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Klyuchnikov E, Langebrake C, Badbaran A, Dadkhah A, Massoud R, Freiberger P, Ayuk F, Janson D, Wolschke C, Bacher U, Kröger N. Individualized busulfan dosing improves outcomes compared to fixed-dose administration in pre-transplant minimal residual disease-positive acute myeloid leukemia patients with intermediate-risk undergoing allogeneic stem cell transplantation in CR. Eur J Haematol Suppl 2023; 110:188-197. [PMID: 36335432 DOI: 10.1111/ejh.13893] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 10/30/2022] [Accepted: 11/02/2022] [Indexed: 11/07/2022]
Abstract
Pre-transplant minimal residual disease (MRD) impacts negatively on post-transplant relapse risk in acute myeloid leukemia (AML). Therapeutic drug monitoring by calculating area under the curve (AUC) was developed to optimize busulfan (Bu) exposure. Here, we compared post-transplant outcomes after individualized versus fixed busulfan dosage in intermediate-risk AML who achieved CR prior to allograft focusing on pre-transplant flow-MRD. Eighty-seven patients (median, 56 years) with intermediate-risk AML and pre-transplant flow-MRD ("different from normal") were included. Thirty-two patients received individualized busulfan; 54 fixed dosages. Individualized dosage was adjusted in 25/32 patients: increased, n = 18/25 (72%); decreased: n = 7/25 (28%). After median follow-up of 27 months, we observed lower 3-year relapses (6%, 2%-19% vs. 35%, 23%-49% p = 0.02), improved 3-year leukemia-free survival (LFS) (78%, 54%-91% vs. 55%, 40%-70% p = 0.009) and - overall survival (OS) (82%, 60%-93% vs. 69%, 54%-81% p = 0.05) after individualized compared to fixed Bu. Non-relapsed mortality (NRM) and acute graft versus host disease (GvHD) were not different. In multivariate analysis, fixed Bu showed unfavorable impact on OS (hazard ratio [HR] 4.6, p = 0.044), LFS (HR 3.6, p = 0.018) and relapses (HR 3.6, p = 0.033). Fixed Bu also had unfavorable impact on LFS (3.6, 1.1-12.6, p = 0.041) in pre-transplant MRD-positive patients. Individualized, AUC-based, busulfan is associated with lower relapses in intermediate-risk AML patients allografted in CR and may overcome pre-transplant MRD-positivity.
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Affiliation(s)
- Evgeny Klyuchnikov
- Department of Stem Cell Transplantation, University Medical Center Eppendorf, University of Hamburg, Hamburg, Germany
| | - Claudia Langebrake
- Department of Stem Cell Transplantation, University Medical Center Eppendorf, University of Hamburg, Hamburg, Germany.,Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anita Badbaran
- Department of Stem Cell Transplantation, University Medical Center Eppendorf, University of Hamburg, Hamburg, Germany
| | - Adrin Dadkhah
- Department of Stem Cell Transplantation, University Medical Center Eppendorf, University of Hamburg, Hamburg, Germany.,Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Radwan Massoud
- Department of Stem Cell Transplantation, University Medical Center Eppendorf, University of Hamburg, Hamburg, Germany
| | - Petra Freiberger
- Department of Stem Cell Transplantation, University Medical Center Eppendorf, University of Hamburg, Hamburg, Germany
| | - Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Center Eppendorf, University of Hamburg, Hamburg, Germany
| | - Dietlinde Janson
- Department of Stem Cell Transplantation, University Medical Center Eppendorf, University of Hamburg, Hamburg, Germany
| | - Christine Wolschke
- Department of Stem Cell Transplantation, University Medical Center Eppendorf, University of Hamburg, Hamburg, Germany
| | - Ulrike Bacher
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Eppendorf, University of Hamburg, Hamburg, Germany
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2
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Smita P, Narayan PA, J K, Gaurav P. Therapeutic drug monitoring for cytotoxic anticancer drugs: Principles and evidence-based practices. Front Oncol 2022; 12:1015200. [PMID: 36568145 PMCID: PMC9773989 DOI: 10.3389/fonc.2022.1015200] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/24/2022] [Indexed: 12/13/2022] Open
Abstract
Cytotoxic drugs are highly efficacious and also have low therapeutic index. A great degree of caution needs to be exercised in their usage. To optimize the efficacy these drugs need to be given at maximum tolerated dose which leads to significant amount of toxicity to the patient. The fine balance between efficacy and safety is the key to the success of cytotoxic chemotherapeutics. However, it is possibly more rewarding to obtain that balance for this class drugs as the frequency of drug related toxicities are higher compared to the other therapeutic class and are potentially life threatening and may cause prolonged morbidity. Significant efforts have been invested in last three to four decades in therapeutic drug monitoring (TDM) research to understand the relationship between the drug concentration and the response achieved for therapeutic efficacy as well as drug toxicity for cytotoxic drugs. TDM evolved over this period and the evidence gathered favored its routine use for certain drugs. Since, TDM is an expensive endeavor both from economic and logistic point of view, to justify its use it is necessary to demonstrate that the implementation leads to perceivable improvement in the patient outcomes. It is indeed challenging to prove the utility of TDM in randomized controlled trials and at times may be nearly impossible to generate such data in view of the obvious findings and concern of compromising patient safety. Therefore, good quality data from well-designed observational study do add immense value to the scientific knowledge base, when they are examined in totality, despite the heterogeneity amongst them. This article compiles the summary of the evidence and the best practices for TDM for the three cytotoxic drug, busulfan, 5-FU and methotrexate. Traditional use of TDM or drug concentration data for dose modification has been witnessing a sea change and model informed precision dosing is the future of cytotoxic drug therapeutic management.
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Affiliation(s)
- Pattanaik Smita
- Department of Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, India,*Correspondence: Pattanaik Smita,
| | - Patil Amol Narayan
- Department of Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Kumaravel J
- Department of Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Prakash Gaurav
- Department of Clinical Hematology and Medical Oncology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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3
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Liu MA, Lee CC, Phung Q, Dao QL, Tehrani B, Yao M, Li CC, Wu KH, Chen TC, Gau JP, Li SS, Wang PN, Liu YC, Wang TF, Chiou LW, Lee MY, Yu MS, Wang CC, Lin SC, Chen YC, Chao TY, Ma MC, Chen CC, Chang HH. Incidence and predictors of idiopathic pneumonia syndrome in hematopoietic stem cell transplant patients: a nationwide registry study. Int J Hematol 2022; 116:770-777. [PMID: 35838917 DOI: 10.1007/s12185-022-03417-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 07/04/2022] [Accepted: 07/05/2022] [Indexed: 11/24/2022]
Abstract
Idiopathic pneumonia syndrome (IPS) is a rare but deadly complication of hematopoietic stem cell transplantation (HSCT). This study characterized the incidence and risk factors for IPS after HSCT in Taiwan. Data from January 2009 to February 2019 was collected from the Taiwan Society of BMT national registry. Forty-three (1.1%) of 3924 HSCT patients who developed IPS were identified. Incidence of IPS was lower in patients who received autologous HSCT than patients who received allogeneic HSCT (0.68% vs 1.44%, P = 0.022). Multivariate analysis showed that use of TBI and intravenous busulfan in the conditioning regimen were each independent predictor of IPS after HSCT. In addition, development of IPS was significantly associated with increased risk of death in the first 120 days post-HSCT (HR, 2.09; 95% CI, 1.08 to 4.05, P = 0.029) and 2 years post-HSCT (HR, 1.65; 95% CI, 1.07 to 2.542, P = 0.023), but not beyond 2 years post-HSCT. However, survival outcomes did not differ significantly between patients with IPS who received autologous versus allogeneic HSCT (P = 0.52). In conclusion, despite the relatively low incidence of post-HSCT IPS in Taiwan, mortality remains high. The results of this study will help to identify high-risk patients for early intervention and guide future therapeutic research.
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Affiliation(s)
- Michael A Liu
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Chien-Chang Lee
- Department of Emergency Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Quan Phung
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Quynh-Lan Dao
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Babak Tehrani
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Ming Yao
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chi-Cheng Li
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Kang-Hsi Wu
- Department of Pediatrics, China Medical University Children's Hospital, Taichung, Taiwan
| | - Tsung-Chih Chen
- Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Jyh-Pyng Gau
- Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Sin-Syue Li
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Po-Nan Wang
- Department of Internal Medicine, Linkou Branch, Chang Gung Memorial Hospital, Taoyun, Taiwan
| | - Yi-Chang Liu
- Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Tso-Fu Wang
- Department of Hematology and Oncology, Buddhist Tzu-Chi General Hospital, Hualien, Taiwan
| | - Lun-Wei Chiou
- Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan
| | - Ming-Yang Lee
- Department of Internal Medicine, Ditmanson Medical Foundation Chiayi Christian Hospital, Chiayi, Taiwan
| | - Ming-Sun Yu
- Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Chuan-Cheng Wang
- Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Shih-Chiang Lin
- Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Yeu-Chin Chen
- Department of Medicine, Tri-Service General Hospital, Taipei, Taiwan
| | - Tsu-Yi Chao
- Department of Medicine, Taipei Medical University-Shuang Ho Hospital, New Taipei City, Taiwan
| | - Ming-Chun Ma
- Department of Internal Medicine, Kaohsiung Chang-Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Chih-Cheng Chen
- Department of Internal Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Hsiu-Hao Chang
- Department of Pediatrics, National Taiwan University Hospital, National Taiwan University College of Medicine, No. 8 Chung-Shan South Road, Taipei, 10041, Taiwan.
