Myeloid, Acute/diagnosis
- Leukemia, Myeloid, Acute/drug therapy
- Leukemia, Myeloid, Acute/genetics
- Leukemia, Myeloid, Acute/metabolism
- Molecular Targeted Therapy
- Randomized Controlled Trials as Topic
- Sialic Acid Binding Ig-like Lectin 3/antagonists & inhibitors
- Sialic Acid Binding Ig-like Lectin 3/genetics
- Sialic Acid Binding Ig-like Lectin 3/metabolism
- Treatment Outcome
- United States
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Affiliation(s)
- Mohammed Gbadamosi
- Department of Pharmacotherapy & Translational Research, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
| | - Soheil Meshinchi
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA
| | - Jatinder K Lamba
- Department of Pharmacotherapy & Translational Research, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
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Pickles T, Christensen R, Tam LS, Simon LS, Choy EH. Early phase and adaptive design clinical trials in rheumatoid arthritis: a systematic review of early phase trials. Rheumatol Adv Pract 2018; 2:rky045. [PMID: 31431982 PMCID: PMC6649924 DOI: 10.1093/rap/rky045] [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] [Received: 01/08/2018] [Revised: 09/17/2018] [Indexed: 12/21/2022] Open
Abstract
Objective Adaptive designs can enable highly sophisticated and efficient early phase trials, but the clinical inference from these trials is surrounded by complexity, and currently there is a paucity but steadily increasing amount of use of these designs in all fields of medicine. We aim to review early phase trials in RA to discover those that have used adaptive designs and benchmark trial characteristics. Methods From an OVID search for journal articles reporting the results of early phase trials in rheumatology, 35 studies were found, with 9 subsequently excluded; 11 were added from manual searches and 19 from searching the references. Study characteristics were extracted from the 56 papers (describing 62 trials), including the number of arms, number of patients, the primary outcome and when it was measured. Result One early phase trial using an adaptive design was found. The benchmark early phase trial in RA is a phase II double-blinded randomized trial, with four arms (one control and three intervention), each with 34 patients, and ACR20 measured at 16 weeks as the primary outcome. Conclusion The one adaptive design reviewed here, and a simulation study found in the search, both indicate that adaptive designs can be applied to early phase trials in RA. We have described the benchmark, which the efficiency of early phase trials using an adaptive design needs to exceed. These efficient designs could drive down numbers required, time for data collection and thus cost. Changes have been suggested, but more needs to be done.
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Affiliation(s)
- Tim Pickles
- Cardiff Regional Experimental Arthritis Treatment and Evaluation (CREATE) Centre, Division of Infection and Immunity, School of Medicine, College of Biomedical and Life Sciences, Cardiff University.,Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Robin Christensen
- Musculoskeletal Statistics Unit, The Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Lai-Shan Tam
- Department of Medicine & Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | | | - Ernest H Choy
- Cardiff Regional Experimental Arthritis Treatment and Evaluation (CREATE) Centre, Division of Infection and Immunity, School of Medicine, College of Biomedical and Life Sciences, Cardiff University
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A phase 1 trial of vadastuximab talirine combined with hypomethylating agents in patients with CD33-positive AML. Blood 2018; 132:1125-1133. [PMID: 30045838 DOI: 10.1182/blood-2018-03-841171] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 07/11/2018] [Indexed: 01/05/2023] Open
Abstract
Treatment of acute myeloid leukemia (AML) among the elderly is challenging because of intolerance of intensive therapy and therapy-resistant biology. Hypomethylating agents (HMAs) are commonly used, with suboptimal outcomes. Vadastuximab talirine is a CD33-directed antibody conjugated to pyrrolobenzodiazepine (PBD) dimers. Preclinically, HMAs followed by vadastuximab talirine produced upregulated CD33 expression, increased DNA incorporation by PBD, and enhanced cytotoxicity. A combination cohort in a phase 1 study (NCT01902329) assessed safety, tolerability, and activity of vadastuximab talirine with HMAs. Those eligible had Eastern Cooperative Oncology Group status 0 to 1 and previously untreated CD33-positive AML, and declined intensive therapy. Vadastuximab talirine was administered intravenously at 10 μg/kg on last day of HMA (azacitidine or decitabine) infusion in 4-week cycles. Among 53 patients treated, the median age was 75 years. Patients had adverse (38%) or intermediate (62%) cytogenetic risk. Median treatment duration was 19.3 weeks. No dose-limiting toxicities were reported. The majority of adverse events were a result of myelosuppression, with some causing therapy delays. Thirty- and 60-day mortality rates were 2% and 8%, respectively. The composite remission rate (complete remission [CR] and CR with incomplete blood count recovery) was 70%. Fifty-one percent of remissions were minimal residual disease-negative by flow cytometry. Similarly high remission rates were observed in patients with secondary AML, aged at least 75 years, and with adverse cytogenetic risk. Median relapse-free survival and overall survival were 7.7 and 11.3 months, respectively. Compared with historical data for HMA monotherapy, the combination of vadastuximab talirine with HMAs produced a high remission rate, but was accompanied by increased hematologic toxicity.