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Baccarani M, Bonifazi F, Soverini S, Castagnetti F, Gugliotta G, Saber W, Estrada-Merly N, Rosti G, Gale RP. Questions concerning tyrosine kinase-inhibitor therapy and transplants in chronic phase chronic myeloid leukaemia. Leukemia 2022; 36:1227-1236. [PMID: 35338251 PMCID: PMC9061294 DOI: 10.1038/s41375-022-01522-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 01/25/2022] [Accepted: 02/02/2022] [Indexed: 01/07/2023]
Abstract
In this provocative commentary, we consider several questions posed by the late chronic myeloid leukaemia (CML) expert Prof. Michele Baccarani, which he challenged us to address after his death. He noted only a small proportion of people with chronic phase CML receiving tyrosine kinase-inhibitor (TKI)-therapy are likely to achieve sustained therapy-free remission (TFR) and even fewer are likely to be cured. Persons most likely to fail TKItherapy can be identified at diagnosis or soon after starting TKI-therapy. These persons are likely to need lifetime TKI-therapy with attendant risks of adverse events, cost and psychological consequences. Allogeneic transplants achieve much higher rates of leukaemia-free survival compared with TKI-therapy but are associated with transplant-related adverse events including an almost 20 percent risk of transplant-related deaths within 1 year post-transplant and a compromised quality-of-life because of complications such as chronic graft-versus-host disease. Subject-, disease- and transplant-related co-variates associated with transplant outcomes are known with reasonable accuracy. Not everyone likely to fail TKI-therapy is a transplant candidate. However, in those who candidates are physicians and patients need to weigh benefits and risks of TKI-therapy versus a transplant. We suggest transplants should be more often considered in the metric when counseling people with chronic phase CML unlikely to achieve TFR with TKI-therapy. We question whether we are discounting a possible important therapy intervention; we think so.
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Affiliation(s)
- Michele Baccarani
- IRCCS Azienda Ospedaliero -Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Hematology 'Lorenzo e Ariosto Seràgnoli', University of Bologna, Bologna, Italy
| | | | - Simona Soverini
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Hematology 'Lorenzo e Ariosto Seràgnoli', University of Bologna, Bologna, Italy
| | - Fausto Castagnetti
- IRCCS Azienda Ospedaliero -Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Hematology 'Lorenzo e Ariosto Seràgnoli', University of Bologna, Bologna, Italy
| | | | - Wael Saber
- Center for International Blood and Marrow Transplant Research), Milwaukee, WI, USA
- Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Noel Estrada-Merly
- Center for International Blood and Marrow Transplant Research), Milwaukee, WI, USA
| | | | - Robert Peter Gale
- Haematology Research Centre, Department of Immunology and Inflammation, Imperial College London, London, UK
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5
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Myeloablative vs reduced-intensity conditioning allogeneic hematopoietic cell transplantation for chronic myeloid leukemia. Blood Adv 2019; 2:2922-2936. [PMID: 30396912 DOI: 10.1182/bloodadvances.2018024844] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 10/04/2018] [Indexed: 12/12/2022] Open
Abstract
Allogeneic hematopoietic cell transplantation (allo-HCT) is a potentially curative treatment of chronic myeloid leukemia (CML). Optimal conditioning intensity for allo-HCT for CML in the era of tyrosine kinase inhibitors (TKIs) is unknown. Using the Center for International Blood and Marrow Transplant Research database, we sought to determine whether reduced-intensity/nonmyeloablative conditioning (RIC) allo-HCT and myeloablative conditioning (MAC) result in similar outcomes in CML patients. We evaluated 1395 CML allo-HCT recipients between the ages of 18 and 60 years. The disease status at transplant was divided into the following categories: chronic phase 1, chronic phase 2 or greater, and accelerated phase. Patients in blast phase at transplant and alternative donor transplants were excluded. The primary outcome was overall survival (OS) after allo-HCT. MAC (n = 1204) and RIC allo-HCT recipients (n = 191) from 2007 to 2014 were included. Patient, disease, and transplantation characteristics were similar, with a few exceptions. Multivariable analysis showed no significant difference in OS between MAC and RIC groups. In addition, leukemia-free survival and nonrelapse mortality did not differ significantly between the 2 groups. Compared with MAC, the RIC group had a higher risk of early relapse after allo-HCT (hazard ratio [HR], 1.85; P = .001). The cumulative incidence of chronic graft-versus-host disease (cGVHD) was lower with RIC than with MAC (HR, 0.77; P = .02). RIC provides similar survival and lower cGVHD compared with MAC and therefore may be a reasonable alternative to MAC for CML patients in the TKI era.
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6
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Uchida N, Nassehi T, Drysdale CM, Gamer J, Yapundich M, Bonifacino AC, Krouse AE, Linde N, Hsieh MM, Donahue RE, Dunbar CE, Kean LS, Tisdale JF. Busulfan Combined with Immunosuppression Allows Efficient Engraftment of Gene-Modified Cells in a Rhesus Macaque Model. Mol Ther 2019; 27:1586-1596. [PMID: 31253582 PMCID: PMC6731177 DOI: 10.1016/j.ymthe.2019.05.022] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 05/13/2019] [Accepted: 05/29/2019] [Indexed: 01/24/2023] Open
Abstract
Busulfan conditioning is utilized for hematopoietic stem cell (HSC) depletion in the context of HSC gene-therapy conditioning but may result in insufficient immunosuppression. In this study, we evaluated whether additional immunosuppression is required for efficient engraftment of gene-modified cells using a rhesus HSC lentiviral gene-therapy model. We transduced half of rhesus CD34+ cells with an enhanced green fluorescent protein (GFP)-encoding vector (immunogenic) and the other half with a γ-globin-encoding vector (no predicted immunogenicity). After autologous transplantation of both transduced cell populations following myeloablative busulfan conditioning (5.5 mg/kg/day for 4 days), we observed immunological rejection of GFP-transduced cells up to 3 months post-transplant and stable engraftment of γ-globin-transduced cells in two animals, demonstrating that ablative busulfan conditioning is sufficient for engraftment of gene-modified cells producing non-immunogenic proteins but insufficient to permit engraftment of immunogenic proteins. We then added immunosuppression with abatacept and sirolimus to busulfan conditioning and observed engraftment of both GFP- and γ-globin-transduced cells in two animals, demonstrating that additional immunosuppression allows for engraftment of gene-modified cells expressing immunogenic proteins. In conclusion, myeloablative busulfan conditioning should permit engraftment of gene-modified cells producing non-immunogenic proteins, while additional immunosuppression is required to prevent immunological rejection of a neoantigen.
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Affiliation(s)
- Naoya Uchida
- Cellular and Molecular Therapeutics Branch, National Heart Lung and Blood Institutes (NHLBI)/National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), NIH, Bethesda, MD, USA
| | - Tina Nassehi
- Cellular and Molecular Therapeutics Branch, National Heart Lung and Blood Institutes (NHLBI)/National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), NIH, Bethesda, MD, USA
| | - Claire M Drysdale
- Cellular and Molecular Therapeutics Branch, National Heart Lung and Blood Institutes (NHLBI)/National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), NIH, Bethesda, MD, USA
| | - Jackson Gamer
- Cellular and Molecular Therapeutics Branch, National Heart Lung and Blood Institutes (NHLBI)/National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), NIH, Bethesda, MD, USA
| | - Morgan Yapundich
- Cellular and Molecular Therapeutics Branch, National Heart Lung and Blood Institutes (NHLBI)/National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), NIH, Bethesda, MD, USA
| | | | - Allen E Krouse
- Translational Stem Cell Biology Branch, NHLBI, NIH, Bethesda, MD, USA
| | - Nathaniel Linde
- Translational Stem Cell Biology Branch, NHLBI, NIH, Bethesda, MD, USA
| | - Matthew M Hsieh
- Cellular and Molecular Therapeutics Branch, National Heart Lung and Blood Institutes (NHLBI)/National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), NIH, Bethesda, MD, USA
| | - Robert E Donahue
- Cellular and Molecular Therapeutics Branch, National Heart Lung and Blood Institutes (NHLBI)/National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), NIH, Bethesda, MD, USA
| | - Cynthia E Dunbar
- Translational Stem Cell Biology Branch, NHLBI, NIH, Bethesda, MD, USA
| | - Leslie S Kean
- Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, MA, USA
| | - John F Tisdale
- Cellular and Molecular Therapeutics Branch, National Heart Lung and Blood Institutes (NHLBI)/National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), NIH, Bethesda, MD, USA.
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7
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Mehta PA, Emoto C, Fukuda T, Seyboth B, Teusink-Cross A, Davies SM, Wilhelm J, Fuller K, Vinks AA, Boulad F. Busulfan Pharmacokinetics and Precision Dosing: Are Patients with Fanconi Anemia Different? Biol Blood Marrow Transplant 2019; 25:2416-2421. [PMID: 31326610 DOI: 10.1016/j.bbmt.2019.07.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 07/11/2019] [Accepted: 07/15/2019] [Indexed: 12/14/2022]
Abstract
It is well known that pharmacokinetics (PK)-guided busulfan (BU) dosing increases engraftment rates and lowers hepatotoxicity in patients undergoing hematopoietic cell transplantation (HCT). However, there are no published PK data in patients with Fanconi anemia (FA), who are known to have baseline DNA repair defect and related inherent sensitivity to chemotherapy. In our prospective, multi-institutional study of alternative donor HCT for FA using chemotherapy-only conditioning, we replaced the single dose of total-body irradiation with BU at initial doses of 0.8 to 1.0 mg/kg and 0.6 to 0.8 mg/kg given i.v. every 12 hours for 4 doses. Patients received the first dose of i.v. busulfan on day -8, and blood levels for PK were obtained. PK samples were drawn following completion of infusion. BU PK levels were collected at 2 hours, 2 hours and 15 minutes, and 4, 5, 6, and 8 hours from the start of infusion. The remaining 3 doses of BU were given on days -7 and -6. Thirty-seven patients with available BU PK data with a median age of 9.2 years (range, 4.3 to 44 years) are included in the final analyses. The overall BU PK profile in patients with FA is similar to non-FA patients after considering their body weight. In our cohort, a strong correlation between BU clearance and weight supports current practice of per kilogram dosing. However, not surprisingly, we show that the disease (ie, host) sensitivity related to FA is the main determinant of total dose of BU that can be safely administered to patients in this high-risk population. On the basis of our results, we propose an optimal BU concentration at steady-state level of ≤350 ng/mL (equivalent to total cumulative exposure of 16.4 mg*h/L for 4 doses over 2 days) for patients with FA undergoing HCT. To our knowledge, this is the first and largest report of prospective BU PK in patients with FA undergoing HCT, providing an optimal BU target cutoff to achieve stable donor engraftment while avoiding excessive toxicity.
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Affiliation(s)
- Parinda A Mehta
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.
| | - Chie Emoto
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Tsuyoshi Fukuda
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Brian Seyboth
- Department of Pediatrics, Bone Marrow Transplant Service, Memorial Sloan Kettering, New York, New York; Division of Pediatric Hematology-Oncology, New York Presbyterian Hospital-Weill Cornell Medical College, New York, New York
| | - Ashley Teusink-Cross
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Stella M Davies
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Jamie Wilhelm
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Kirsten Fuller
- Department of Pediatrics, Bone Marrow Transplant Service, Memorial Sloan Kettering, New York, New York; Division of Pediatric Hematology-Oncology, New York Presbyterian Hospital-Weill Cornell Medical College, New York, New York
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Farid Boulad
- Department of Pediatrics, Bone Marrow Transplant Service, Memorial Sloan Kettering, New York, New York; Division of Pediatric Hematology-Oncology, New York Presbyterian Hospital-Weill Cornell Medical College, New York, New York
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8
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McCune JS, Quinones CM, Ritchie J, Carpenter PA, van Maarseveen E, Yeh RF, Anasetti C, Boelens JJ, Hamerschlak N, Hassan M, Kang HJ, Kanda Y, Paci A, Perales MA, Shaw PJ, Seewaldt VL, Savani BN, Hsieh A, Poon B, Mohty M, Pulsipher MA, Pasquini M, Dupuis LL. Harmonization of Busulfan Plasma Exposure Unit (BPEU): A Community-Initiated Consensus Statement. Biol Blood Marrow Transplant 2019; 25:1890-1897. [PMID: 31136799 DOI: 10.1016/j.bbmt.2019.05.021] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 04/26/2019] [Accepted: 05/21/2019] [Indexed: 12/12/2022]
Abstract
Busulfan therapeutic drug monitoring (TDM) is often used to achieve target plasma exposures. Variability in busulfan plasma exposure units (BPEU) is a potential source for misinterpretation of publications and protocols and is a barrier to data capture by hematopoietic cell transplantation (HCT) registry databases. We sought to harmonize to a single BPEU for international use. Using Delphi consensus methodology, iterative surveys were sent to an increasing number of relevant clinical stakeholders. In survey 1, 14 stakeholders were asked to identify ideal properties of a BPEU. In survey 2, 52 stakeholders were asked (1) to evaluate BPEU candidates according to ideal BPEU properties established by survey 1 and local position statements for TDM and (2) to identify potential facilitators and barriers to adoption of the harmonized BPEU. The most frequently used BPEU identified, in descending order, were area under the curve (AUC) in μM × min, AUC in mg × h/L, concentration at steady state (Css) in ng/mL, AUC in μM × h, and AUC in μg × h/L. All respondents conceptually agreed on the ideal properties of a BPEU and to adopt a harmonized BPEU. Respondents were equally divided between selecting AUC in μM × min versus mg × h/L for harmonization. AUC in mg × h/L was finally selected as the harmonized BPEU, because it satisfied most of the survey-determined ideal properties for the harmonized BPEU and is read easily understood in the clinical practice environment. Furthermore, 10 major professional societies have endorsed AUC in mg × h/L as the harmonized unit for reporting to HCT registry databases and for use in future protocols and publications.
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Affiliation(s)
- Jeannine S McCune
- Clinical Research Division, Fred Hutchinson Cancer Research Center and Department of Pharmaceutics, University of Washington, Seattle, WA, USA; Molecular Prevention, Intervention and Technology Division, Beckman Research Institute, City of Hope, Duarte, CA, USA.
| | - Christine M Quinones
- Molecular Prevention, Intervention and Technology Division, Beckman Research Institute at City of Hope, Duarte, CA, USA
| | - James Ritchie
- Pathology & Laboratory Medicine Department, Emory University, Atlanta, GA, USA
| | - Paul A Carpenter
- Clinical Research Division, Fred Hutchinson Cancer Research Center and Department of Pharmaceutics, University of Washington, Seattle, WA, USA
| | - Erik van Maarseveen
- Clinical Pharmacology, University Medical Center Utrecht, Utrecht, Princess Maxima Center for Pediatric Oncology, Utrecht and Drug Analysis and Toxicology division (KKGT) of the Dutch Foundation for Quality Assessment in Medical Laboratories (SKML), Utrecht, Netherlands
| | - Rosa F Yeh
- Pharmacokinetics Laboratory, Seattle Cancer Care Alliance, Seattle, WA, USA
| | - Claudio Anasetti
- Department of Blood and Marrow Transplant, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA; Molecular Prevention, Intervention and Technology Division, Beckman Research Institute, City of Hope, Duarte, CA, USA
| | - Jaap J Boelens
- Pediatric Blood and Marrow Transplantation Program, University Medical Center Utrecht, Utrecht, Princess Maxima Center for Pediatric Oncology, Utrecht, Netherlands; Stem Cell Transplantation and Cellular Therapies, MSK Kids, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nelson Hamerschlak
- Hematology and Bone Marrow Transplantation Department, Hospital Israelita Albert Einstein, São Paulo Area, Brazil
| | - Moustapha Hassan
- Division of Experimental Cancer Medicine, Department of Laboratory Medicine at Karolinska Institutet and Division of Clinical Research Centrum at Karolinska University Hospital, Stockholm, Sweden
| | - Hyoung Jin Kang
- Department of Pediatrics, Seoul National Univeristy College of Medicine, Seoul National University Cancer Research Institute, Seoul National University Children's Hospital, Seoul, Korea
| | - Yoshinobu Kanda
- Division of Hematology, Department of Medicine, Jichi Medical University and Division of Hematology, Saitama Medical Center, Jichi Medical University, Japan
| | - Angelo Paci
- Department of Pharmacology, Institute Gustave Roussy Cancer Center, Grand Paris, School of Pharmacy - Paris Sud University, France
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center and Department of Medicine, Weill Cornell Medical College New York, NY, USA
| | - Peter J Shaw
- BMT Services, The Children's Hospital at Westmead, Westmead, New South Wales, and Discipline of Child and Adolescent Health, University of Sydney, Australia
| | - Victoria L Seewaldt
- Molecular Prevention, Intervention and Technology Division, Beckman Research Institute at City of Hope, Duarte, CA, USA
| | - Bipin N Savani
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Angela Hsieh
- Medical Content Manager at McKesson Specialty Health, Seattle, WA, USA
| | - Betsy Poon
- Department of Pharmacy, AdventHealth for Children, Orlando, FL, USA
| | - Mohamad Mohty
- Department of Hematology and Cell Therapy, Acute Leukemia Working Party EBMT Paris Office, Hôpital Saint-Antoine, Paris, France
| | - Michael A Pulsipher
- Division of Hematology, Oncology, and Blood and Marrow Transplantation, Children's Hospital Los Angeles, USC Keck School of Medicine, Los Angeles, CA, USA
| | - Marcelo Pasquini
- CIBMTR (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - L Lee Dupuis
- Department of Pharmacy and Research Institute, The Hospital for Sick Children and Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
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9
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Jain T, Kunze KL, Khetarpal BK, McCallen MR, Betcher JA, Ofori HT, Khera N, Slack JL, Leis JF, Sproat LZ, Noel P, Palmer J. Early fluctuations in busulfan levels with therapeutic dose monitoring during allogeneic stem cell transplantation: do they matter? Leuk Lymphoma 2019; 60:2034-2041. [PMID: 30626239 DOI: 10.1080/10428194.2018.1562183] [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: 10/27/2022]
Abstract
Therapeutic dose monitoring is widely adopted for determination of busulfan (Bu) dose for use as a conditioning regimen. However, while dose adjustments are being incorporated, transient fluctuations of Bu levels may occur. We aim to understand if these fluctuations affect clinical outcomes of these patients. We compared outcomes in patients in whom the absolute dose changes and fluctuation of AUC were ≥ median% versus < median%. Rates of sinusoidal obstructive syndrome, grades 2-4/grades 3-4 acute and chronic graft versus host disease were not different between the two cohorts. The Kaplan-Meier curves for overall survival showed no significant differences. Six patients required >50% dose adjustment and four had a fluctuation in AUC of >50%. One of these patients died of sinusoidal obstruction syndrome and two died of infections. In our study, the transient fluctuations in Bu levels did not affect clinical outcomes; hence obviating the need for test dose strategy.
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Affiliation(s)
- Tania Jain
- a Division of Hematology/Medical Oncology , Mayo Clinic , Phoenix , AZ , USA
| | - Katie L Kunze
- b Division of Biostatistics , Mayo Clinic , Phoenix , AZ , USA
| | | | | | | | - Henry T Ofori
- d Division of Pharmacy , Mayo Clinic , Phoenix , AZ , USA
| | - Nandita Khera
- a Division of Hematology/Medical Oncology , Mayo Clinic , Phoenix , AZ , USA
| | - James L Slack
- a Division of Hematology/Medical Oncology , Mayo Clinic , Phoenix , AZ , USA
| | - Jose F Leis
- a Division of Hematology/Medical Oncology , Mayo Clinic , Phoenix , AZ , USA
| | - Lisa Z Sproat
- a Division of Hematology/Medical Oncology , Mayo Clinic , Phoenix , AZ , USA
| | - Pierre Noel
- a Division of Hematology/Medical Oncology , Mayo Clinic , Phoenix , AZ , USA
| | - Jeanne Palmer
- a Division of Hematology/Medical Oncology , Mayo Clinic , Phoenix , AZ , USA
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10
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TBI: To Be (Irradiated) or Not To Be? That Remains the Question. Biol Blood Marrow Transplant 2018; 24:1535-1536. [DOI: 10.1016/j.bbmt.2018.06.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 06/07/2018] [Indexed: 11/20/2022]
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11
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Radich J. When to Consider Allogeneic Transplantation in CML. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2017; 16 Suppl:S93-5. [PMID: 27521333 DOI: 10.1016/j.clml.2016.02.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 02/09/2016] [Indexed: 11/26/2022]
Abstract
Tyrosine kinase inhibitor (TKI) therapy has radically altered the treatment strategy for chronic myeloid leukemia. Allogeneic transplantation, which over a decade ago was considered the definitive therapy for CML, is now appropriately used in cases where all TKIs are not tolerated, in cases of resistance to TKI therapy, or when the disease progresses from chronic phase to accelerated or blast phase.
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Affiliation(s)
- Jerald Radich
- Clinical Research Division, Fred Hutchison Cancer Research Center, Seattle, WA.
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12
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Abstract
In chronic myeloid leukemia (CML), the BCR-ABL fusion gene is both the therapeutic target of tyrosine kinase inhibitors and the indisputable direct marker of disease burden. Thus, sensitive assays for BCR-ABL now drive therapeutic options and are good surrogates for short- and long-term outcomes. Because CML is such an ideal model, new methods are arising that should make testing in CML faster, more reliable, and reach a greater sensitivity. These methods should be able to be transferred to other hematological malignancies that have mutation markers.