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43
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Burnett AK. Treatment of Older Patients With Newly Diagnosed AML Unfit for Traditional Therapy. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2018; 18:553-557. [PMID: 30007570 DOI: 10.1016/j.clml.2018.06.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 06/26/2018] [Indexed: 11/28/2022]
Abstract
Older patients with acute myeloid leukemia represent at least one half of those with the disease for whom randomized clinical trials of new treatments are in development. These patients represent an appropriate population in which to evaluate new treatments against the current standards of care, which could be azacitidine, decitabine, or low-dose cytarabine. However, despite the identification of treatments that can deliver a worthwhile increase in remission, none has yet delivered a survival superiority when assessed in a randomized setting, although some recent efforts provide encouragement.
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Affiliation(s)
- Alan K Burnett
- (Retired), Cardiff University Ty Mawr, Blackwaterfoot, United Kingdom.
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Candoni A, Papayannidis C, Martinelli G, Simeone E, Gottardi M, Iacobucci I, Gherlinzoni F, Visani G, Baccarani M, Fanin R. Flai (fludarabine, cytarabine, idarubicin) plus low-dose Gemtuzumab Ozogamicin as induction therapy in CD33-positive AML: Final results and long term outcome of a phase II multicenter clinical trial. Am J Hematol 2018; 93:655-663. [PMID: 29396857 DOI: 10.1002/ajh.25057] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 01/29/2018] [Accepted: 01/30/2018] [Indexed: 11/12/2022]
Abstract
The aim of this prospective clinical trial was to evaluate the efficacy and safety of a combination of Gemtuzumab-Ozogamicin (GO) and FLAI scheme (fludarabine, cytarabine, idarubicin) as a first-line therapy in CD33 positive AML. We treated 130 patients, aged <65, with a median age of 52 years. FLAI-GO induction regimen included fludarabine (30 mg/sqm) and cytarabine (2 g/sqm) on days 1-5; idarubicin (10 mg/sqm) on days 1, 3, and 5; and GO (3 mg/sqm) on day 6. SCT was planned for all high-risk AML patients, after consolidation with intermediate doses of cytarabine and idarubicin and a high dose of cytarabine. CD33 expression exceeded 20% in all cases. Primary endpoints of the study included feasibility, overall response rate (ORR) and toxicity. Secondary endpoints included the evaluation of MRD by WT1 expression, feasibility and outcome of consolidation with SCT, overall survival (OS) and disease-free survival (DFS). After induction with FLAI-GO, complete remission (CR) rate was 82%. Four patients achieved partial remission (PR) and 12% were resistant (ORR 85%); death during induction (DDI) was 3%. The hematological and extra hematological toxicity of FLAI-GO was manageable; 45% of patients experienced transient and reversible GO infusion related adverse events. In the setting of patients who achieved a cytological CR after FLAI-GO, the mean of WT1 copies dropped from 8337±9936 copies/104 ABL (diagnosis) to 182 ± 436 copies after induction therapy (p = 0.0001) showing a very good disease debulking. After a median follow-up of 54 months, 67/130 (52%) patients were alive. The probability of 1, 2, and 5-year OS was 80%, 63%, and 52%, respectively. The probability of 1, 2, and 5-year DFS was 77%, 58%, and 52%, respectively. Allogeneic and autologous SCT was performed in 60 (46%) and 23 (18%) patients, respectively. In summary, the final results of this trial confirm that FLAI-GO is an active and safe treatment strategy for CD33-positive AML patients aged ≤ 65 years, allowing a high ORR, a good disease debulking, favorable safety profile, low DDI, and subsequent high SCT rate. The encouraging results of this trial, consolidated by a long follow-up, support the reintroduction of GO in clinical practice.