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Affiliation(s)
- Cecilia C S Yeung
- Clinical Research Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave North, G7-910, Seattle, WA, 98109, USA.
| | - Daniel Egan
- Clinical Research Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave North, G7-910, Seattle, WA, 98109, USA
| | - Jerald Radich
- Clinical Research Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave North, G7-910, Seattle, WA, 98109, USA
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13
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Lin YS, Kerr SJ, Randolph T, Shireman LM, Senn T, McCune JS. Prediction of Intravenous Busulfan Clearance by Endogenous Plasma Biomarkers Using Global Pharmacometabolomics. Metabolomics 2016; 12:161. [PMID: 28827982 PMCID: PMC5562150 DOI: 10.1007/s11306-016-1106-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION High-dose busulfan (busulfan) is an integral part of the majority of hematopoietic cell transplantation conditioning regimens. Intravenous (IV) busulfan doses are personalized using pharmacokinetics (PK)-based dosing where the patient's IV busulfan clearance is calculated after the first dose and is used to personalize subsequent doses to a target plasma exposure. PK-guided dosing has improved patient outcomes and is clinically accepted but highly resource intensive. OBJECTIVE We sought to discover endogenous plasma biomarkers predictive of IV busulfan clearance using a global pharmacometabolomics-based approach. METHODS Using LC-QTOF, we analyzed 59 (discovery) and 88 (validation) plasma samples obtained before IV busulfan administration. RESULTS In the discovery dataset, we evaluated the association of the relative abundance of 1885 ions with IV busulfan clearance and found 21 ions that were associated with IV busulfan clearance tertiles (r2 ≥ 0.3). Identified compounds were deoxycholic acid and/or chenodeoxycholic acid, and linoleic acid. We used these 21 ions to develop a parsimonious seven-ion linear predictive model that accurately predicted IV busulfan clearance in 93% (discovery) and 78% (validation) of samples. CONCLUSION IV busulfan clearance was significantly correlated with the relative abundance of 21 ions, seven of which were included in a predictive model that accurately predicted IV busulfan clearance in the majority of the validation samples. These results reinforce the potential of pharmacometabolomics as a critical tool in personalized medicine, with the potential to improve the personalized dosing of drugs with a narrow therapeutic index such as busulfan.
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Affiliation(s)
- Yvonne S. Lin
- Department of Pharmaceutics, University of Washington, Seattle, WA
| | - Savannah J. Kerr
- Department of Pharmaceutics, University of Washington, Seattle, WA
| | | | | | - Tauri Senn
- Department of Pharmaceutics, University of Washington, Seattle, WA
| | - Jeannine S. McCune
- Department of Pharmaceutics, University of Washington, Seattle, WA
- Department of Pharmacy, University of Washington, Seattle, WA
- Fred Hutchinson Cancer Research Center, Seattle, WA
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14
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Comparison of Cyclophosphamide Combined with Total Body Irradiation, Oral Busulfan, or Intravenous Busulfan for Allogeneic Hematopoietic Cell Transplantation in Adults with Acute Lymphoblastic Leukemia. Biol Blood Marrow Transplant 2016; 22:2194-2200. [PMID: 27638362 DOI: 10.1016/j.bbmt.2016.09.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 09/06/2016] [Indexed: 11/24/2022]
Abstract
We conducted a retrospective analysis to compare outcomes in adult patients with acute lymphoblastic leukemia (ALL) who underwent allogeneic hematopoietic cell transplantation (allo-HCT) with conditioning regimens containing cyclophosphamide (CY) in combination with total body irradiation (TBI), oral busulfan (p.o. BU), or intravenous busulfan (i.v. BU). We used data for January 2000 to December 2012 from the Transplant Registry Unified Management Program of the Japan Society of Hematopoietic Cell Transplantation. We identified 2130 patients treated with TBI/CY (n = 2028), p.o. BU/CY (n = 60), or i.v. BU/CY (n = 42). Two-year overall survival (OS) and 2-year relapse-free survival rates were 69.0% and 62.1%, respectively, in the TBI/CY group, 55.9% and 54.2% in the p.o. BU/CY group, and 71.0% and 46.8% in the i.v. BU/CY group. In multivariate analysis, compared with TBI/CY, p.o. BU/CY, but not i.v. BU/CY, was associated with lower OS (hazard ratio [HR], 1.46; P = .047) and a higher incidence of sinusoidal obstruction syndrome (HR, 3.36; P = .030). No between-group differences were seen in the incidence of nonrelapse mortality, relapse, acute graft-versus-host disease (GVHD), or chronic GVHD. We suggest that i.v. BU/CY might be a possible alternative allo-HCT conditioning regimen for adults with ALL who are not suitable for TBI.
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15
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Yeung CCS, Egan D, Radich JP. Molecular monitoring of chronic myeloid leukemia: present and future. Expert Rev Mol Diagn 2016; 16:1083-1091. [PMID: 27552202 DOI: 10.1080/14737159.2016.1227243] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Fusion of BCR-ABL1 genes causes chronic myeloid leukemia (CML). As a reliable marker of disease burden, it also serves as the target of tyrosine kinase inhibitors (TKIs). New more sensitive molecular diagnostic tools for BCR-ABL1 can contribute to therapeutic decision-making, especially in considering drug discontinuation for patients enjoying prolonged deep molecular response. Areas covered: Several novel platforms are transforming CML molecular diagnostics to enable faster point-of-care devices, better understanding of clonal diversity and resistance mutations. Here, we review these molecular platforms, knowing implementation in other hematological malignancies will ensue. Expert commentary: Treatment with TKI in CML is the first example of a highly effective targeted therapy. Monitoring of BCR-ABL1 mRNA is standard in assessing disease burden being highly predictive of outcomes recommended by both European LeukemiaNet (ELN) and National Comprehensive Cancer Network (NCCN); however, studies has demonstrated poor adherence to these recommendations. In both clinical practice and assay performance, further optimizing of BCR-ABL1 monitoring can be envisioned including point-of-care methods for increased availability of rapid, standardized testing and increasingly sensitive molecular assays that allow for quantification of MRD and detecting resistance mutations.
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Affiliation(s)
- Cecilia Ching Sze Yeung
- a Clinical Research Division , Fred Hutchinson Cancer Research Center Ringgold standard institution , Seattle , WA , USA.,b Pathology , University of Washington School of Medicine Ringgold standard institution , Seattle , WA , USA
| | - Daniel Egan
- a Clinical Research Division , Fred Hutchinson Cancer Research Center Ringgold standard institution , Seattle , WA , USA
| | - Jerald P Radich
- c Fred Hutchinson Cancer Research Center , Seattle , WA , USA
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16
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Palmer J, McCune JS, Perales MA, Marks D, Bubalo J, Mohty M, Wingard JR, Paci A, Hassan M, Bredeson C, Pidala J, Shah N, Shaughnessy P, Majhail N, Schriber J, Savani BN, Carpenter PA. Personalizing Busulfan-Based Conditioning: Considerations from the American Society for Blood and Marrow Transplantation Practice Guidelines Committee. Biol Blood Marrow Transplant 2016; 22:1915-1925. [PMID: 27481448 DOI: 10.1016/j.bbmt.2016.07.013] [Citation(s) in RCA: 107] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 07/21/2016] [Indexed: 12/12/2022]
Abstract
The Practice Guidelines Committee of the American Society of Blood or Marrow Transplantation (ASBMT) sought to develop an evidence-based review about personalizing busulfan-based conditioning. The Committee sought to grade the relevant published studies (June 1, 2008 through March 31, 2016) according to criteria set forth by the Steering Committee for Evidence Based Reviews from ASBMT. Unfortunately, the published literature was too heterogeneous and lacked adequately powered and sufficiently controlled studies for this to be feasible. Despite this observation, the continued interest in this topic led the Practice Guidelines Committee to develop a list of most frequently asked questions (FAQs) regarding personalized busulfan dosing. This "Considerations" document is a list of these FAQs and their responses, addressing topics of practical relevance to hematopoietic cell transplantation clinicians.
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Affiliation(s)
- Jeanne Palmer
- Division of Hematology/Oncology, Mayo Clinic, Phoenix, Arizona.
| | - Jeannine S McCune
- Department of Pharmacology University of Washington, Fred Hutchinson Cancer Research Center, Seattle, Washington.
| | - Miguel-Angel Perales
- Division of Hematology/Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - David Marks
- Pediatric Bone Marrow Transplant, University Hospitals Bristol NHS Trust, Bristol Royal Infirmary, Bristol, United Kingdom
| | - Joseph Bubalo
- Department of Pharmacy Practice, Oregon Health Sciences University, Portland, Oregon
| | - Mohamad Mohty
- Department of Hematology, Hospital Saint-Antoine, University UPMC, Paris, France
| | - John R Wingard
- Division of Hematology/Oncology, University of Florida, Gainesville, Florida
| | - Angelo Paci
- Pharmacology and Drug Analysis Department, Institut de Cancerologie Gustav Roussy, Villejuif, France
| | - Moustapha Hassan
- Department of Clinical Research Centre, Karolinska Institutet, Stockholm, Sweden
| | - Christopher Bredeson
- Hematology, Department of Medicine, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Joseph Pidala
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Nina Shah
- Department of Stem Cell Transplantation and Cellular Therapy, MD Anderson Cancer Center, Houston, Texas
| | - Paul Shaughnessy
- Adult Blood and Marrow Transplant, Texas Transplant Physician's Group, San Antonio, Texas
| | - Navneet Majhail
- Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Jeff Schriber
- Cancer Transplant Institute, Honor Health, Scottsdale, Arizona
| | - Bipin N Savani
- Division of Hematology/Oncology, Vanderbuilt-Ingram Cancer Center, Nashville, Tennessee
| | - Paul A Carpenter
- Department of Pediatrics, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington
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17
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How I treat hepatitis C virus infection in patients with hematologic malignancies. Blood 2016; 128:1449-57. [PMID: 27443290 DOI: 10.1182/blood-2016-05-718643] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 07/12/2016] [Indexed: 12/20/2022] Open
Abstract
Hepatitis C virus (HCV) infection is not uncommon in cancer patients. Over the past 5 years, treatment of chronic HCV infection in patients with hematologic malignancies has evolved rapidly as safe and effective direct-acting antivirals (DAAs) have become the standard-of-care treatment. Today, chronic HCV infection should not prevent a patient from receiving cancer therapy or participating in clinical trials of chemotherapy because most infected patients can achieve virologic cure. Elimination of HCV from infected cancer patients confers virologic, hepatic, and oncologic advantages. Similar to the optimal therapy for HCV-infected patients without cancer, the optimal therapy for HCV-infected patients with cancer is evolving rapidly. The choice of regimens with DAAs should be individualized after thorough assessment for potential hematologic toxic effects and drug-drug interactions. This study presents clinical scenarios of HCV-infected patients with hematologic malignancies, focusing on diagnosis, clinical and laboratory presentations, complications, and DAA therapy. An up-to-date treatment algorithm is presented.
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18
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Navarro SL, Randolph TW, Shireman LM, Raftery D, McCune JS. Pharmacometabonomic Prediction of Busulfan Clearance in Hematopoetic Cell Transplant Recipients. J Proteome Res 2016; 15:2802-11. [PMID: 27350098 DOI: 10.1021/acs.jproteome.6b00370] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Intravenous (IV) busulfan doses are often personalized to a concentration at steady state (Css) using the patient's clearance, which is estimated with therapeutic drug monitoring. We sought to identify biomarkers of IV busulfan clearance using a targeted pharmacometabonomics approach. A total of 200 metabolites were quantitated in 106 plasma samples, each obtained before IV busulfan administration in hematopoietic cell transplant (HCT) recipients. Both univariate linear regression with false discovery rate (FDR) and pathway enrichment analyses using the Global test were performed. In the univariate analysis, glycine, N-acetylglycine, 2-hydroxyisovaleric acid, creatine, serine, and tyrosine were statistically significantly associated with IV busulfan clearance at P < 0.05, with the first three satisfying the FDR of q < 0.1. Using pathway enrichment analysis, the glycine, serine, and threonine metabolism pathway was statistically significantly associated with IV busulfan clearance at P < 0.05 and q < 0.1, and a pathway impact >0.1. Glycine is a component of glutathione, which is conjugated with busulfan via glutathione transferase enzymes. These results demonstrate the potential utility of pharmacometabonomics to inform IV busulfan dosing. Future studies are required to validate these findings.
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Affiliation(s)
- Sandi L Navarro
- Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue North, Seattle, Washington 98109, United States.,University of Washington , Seattle, Washington 98195, United States
| | - Timothy W Randolph
- Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue North, Seattle, Washington 98109, United States
| | - Laura M Shireman
- University of Washington , Seattle, Washington 98195, United States
| | - Daniel Raftery
- Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue North, Seattle, Washington 98109, United States.,University of Washington , Seattle, Washington 98195, United States
| | - Jeannine S McCune
- Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue North, Seattle, Washington 98109, United States.,University of Washington , Seattle, Washington 98195, United States
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19
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Ma YR, Huang XJ, Xu ZL, Liu KY, Chen H, Zhang XH, Han W, Chen YH, Wang FR, Wang JZ, Wang Y, Chen Y, Yan CH, Xu LP. Transplantation from haploidentical donor is not inferior to that from identical sibling donor for patients with chronic myeloid leukemia in blast crisis or chronic phase from blast crisis. Clin Transplant 2016; 30:994-1001. [PMID: 27292967 DOI: 10.1111/ctr.12779] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2016] [Indexed: 12/28/2022]
Abstract
OBJECTIVES Allogeneic hematopoietic stem cell transplantation (HSCT) is the only curative therapy for chronic myeloid leukemia (CML) patients in blast crisis (BC), and haploidentical donors (HID) are immediately available for most patients. We compared the outcomes of HID transplantation with those of matched related donor (MRD) transplantation in a cohort study. PATIENTS AND METHODS A total of 90 consecutive patients who received allogeneic HSCT because of CML-BC were investigated retrospectively. A total of 67 patients underwent transplantation from HID and 23 from MRD. Survival outcomes were compared between the two cohorts. RESULTS Of the 90 patients, 86 patients were engrafted. Three-year overall survival (OS) and relapse-free survival (RFS) were comparable between HID and MRD recipients (OS: 60.0% vs 55.3%, respectively, P=.580; RFS: 51.1% vs 47.8%, respectively, P=.512). Three-year incidences of transplant-related mortality (TRM) and relapse did not differ between HID and MRD recipients (relapse: 21.0% vs 26.1%, respectively, P=.626; TRM: 27.9% vs 26.1%, respectively, P=.937). In multivariate analyses, previous chemotherapy history and not achieving CHR before HSCT are independent adverse predictors of OS. CONCLUSIONS For CML-blast crisis or chronic phase from blast crisis patients, HID transplantation achieves comparable survival to MRD transplantation. HID donors can be regarded as regular donors for these special patients at selected centers.
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Affiliation(s)
- Yan-Ru Ma
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China
| | - Xiao-Jun Huang
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China.,Peking-Tsinghua Center for Life Sciences, Beijing, China
| | - Zheng-Li Xu
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China
| | - Kai-Yan Liu
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China
| | - Huan Chen
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China
| | - Xiao-Hui Zhang
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China
| | - Wei Han
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China
| | - Yu-Hong Chen
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China
| | - Feng-Rong Wang
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China
| | - Jing-Zhi Wang
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China
| | - Yu Wang
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China
| | - Yao Chen
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China
| | - Chen-Hua Yan
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China
| | - Lan-Ping Xu
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China.
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20
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Egan D, Radich J. Monitoring disease burden in chronic myeloid leukemia: Past, present, and future. Am J Hematol 2016; 91:742-6. [PMID: 27059166 DOI: 10.1002/ajh.24381] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Revised: 03/29/2016] [Accepted: 04/04/2016] [Indexed: 01/01/2023]
Abstract
Tyrosine kinase inhibitor (TKI) therapy yields sustained cytogenetic remissions in most patients with chronic-phase chronic myeloid leukemia (CML). Peripheral blood quantitative reverse transcription polymerase chain reaction (qRT-PCR) monitoring of the chimeric BCR-ABL1 mRNA transcript levels is a very sensitive method to measure disease burden in patients with cytogenetic remission. qRT-PCR allows identification of patients (1) at high risk of progression early (3-6 months) after treatment initiation, (2) with no response to TKI therapy, (3) with undetectable disease who could be eligible for TKI discontinuation trials. Molecular monitoring is a minimally invasive method to optimize treatment and outcomes in CML. Am. J. Hematol. 91:742-746, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Daniel Egan
- Clinical Research Division; Fred Hutchinson Cancer Research Center; Seattle Washington
| | - Jerald Radich
- Clinical Research Division; Fred Hutchinson Cancer Research Center; Seattle Washington
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21
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Damlaj M, Alkhateeb HB, Hefazi M, Partain DK, Hashmi S, Gastineau DA, Al-Kali A, Wolf RC, Gangat N, Litzow MR, Hogan WJ, Patnaik MM. Fludarabine-Busulfan Reduced-Intensity Conditioning in Comparison with Fludarabine-Melphalan Is Associated with Increased Relapse Risk In Spite of Pharmacokinetic Dosing. Biol Blood Marrow Transplant 2016; 22:1431-1439. [PMID: 27164061 DOI: 10.1016/j.bbmt.2016.04.026] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 04/30/2016] [Indexed: 11/16/2022]
Abstract
Fludarabine with busulfan (FB) and fludarabine with melphalan (FM) are commonly used reduced-intensity conditioning (RIC) regimens. Pharmacokinetic dosing of busulfan (Bu) is frequently done for myeloablative conditioning, but evidence for its use is limited in RIC transplants. We compared transplant outcomes of FB versus FM using i.v. Bu targeted to the area under the curve (AUC). A total of 134 RIC transplants (47 FB and 87 FM) for acute myelogenous leukemia and myelodysplastic syndrome were identified, and median follow-up of the cohort was 40 months (range, 0 to 63.3). A significantly higher 2-year cumulative incidence of relapse (CIR) was associated with FB versus FM at 35.6% versus 17.3%, respectively (P = .0058). Furthermore, 2-year progression-free survival rates were higher for FM versus FB at 60.5% versus 48.7%, respectively (P = .04). However, 2-year rates of nonrelapse mortality (NRM) and overall survival (OS) were similar. The need for dose adjustment based on AUC did not alter relapse risk or NRM. Patients with Karnofsky performance status ≥ 90 who received FM had a 2-year OS rate of 74.8% versus 48.3% for FB (P = .03). FB use remained prognostic for relapse in multivariable analysis (hazard ratio, 2.75; 95% confidence interval, 1.28 to 5.89; P = .0097). In summary, in spite of AUC-directed dosing, FB compared with FM was associated with a significantly higher CIR.
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Affiliation(s)
- Moussab Damlaj
- Division of Hematology & HSCT, Department of Oncology, King AbdulAziz Medical City, Riyadh, Saudi Arabia; Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota.
| | - Hassan B Alkhateeb
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mehrdad Hefazi
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Daniel K Partain
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Shahrukh Hashmi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Dennis A Gastineau
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Aref Al-Kali
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Robert C Wolf
- Department of Pharmacy Services, Mayo Clinic, Rochester, Minnesota
| | - Naseema Gangat
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mark R Litzow
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - William J Hogan
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mrinal M Patnaik
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
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Is cure for chronic myeloid leukemia possible in the tyrosine kinase inhibitors era? Curr Opin Hematol 2016; 23:115-20. [DOI: 10.1097/moh.0000000000000224] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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DeFilipp Z, Khoury HJ. Management of advanced-phase chronic myeloid leukemia. Curr Hematol Malig Rep 2016; 10:173-81. [PMID: 25929768 DOI: 10.1007/s11899-015-0249-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The management of chronic myeloid leukemia (CML) in accelerated or blast phase (advanced phase) remains a significant challenge despite the introduction of very effective tyrosine kinase inhibitors (TKIs). The biology of advanced-phase CML is complex and engages several pathways that are not optimally targeted by TKIs. Allogeneic stem cell transplantation remains the only potentially curative therapy, but the effectiveness of this conventional approach is limited. New strategies are required to improve the outlook for these patients.