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Affiliation(s)
- Anna Candoni
- Division of Hematology and SCT; University of Udine; Udine Italy
| | - Cristina Papayannidis
- Institute of Hematology and Oncology L. and A. Seràgnoli, University of Bologna; Bologna Italy
| | - Giovanni Martinelli
- Institute of Hematology and Oncology L. and A. Seràgnoli, University of Bologna; Bologna Italy
| | - Erica Simeone
- Division of Hematology and SCT; University of Udine; Udine Italy
| | | | - Ilaria Iacobucci
- Institute of Hematology and Oncology L. and A. Seràgnoli, University of Bologna; Bologna Italy
| | | | - Giuseppe Visani
- Hematology and SCT Center; San Salvatore Hospital; Pesaro Italy
| | - Michele Baccarani
- Institute of Hematology and Oncology L. and A. Seràgnoli, University of Bologna; Bologna Italy
| | - Renato Fanin
- Division of Hematology and SCT; University of Udine; Udine Italy
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Michaelis LC, Klepin HD, Walter RB. Advancements in the management of medically less-fit and older adults with newly diagnosed acute myeloid leukemia. Expert Opin Pharmacother 2018; 19:865-882. [PMID: 29697000 DOI: 10.1080/14656566.2018.1465562] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Treating acute myeloid leukemia (AML) in older adults remains daunting. The unique biology often renders conventional chemotherapies less effective. Accurately predicting the toxicities of treatment is another unresolved challenge. Treatment planning thus requires a good knowledge of the current trial data and familiarity with clinical tools, including formal fitness and geriatric assessments. Both obstacles - disease biology and patient fitness - might be easier overcome with specific, AML cell-targeted agents rather than traditional cytotoxic chemotherapy. This may be the future of AML therapy, but it is not our current state. AREAS COVERED Herein, the authors appraise the data supporting a standard induction approach, including an outline of how to predict treatment-related mortality and a review of the most up-to-date methods of geriatric assessment. They also discuss treatment expectations with less-intense therapies and highlight novel agents in development. Finally, they provide a basic approach to choosing treatment intensity. EXPERT OPINION In an older and/or medically less-fit patient, treatment choice should begin with a thorough disease assessment, a formal evaluation of patient fitness and frailty. There should also be a clear communication with the patient and patient's family about the risks and anticipated benefits of either an intense or nonintense treatment approach.