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Affiliation(s)
- Zachariah DeFilipp
- Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, 1365 Clifton Road NE C5010, Atlanta, GA, 30322, USA,
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Schmidt F, Hilger N, Oelkrug C, Svanidze E, Ruschpler P, Eichler W, Boldt A, Emmrich F, Fricke S. Flow cytometric analysis of the graft-versus-Leukemia-effect after hematopoietic stem cell transplantation in mice. Cytometry A 2015; 87:334-45. [PMID: 25717029 DOI: 10.1002/cyto.a.22619] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 11/14/2014] [Accepted: 12/05/2014] [Indexed: 01/23/2023]
Abstract
Acute Graft-versus-Host-Disease (aGvHD) is one of the major complications following allogeneic hematopoietic stem cell transplantation (HSCT). Although rather helpful, the use of conventional immunosuppressive drugs leads to general immunosuppression and is toxic. The effects of CD4(+) T-cells, in respect to the development of aGvHD, can be altered by administration of antihuman CD4 monoclonal antibodies, here MAX.16H5 IgG1 . This approach must be tested for possible interference with the Graft-versus-Leukemia-Effect (GvL). Thus, in vitro experiments were conducted, exposing P815 leukemic cells to bone marrow and splenocytes from cd4(-/-) -C57Bl/6 mice transgenic for human CD4 and HLA-DR3 (triple transgenic mice, [TTG]) as well as previously irradiated splenocytes from Balb/c(wt) mice. Using flow cytometry, the vitality of the various malignant and graft cells was analyzed over the course of 4 days. The survival rate of P815 cells did not change significantly when exposed to MAX.16H5 IgG1 , neither did the viability of the graft cells. This provides evidence that MAX.16H5 IgG1 does not impair the GvL effect in vitro. Additionally, P815-Balb/c(wt) leukemic mice were transplanted with P815(GFP) cells, bone marrow, and splenocytes from TTG mice with and without MAX.16H5 IgG1 . Without transplantation, P815(GFP) leukemic cells could be detected by flow cytometry in the liver, the bone marrow, and the spleen of recipients. The antibodies prevented aGvHD while leaving the GvL effect intact. These findings indicate no negative effect of MAX.16H5 IgG1 on the GvL effect in vitro and in vivo after HSCT in a murine model.
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Affiliation(s)
- Felix Schmidt
- Department of Immunology, Fraunhofer Institute for Cell Therapy and Immunology (IZI), Leipzig, Germany
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25
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Outcomes after autologous SCT in lymphoma patients grouped by weight. Bone Marrow Transplant 2015; 50:652-7. [PMID: 25665041 DOI: 10.1038/bmt.2014.327] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Revised: 12/12/2014] [Accepted: 12/17/2014] [Indexed: 01/09/2023]
Abstract
Obesity continues to be an increasing global health issue contributing to the complexity of chemotherapy dosing in the field of SCT. Investigation into the optimal dosing weight used to calculate chemotherapy doses in obese patients undergoing SCT is limited and inconclusive. Our single-center, retrospective study compared safety and efficacy outcomes by body mass index (BMI) for 476 adult lymphoma patients who underwent auto-SCT with a myeloablative chemotherapeutic regimen of BU, CY and etoposide dosed using adjusted body weight. Three weight groups categorized based on BMI were defined: normal/underweight ⩽24.9 kg/m(2), overweight 25-29.9 kg/m(2) and obese ⩾30 kg/m(2). Severity of mucositis, incidence of secondary malignancy, incidence of bacteremia and median hospital length of stay did not differ among the groups. The median times to absolute neutrophil count and platelet recovery were 10 days (P=0.75) and 14 days (P=0.17), respectively. Obese patients had a lower 100-day mortality compared with other weight groups, although this did not translate into an OS benefit. OS and disease relapse were similar among the groups. Our study demonstrates that use of adjusted body weight to calculate chemotherapy doses does not negatively have an impact on outcomes in obese patients undergoing auto-SCT with BU, CY and etoposide.
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Copelan EA, Avalos BR, Ahn KW, Zhu X, Gale RP, Grunwald MR, Hamadani M, Hamilton BK, Hale GA, Marks DI, Waller EK, Savani BN, Costa LJ, Ramanathan M, Cahn JY, Khoury HJ, Weisdorf DJ, Inamoto Y, Kamble RT, Schouten HC, Wirk B, Litzow MR, Aljurf MD, van Besien KW, Ustun C, Bolwell BJ, Bredeson CN, Fasan O, Ghosh N, Horowitz MM, Arora M, Szer J, Loren AW, Alyea EP, Cortes J, Maziarz RT, Kalaycio ME, Saber W. Comparison of outcomes of allogeneic transplantation for chronic myeloid leukemia with cyclophosphamide in combination with intravenous busulfan, oral busulfan, or total body irradiation. Biol Blood Marrow Transplant 2014; 21:552-8. [PMID: 25528388 DOI: 10.1016/j.bbmt.2014.12.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 12/10/2014] [Indexed: 12/21/2022]
Abstract
Cyclophosphamide (Cy) in combination with busulfan (Bu) or total body irradiation (TBI) is the most commonly used myeloablative conditioning regimen in patients with chronic myeloid leukemia (CML). We used data from the Center for International Bone Marrow Transplantation Research to compare outcomes in adults who underwent hematopoietic cell transplantation for CML in first chronic phase after myeloablative conditioning with Cy in combination with TBI, oral Bu, or intravenous (i.v.) Bu. Four hundred thirty-eight adults received human leukocyte antigen (HLA)-matched sibling grafts and 235 received well-matched grafts from unrelated donors (URD) from 2000 through 2006. Important differences existed between the groups in distribution of donor relation, exposure to tyrosine kinase inhibitors, and year of transplantation. In multivariate analysis, relapse occurred less frequently among patients receiving i.v. Bu compared with TBI (relative risk [RR], .36; P = .022) or oral Bu (RR, .39; P = .028), but nonrelapse mortality and survival were similar. A significant interaction was detected between donor relation and the main effect in leukemia-free survival (LFS). Among recipients of HLA-identical sibling grafts, but not URD grafts, LFS was better in patients receiving i.v. Bu (RR, .53; P = .025) or oral Bu (RR, .64; P = .017) compared with TBI. In CML in first chronic phase, Cy in combination with i.v. Bu was associated with less relapse than TBI or oral Bu. LFS was better after i.v. or oral Bu compared with TBI.
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Affiliation(s)
- Edward A Copelan
- Levine Cancer Institute, Carolinas Healthcare System, Charlotte, North Carolina.
| | - Belinda R Avalos
- Levine Cancer Institute, Carolinas Healthcare System, Charlotte, North Carolina
| | - Kwang Woo Ahn
- Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Medicine, Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Xiaochun Zhu
- Department of Medicine, Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Robert Peter Gale
- Division of Experimental Medicine, Department of Medicine, Hematology Research Centre, Imperial College of London, London, United Kingdom
| | - Michael R Grunwald
- Levine Cancer Institute, Carolinas Healthcare System, Charlotte, North Carolina
| | - Mehdi Hamadani
- Department of Medicine, Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Betty K Hamilton
- Department of Hematology and Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Gregory A Hale
- Department of Hematology/Oncology, All Children's Hospital, St Petersburg, Florida
| | - David I Marks
- University Hospitals Bristol NHS Trust, Bristol, United Kingdom
| | - Edmund K Waller
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Bipin N Savani
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Luciano J Costa
- Division of Hematology/Oncology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Muthalagu Ramanathan
- Division of Hematology Oncology, UMass Memorial Medical Center, Worcester, Massachusetts
| | - Jean-Yves Cahn
- Department of Hematology, University Hospital, Grenoble, France
| | - H Jean Khoury
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Daniel J Weisdorf
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Yoshihiro Inamoto
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Rammurti T Kamble
- Division of Hematology and Oncology, Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, Texas
| | - Harry C Schouten
- Divison of Hematology, Academische Ziekenhuis Maastricht, Maastricht, Netherlands
| | - Baldeep Wirk
- Department of Internal Medicine, Stony Brook University Medical Center, Stony Brook, New York
| | - Mark R Litzow
- Department of Hematology, Mayo Clinic, Rochester, Minnesota
| | - Mahmoud D Aljurf
- Department of Oncology, King Faisal Specialist Hospital Center & Research, Riyadh, Saudi Arabia
| | - Koen W van Besien
- Department of Medical Oncology, Weill Cornell Medical College, New York, New York
| | - Celalettin Ustun
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Brian J Bolwell
- Department of Hematology and Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Christopher N Bredeson
- The Ottawa Hospital Blood & Marrow Transplant Program and the Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Omotayo Fasan
- Levine Cancer Institute, Carolinas Healthcare System, Charlotte, North Carolina
| | - Nilanjan Ghosh
- Levine Cancer Institute, Carolinas Healthcare System, Charlotte, North Carolina
| | - Mary M Horowitz
- Department of Medicine, Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Mukta Arora
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Jeffrey Szer
- Department of Clinical Haematology and Bone Marrow Transplantation, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Alison W Loren
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Edwin P Alyea
- Center of Hematologic Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Jorge Cortes
- Division of Cancer Medicine, Department of Leukemia, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Richard T Maziarz
- Center for Hematologic Malignancies, Oregon Health and Science University, Portland, Oregon
| | - Matt E Kalaycio
- Department of Hematology and Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Wael Saber
- Department of Medicine, Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
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Cai X, Wei J, He Y, Yang D, Jiang E, Huang Y, Han M, Feng S. A modified busulfan and cyclophosphamide preparative regimen for allogeneic transplantation in myeloid malignancies. Int J Clin Pharm 2014; 37:44-52. [PMID: 25432692 DOI: 10.1007/s11096-014-0036-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 11/02/2014] [Indexed: 01/14/2023]
Abstract
BACKGROUND Busulfan/cyclophosphamide (Bu/Cy) is commonly used as a standard conditioning regimen without total body irradiation for patients with hematological myeloid malignancies undergoing hematopoietic stem cell transplantation (HSCT). OBJECTIVE To develop a new myeloablative conditioning regimen incorporating fludarabine (Flu) and cytarabine (Ara-c). SETTING A tertiary blood disease hospital in Tianjin, China. METHODS A Bu/Cy preparative regimen was used, modified by Flu 90 mg/m(2) and Ara-c 6 g/m(2) in 57 unselected patients (median age 37 years) with hematological myeloid malignancies. The patients were to receive allogeneic hematopoietic stem cell transplantation (allo-HSCT). Thirteen patients had high-risk leukemia, fifty patients had HLA matched sibling donors while seven patients had HLA mismatched sibling donors. Cy was given 50 mg/kg/day for 2 days while Bu was given 3.2 mg/kg/day intravenously for 3 days. MAIN OUTCOME MEASURE Post-transplant donor chimerism, relapse tendency and minimal residual disease. RESULTS Extramedullar toxicity was relatively limited; the incidence of treatment-related mortality (TRM) within 100 days was 3.5 %. The incidence of grade II-IV, grade III-IV acute graft versus host disease (GVHD) and chronic GVHD of the evaluable patients were 21.1, 8.8 and 36.4 %, respectively. With a median follow up of 59 (13-96.5) months, TRM and relapse rate (RR) at eight years were 24.1 ± 5.8 and 14.7 ± 4.8 %, respectively. Disease free survival at eight years was 67.9 ± 6.2 % for the entire group, 60.0 ± 8.9 % for patients with AML, 77.3 ± 8.9 % for patients with CML, 70.0 ± 6.5 and 42.9 ± 18.7 % or matched sibling and mismatched sibling HSCT respectively. CONCLUSION The new regimen was associated with a low relapse rate, low incidence and severity of graft versus host disease and satisfactory survival for patients with myeloid malignancies.