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Affiliation(s)
- Laura C Michaelis
- a Associate Professor of Medicine, Department of Hematology and Oncology , Medical College of Wisconsin , Milwaukee , WI , USA
| | - Heidi D Klepin
- b Associate Professor of Internal Medicine, Section on Hematology and Oncology , Wake Forest School of Medicine , Winston-Salem , NC , USA
| | - Roland B Walter
- c Associate Member, Clinical Research Division , Fred Hutchinson Cancer Research Center , Seattle , WA , USA.,d Associate Professor of Medicine, Department of Medicine, Division of Hematology , University of Washington , Seattle , WA , USA.,e Adjunct Associate Professor, Department of Epidemiology , University of Washington , Seattle , WA , USA
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Bloomfield CD, Estey E, Pleyer L, Schuh AC, Stein EM, Tallman MS, Wei A. Time to repeal and replace response criteria for acute myeloid leukemia? Blood Rev 2018; 32:416-425. [PMID: 29706486 DOI: 10.1016/j.blre.2018.03.006] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 02/14/2018] [Accepted: 03/22/2018] [Indexed: 01/08/2023]
Abstract
The International Working Group (IWG) response criteria for acute myeloid leukemia, published in 2003, have remained the standard by which the efficacy of new drugs is measured in clinical trials. Over the last decade, concepts related to treatment response have been challenged by several factors; for example, the dissociation between early clinical response and survival outcome in older patients, the recognition that epigenetic and newer differentiating-agent therapies may produce delayed responses and also hematologic improvement/transfusion independence without a morphologic response, and evidence that remissions without minimal (or measurable) residual disease (MRD) may result in outcomes superior to those of morphologic remissions with persistent MRD. The evolving role of MRD status as a potential surrogate for predicting long-term survival has enhanced the clinical need to standardize and incorporate emerging technologies that enable deeper responses beyond those recognized by the IWG, and to pre-emptively identify patients at risk of early relapse. The potential for therapeutic interventions to erase MRD and alter the natural history represents an important and open research question. Reviewed here are some of the implications and challenges associated with establishing and incorporating new treatment response criteria, initially into clinical research, and eventually into real-world practice.
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Affiliation(s)
| | - Elihu Estey
- Fred Hutchinson Cancer Research Center, Seattle, United States
| | - Lisa Pleyer
- Paracelsus Medical University, Salzburg, Austria; Salzburg Cancer Research Institute, Center for Clinical Cancer and Immunology Trials, Salzburg, Austria; Cancer Cluster Salzburg, Salzburg, Austria
| | | | - Eytan M Stein
- Memorial Sloan-Kettering Cancer Center, New York, United States; Weill Cornell Medical College, New York, United States
| | - Martin S Tallman
- Memorial Sloan-Kettering Cancer Center, New York, United States; Weill Cornell Medical College, New York, United States
| | - Andrew Wei
- The Alfred Hospital and Monash University, Melbourne, Australia.
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Rossi C, Chrétien ML, Casasnovas RO. Antibody–Drug Conjugates for the Treatment of Hematological Malignancies: A Comprehensive Review. Target Oncol 2018; 13:287-308. [DOI: 10.1007/s11523-018-0558-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Brinda B, Khan I, Parkin B, Konig H. The rocky road to personalized medicine in acute myeloid leukaemia. J Cell Mol Med 2018; 22:1411-1427. [PMID: 29327808 PMCID: PMC5824388 DOI: 10.1111/jcmm.13478] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 10/11/2017] [Indexed: 12/26/2022] Open
Abstract
Acute myeloid leukaemia (AML) is a malignant disorder of the myeloid blood lineage characterized by impaired differentiation and increased proliferation of hematopoietic precursor cells. Recent technological advances have led to an improved understanding of AML biology but also uncovered the enormous cytogenetic and molecular heterogeneity of the disease. Despite this heterogeneity, AML is mostly managed by a 'one-size-fits-all' approach consisting of intensive, highly toxic induction and consolidation chemotherapy. These treatment protocols have remained largely unchanged for the past several decades and only lead to a cure in approximately 30-35% of cases. The advent of targeted therapies in chronic myeloid leukaemia and other malignancies has sparked hope to improve patient outcome in AML. However, the implementation of targeted agents in AML therapy has been unexpectedly cumbersome and remains a difficult task due to a variety of disease- and patient-specific factors. In this review, we describe current standard and investigational therapeutic strategies with a focus on targeted agents and highlight potential tools that might facilitate the development of targeted therapies for this fatal disease. The classes of agents described in this review include constitutively activated signalling pathway inhibitors, surface receptor targets, epigenetic modifiers, drugs targeting the interaction of the hematopoietic progenitor cell with the stroma and drugs that target the apoptotic machinery. The clinical context and outcome with these agents will be examined to gain insight about their optimal utilization.
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Affiliation(s)
- Bryan Brinda
- Indiana University Melvin and Bren Simon Cancer CenterIndianapolisINUSA
| | - Irum Khan
- Division of Hematology and OncologyCollege of Medicine at ChicagoUniversity of IllinoisChicagoILUSA
| | - Brian Parkin
- University of Michigan Comprehensive Cancer CenterAnn ArborMIUSA
| | - Heiko Konig
- Indiana University Melvin and Bren Simon Cancer CenterIndianapolisINUSA
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Abstract
Acute myeloid leukemia (AML) therapies are rapidly evolving with novel targeted therapies showing high-level responses in a notoriously difficult to treat group of patients - the elderly and unfit. This review will examine the outcomes of older AML patients (>60 years old) with conventional induction strategies, and published literature on risks of pursuit of induction. Low-intensity combination therapy response rates appear to be approaching that of induction regimens, and with lower toxicity, low-intensity therapy likely represents the future standard approach in this age group. Lastly, allogeneic transplant appears to have a role in increasing durable remissions regardless of age and should be considered in patients with limited comorbidities.
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Affiliation(s)
- Jonathan A Webster
- a Department of Oncology , Johns Hopkins University , Baltimore , MD , USA
| | - Keith W Pratz
- a Department of Oncology , Johns Hopkins University , Baltimore , MD , USA
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50
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Walter RB, Michaelis LC, Othus M, Uy GL, Radich JP, Little RF, Hita S, Saini L, Foran JM, Gerds AT, Klepin HD, Hay AE, Assouline S, Lancet JE, Couban S, Litzow MR, Stone RM, Erba HP. Intergroup LEAP trial (S1612): A randomized phase 2/3 platform trial to test novel therapeutics in medically less fit older adults with acute myeloid leukemia. Am J Hematol 2018; 93:E49-E52. [PMID: 29164656 DOI: 10.1002/ajh.24980] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 11/16/2017] [Indexed: 11/09/2022]
Affiliation(s)
- Roland B. Walter
- Clinical Research Division; Fred Hutchinson Cancer Research Center; Seattle Washington
- Department of Medicine; University of Washington; Seattle Washington
| | - Laura C. Michaelis
- Department of Hematology and Oncology; Medical College of Wisconsin; Milwaukee Wisconsin
| | - Megan Othus
- SWOG Statistical Center, Fred Hutchinson Cancer Research Center; Seattle Washington
| | - Geoffrey L. Uy
- Division of Oncology, Department of Medicine; Washington University School of Medicine; St Louis Missouri
| | - Jerald P. Radich
- Clinical Research Division; Fred Hutchinson Cancer Research Center; Seattle Washington
- Department of Medicine; University of Washington; Seattle Washington
| | - Richard F. Little
- Cancer Therapy Evaluation Program, National Cancer Institute; Rockville Madison
| | | | - Lalit Saini
- Department of Medicine; University of Alberta; Edmonton Alberta Canada
| | - James M. Foran
- Division of Hematology and Oncology; Mayo Clinic; Jacksonville Florida
| | - Aaron T. Gerds
- Department of Hematology and Medical Oncology; Cleveland Clinic Taussig Cancer Institute; Cleveland Ohio
| | - Heidi D. Klepin
- Wake Forest Baptist Comprehensive Cancer Center, Wake Forest University; Winston-Salem North Carolina
| | - Annette E. Hay
- Department of Medicine; Queen's University; Kingston Ontario Canada
| | | | | | - Stephen Couban
- Division of Hematology; Dalhousie University; Halifax Nova Scotia Canada
| | - Mark R. Litzow
- Division of Hematology, Department of Internal Medicine; Mayo Clinic; Rochester Minnesota
| | - Richard M. Stone
- Adult Leukemia Program, Dana-Farber Cancer Institute, Harvard Medical School; Boston Massachusetts
| | - Harry P. Erba
- Division of Hematology/Oncology; University of Alabama at Birmingham; Birmingham Alabama
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