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Affiliation(s)
- Xiaojin Cai
- Center of Hematopoietic Stem Cell Transplantation, Blood Disease Hospital, Institute of Hematology, Peking Union College, Chinese Academy of Medical Sciences, Tianjin, China
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Gupta A, Khattry N. Current status of hematopoietic stem cell transplant in chronic myeloid leukemia. Indian J Med Paediatr Oncol 2014; 35:207-10. [PMID: 25336791 PMCID: PMC4202616 DOI: 10.4103/0971-5851.142036] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Indications for hematopoietic stem cell transplant (HSCT) in chronic myeloid leukemia (CML) have changed over time. This change has largely been influenced by the advent of tyrosine kinase inhibitors, increased understanding of the mechanisms underlying disease phase progression as well as drug resistance, refinement of transplant techniques and exploitation of graft versus leukemia effect in this disease. Here, we have discussed the status of HSCT in CML in the present era with regards to the current indications, factors determining outcome and management strategies for posttransplant relapse.
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Affiliation(s)
- Alok Gupta
- Department of Medical Oncology, Bone Marrow Transplant Unit, ACTREC, Tata Memorial Centre, Mumbai, Maharashtra, India
| | - Navin Khattry
- Department of Medical Oncology, Bone Marrow Transplant Unit, ACTREC, Tata Memorial Centre, Mumbai, Maharashtra, India
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Yanada M. Allogeneic hematopoietic cell transplantation for acute myeloid leukemia during first complete remission: a clinical perspective. Int J Hematol 2014; 101:243-54. [PMID: 25212675 DOI: 10.1007/s12185-014-1657-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Revised: 08/26/2014] [Accepted: 09/01/2014] [Indexed: 12/28/2022]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) is the most potent therapy for preventing relapse of acute myeloid leukemia (AML). Although its efficacy is compromised by a high risk of treatment-related morbidity and mortality, an accumulating body of evidence has led to the general recommendation favoring allogeneic HCT from a matched sibling donor during first complete remission (CR1) for younger patients with cytogenetically intermediate- or high-risk AML. Over the past few decades, this field has seen a great many advancements. The indications for allogeneic HCT have been refined by taking into account the molecular profiles of leukemic cells and the degree of comorbidities. The introduction of high-resolution human leukocyte antigen-typing technology and advances in immunosuppressive therapy and supportive care measures have improved outcomes in alternative donor transplantation, while the parallel growth of unrelated donor registries and greater use of umbilical cord blood and haploidentical donors have considerably improved the chance of finding an alternative donor. The development of reduced-intensity and non-myeloablative conditioning has made it possible to receive allogeneic HCT for patients who might once have been considered ineligible due to advanced age or comorbidities. Thanks to these advances, the role of allogeneic HCT during CR1 has become progressively more important in the treatment of AML.
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Affiliation(s)
- Masamitsu Yanada
- Department of Hematology, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, 470-1192, Japan,
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Benyamini N, Rowe JM. Is there a role for allogeneic transplantation in chronic myeloid leukemia? Expert Rev Hematol 2014; 6:759-65. [PMID: 24219552 DOI: 10.1586/17474086.2013.849571] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Allogeneic hemopoietic cell transplantation has moved away from being the standard of care for patients with chronic myeloid leukemia (CML). Its role is currently limited to an unsatisfactory response to therapy with tyrosine kinase inhibitors as well as advanced stages of the disease. The advent of tyrosine kinase inhibitors has been one of the most remarkable advances in any form of cancer. Never-the-less, as a definitive procedure, allogeneic transplantation remains the only curative modality and its use in carefully selected patients, who have an inadequate response, has been increasingly recognized. It remains a standard of care for patients who present with blast crisis CML and is often used also in accelerated phase. The future for patients with CML has become so much brighter over the past decade but new issues and considerations continually emerge.
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Affiliation(s)
- Noam Benyamini
- Department of Hematology & Bone Marrow Transplantation, Rambam Health Care Campus, Haifa 31096, Israel
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31
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Abstract
An essential component of allogeneic and autologous hematopoietic cell transplantation (HCT) is the conditioning regimen administered before the hematopoietic cell infusion. Early regimens relied on dose intensity, assuming that high-dose chemoradiotherapy would eliminate malignant disease and reinfusion of the graft would then restore hematopoiesis. However, as the contribution of graft-versus-tumor effects to the success of allogeneic HCT was recognized over time, in an effort to exploit these, many investigators lowered the dose of radiation and chemotherapeutic agents in the preparative regimen. This resulted in a major paradigm shift, and consequently, the pool of eligible patients underwent a remarkable expansion. In this article, we provide a review of the definition of high-dose, reduced-intensity, and nonmyeloablative conditioning regimens, the most commonly used agents and combinations, and the evolution of some early regimens. We also provide a brief review of the toxicities associated with these regimens.
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32
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Heim D, Gratwohl A. Role of allogeneic transplantation in chronic myeloid leukemia. Expert Rev Hematol 2014; 1:41-50. [DOI: 10.1586/17474086.1.1.41] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Copelan EA, Hamilton BK, Avalos B, Ahn KW, Bolwell BJ, Zhu X, Aljurf M, van Besien K, Bredeson C, Cahn JY, Costa LJ, de Lima M, Gale RP, Hale GA, Halter J, Hamadani M, Inamoto Y, Kamble RT, Litzow MR, Loren AW, Marks DI, Olavarria E, Roy V, Sabloff M, Savani BN, Seftel M, Schouten HC, Ustun C, Waller EK, Weisdorf DJ, Wirk B, Horowitz MM, Arora M, Szer J, Cortes J, Kalaycio ME, Maziarz RT, Saber W. Better leukemia-free and overall survival in AML in first remission following cyclophosphamide in combination with busulfan compared with TBI. Blood 2013; 122:3863-70. [PMID: 24065243 PMCID: PMC3854108 DOI: 10.1182/blood-2013-07-514448] [Citation(s) in RCA: 122] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Accepted: 09/17/2013] [Indexed: 11/20/2022] Open
Abstract
Cyclophosphamide combined with total body irradiation (Cy/TBI) or busulfan (BuCy) are the most widely used myeloablative conditioning regimens for allotransplants. Recent data regarding their comparative effectiveness are lacking. We analyzed data from the Center for International Blood and Marrow Transplant Research for 1230 subjects receiving a first hematopoietic cell transplant from a human leukocyte antigen-matched sibling or from an unrelated donor during the years 2000 to 2006 for acute myeloid leukemia (AML) in first complete remission (CR) after conditioning with Cy/TBI or oral or intravenous (IV) BuCy. Multivariate analysis showed significantly less nonrelapse mortality (relative risk [RR] = 0.58; 95% confidence interval [CI]: 0.39-0.86; P = .007), and relapse after, but not before, 1 year posttransplant (RR = 0.23; 95% CI: 0.08-0.65; P = .006), and better leukemia-free survival (RR = 0.70; 95% CI: 0.55-0.88; P = .003) and survival (RR = 0.68; 95% CI: 0.52-0.88; P = .003) in persons receiving IV, but not oral, Bu compared with TBI. In combination with Cy, IV Bu is associated with superior outcomes compared with TBI in patients with AML in first CR.
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Affiliation(s)
- Edward A Copelan
- Levine Cancer Institute, Carolinas Healthcare System, Charlotte, NC
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Abstract
Tyrosine kinase inhibitor (TKI) therapy has revolutionized the therapy of chronic myeloid Leukemia (CML). Thus, while in the near past allogeneic transplantation was the curative option for CML, imatinib, nilotinib, and dasatinib have pushed transplantation to the role of salvage therapy in CML. Still, TKI therapy still fails some patients, and so the clinical challenge is to integrate transplantation in a safe and sane manner. This manuscript reviews the data on the variables that have an influence on outcome following transplantation, and discusses the variables to consider in determining who and when patients should receive transplantation.
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35
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Chronic myelogenous leukemia: role of stem cell transplant in the imatinib era. Hematol Oncol Clin North Am 2012; 25:1025-48, vi. [PMID: 22054733 DOI: 10.1016/j.hoc.2011.09.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
In the pre-tyrosine kinase (TKI) era, allogeneic stem cell transplant (allo-SCT) was the front-line treatment of choice for young patients with chronic myelogenous leukemia (CML). Today, imatinib is well established as front-line therapy for CML, with excellent long-term outcomes. This has changed the role of allo-SCT and the number of patients undergoing allo-SCT has declined dramatically. Allo-SCT is currently recommended for patients in accelerated/blast phase disease, those who have failed a second-generation TKI and those with TKI-resistant mutations such as T315I. The role of allo-SCT in the management of CML will require continual reappraisal as medical therapies continue to evolve.
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36
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Yeung KY, Gooley TA, Zhang A, Raftery AE, Radich JP, Oehler VG. Predicting relapse prior to transplantation in chronic myeloid leukemia by integrating expert knowledge and expression data. ACTA ACUST UNITED AC 2012; 28:823-30. [PMID: 22296787 DOI: 10.1093/bioinformatics/bts059] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
MOTIVATION Selecting a small number of signature genes for accurate classification of samples is essential for the development of diagnostic tests. However, many genes are highly correlated in gene expression data, and hence, many possible sets of genes are potential classifiers. Because treatment outcomes are poor in advanced chronic myeloid leukemia (CML), we hypothesized that expression of classifiers of advanced phase CML when detected in early CML [chronic phase (CP) CML], correlates with subsequent poorer therapeutic outcome. RESULTS We developed a method that integrates gene expression data with expert knowledge and predicted functional relationships using iterative Bayesian model averaging. Applying our integrated method to CML, we identified small sets of signature genes that are highly predictive of disease phases and that are more robust and stable than using expression data alone. The accuracy of our algorithm was evaluated using cross-validation on the gene expression data. We then tested the hypothesis that gene sets associated with advanced phase CML would predict relapse after allogeneic transplantation in 176 independent CP CML cases. Our gene signatures of advanced phase CML are predictive of relapse even after adjustment for known risk factors associated with transplant outcomes.
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Affiliation(s)
- K Y Yeung
- Department of Microbiology, University of Washington, Seattle, WA 98195, USA.
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37
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Maloney KW, Giller R, Hunger SP. Recent advances in the understanding and treatment of pediatric leukemias. Adv Pediatr 2012; 59:329-58. [PMID: 22789585 DOI: 10.1016/j.yapd.2012.04.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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38
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Intravenous compared with oral busulfan as preparation for allogeneic hematopoietic progenitor cell transplantation for AML and MDS. Bone Marrow Transplant 2011; 47:633-8. [PMID: 21874055 DOI: 10.1038/bmt.2011.167] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BU and CY is a common conditioning regimen for allogeneic hematopoietic progenitor cell transplantation (HPCT). I.v. BU is increasingly used in place of the oral formulation for conditioning. We compared the outcomes of 135 consecutively treated AML and myelodysplastic syndrome patients who underwent allogeneic HPCT at our institution with BUCY2 using oral (n=93) or i.v. (n=42) BU, without dose adjustment. The i.v. BU patients had a lower incidence of any severity of oral mucositis (3 versus 55%, P=0.002) and severe mucositis (3 versus 24%, P=0.005). Other post transplant outcomes were comparable between the groups. In all 26 i.v. BU and 33 oral BU patients are alive; however, the median follow-up was significantly longer for the oral BU group. One- and two-year non-relapse mortality for the i.v. BU patients was 21% for both, and for the oral BU group was 23% and 29%, respectively. One- and two-year relapse mortality for the i.v. BU patients was 21% for both, and for the oral BU group was 24% and 29%, respectively. Substituting i.v. for oral BU reduces variability in drug exposure and potentially improves toxicity as suggested by our finding of significantly less oral mucositis and decreased severity with i.v. BU.
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39
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Mascarenhas J, Hoffman R. Myeloproliferative neoplasms: new translational therapies. ACTA ACUST UNITED AC 2011; 77:667-83. [PMID: 21105128 DOI: 10.1002/msj.20225] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The myeloproliferative neoplasms represent a diverse group of hematologic malignancies that have been the subject of intense investigation over the last decade. Although clinical trials of the much anticipated small molecule inhibitors of Janus kinase 2 have shown that these experimental agents are successful in palliating many of the symptoms associated with the myeloproliferative neoplasms, they have not been reported to affect the disease initiating hematopoietic stem cell population or to alter the natural history of these disorders. Investigators remain optimistic that new information about the genetic and cellular origins gained from the efforts of numerous laboratories will ultimately translate in to the identification of new drug targets and more effective therapies. We hypothesize that ultimately, the use of combinations of drugs including chromatin modifying agents, immunomodulatory agents, anti-apoptotic agents, cellular therapies and monoclonal antibodies will be required to effectively treat patients with myeloproliferative neoplasms.
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Huang XJ, Xu LP, Liu KY, Liu DH, Chen H, Liu YR, Chen YH, Han W, Wang Y. Individualized Intervention Guided by BCR-ABL Transcript Levels after HLA-Identical Sibling Donor Transplantation Improves HSCT Outcomes for Patients with Chronic Myeloid Leukemia. Biol Blood Marrow Transplant 2011; 17:649-56. [DOI: 10.1016/j.bbmt.2010.07.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Accepted: 07/27/2010] [Indexed: 10/19/2022]
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Wong AM, Allen JC, Goh YT, Linn YC, Loh SMY, Diong CP, Chowbay B, Hwang WYK. Single center retrospective analysis of BU-based conditioning regimens in allogeneic transplantation. Bone Marrow Transplant 2011; 47:181-9. [PMID: 21478919 DOI: 10.1038/bmt.2011.43] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
We performed a single institution retrospective analysis of 114 patients treated with BU-based pretransplant conditioning regimens. Oral BU was administered to 76 patients (total dose 16 mg/kg or 8 mg/kg) and i.v. BU to 38 others (total dose 12.8 mg/kg or 6.4 mg/kg). Either CY (n=74) or fludarabine (n=40) was given in combination with BU. Median age was 35 years in the oral BU group and 48.5 years with i.v. BU (P<0.001). OS and PFS rates at 3-years post HSCT were not different in patients who received either i.v. or oral BU (OS: 41.3 vs 44.0% (P=0.981); PFS: 52.7 vs 54.7% (P=0.526), respectively). The i.v. BU, however, was associated with a significantly shorter time to engraftment (13.5 days vs 16 days, respectively; P<0.001). There were no significant differences in survival or 100-day mortality for patients who received either CY or fludarabine, in combination with BU. After adjustment for confounders, multivariate analysis showed that age of transplant (P=0.002), donor type (sibling or unrelated; P=0.003), GVHD (P<0.05) and route of administration (P=0.023) were significant risk factors for OS. The i.v. BU used in an older age group yielded equivalent survival compared with oral BU used in a younger population.
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Affiliation(s)
- A M Wong
- Duke NUS Graduate Medical School, Singapore, Republic of Singapore
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Abstract
Tyrosine kinase inhibitor (TKI) therapy has revolutionized the therapy of chronic myeloid leukemia (CML). Thus, while in the near past allogeneic transplantation was the curative option for CML, imatinib, nilotinib, and dasatinib have pushed transplantation to the role of salvage therapy in CML. Still, TKI therapy still fails some patients, and so the clinical challenge is to integrate transplantation in a safe and sane manner. This article reviews the data on the variables that influence outcome following transplantation, and discusses the variables to consider in determining which patients should receive transplantation and when.
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Affiliation(s)
- Jerald Radich
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA.
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Oyekunle A, Klyuchnikov E, Ocheni S, Kröger N, Zander AR, Baccarani M, Bacher U. Challenges for allogeneic hematopoietic stem cell transplantation in chronic myeloid leukemia in the era of tyrosine kinase inhibitors. Acta Haematol 2011; 126:30-9. [PMID: 21411987 DOI: 10.1159/000323662] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2010] [Accepted: 12/20/2010] [Indexed: 02/02/2023]
Abstract
Following the introduction of the tyrosine kinase inhibitor (TKI) imatinib in the treatment of chronic myeloid leukemia (CML) patients, the allogeneic hematopoietic stem cell transplantation (HSCT) scene in CML has changed dramatically. The number of patients receiving HSCT in first chronic phase (CP) has declined rapidly, as allogeneic HSCT in CP is now performed in these patients only in case of failure or intolerance of TKIs. Second, those CML patients who undergo allogeneic HSCT represent a selection of high-risk patients due to more advanced disease with high rates of accelerated or blast phase (being associated with an increased relapse risk), advanced age and relevant co-morbidities. Efforts at meeting these special challenges are being developed: treatment with TKIs aims to improve the pre-transplant remission status before HSCT. Dose-reduced conditioning protocols were introduced to decrease transplant-related mortality in patients with co-morbidities or older age. In the post-transplant period, TKIs may be administered for prophylaxis and for treatment of post-transplant relapse. Still, the outcome of patients in advanced CML phases remains guarded, and requires an improvement in current transplant strategies.
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Affiliation(s)
- Anthony Oyekunle
- Department for Stem Cell Transplantation, University Cancer Center Hamburg, Hamburg, Germany
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Perkins J, Field T, Kim J, Kharfan-Dabaja MA, Ayala E, Perez L, Fernandez H, Fancher K, Tate C, Shaw LM, Milone MC, Gardiner JA, Miller S, Anasetti C. Pharmacokinetic targeting of i.v. BU with fludarabine as conditioning before hematopoietic cell transplant: the effect of first-dose area under the concentration time curve on transplant-related outcomes. Bone Marrow Transplant 2010; 46:1418-25. [PMID: 21132026 DOI: 10.1038/bmt.2010.315] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
We used pharmacokinetic (PK) targeting of BU in 145 consecutive patients treated with fludarabine and i.v. BU. BU was given once daily at 130 mg/m(2) per day on days 1 and 2; doses for days 3 and 4 were adjusted in 92 patients (63%) to an average daily area under the concentration-time curve (AUC) of 5300 μM/min. In the remaining 53 patients, the first-dose AUC was within the target range and no dosing adjustments were required. First-dose AUC, maximum concentration and clearance were not correlated with age, race, ethnicity, performance status, or hematopoietic cell transplant comorbidity index. Women had higher clearance than men (median 2.9 vs 2.5 mL/min/kg; P=0.001). BU toxicities were not associated with first-dose AUC or any other PK parameter measured. First-dose BU AUC was not associated with non-relapse mortality (NRM) or survival, but higher AUC was predictive of relapse. We did not find an increased risk of toxicity or NRM in patients with high first-dose AUC presumably because of the dose adjustment. We conclude that PK targeting of BU as described here provides a simple, safe and effective method of delivering high BU doses before transplantation in a wide variety of patients.
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Affiliation(s)
- J Perkins
- Blood and Marrow Transplant Program, H. Lee Moffitt Cancer Center, Tampa, FL 33612, USA.
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Abbasi N, Vadnais B, Knutson JA, Blough DK, Kelly EJ, O'Donnell PV, Deeg HJ, Pawlikowski MA, Ho RJY, McCune JS. Pharmacogenetics of intravenous and oral busulfan in hematopoietic cell transplant recipients. J Clin Pharmacol 2010; 51:1429-38. [PMID: 21135089 DOI: 10.1177/0091270010382915] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Kinetics-based dose targeting is often conducted in hematopoietic cell transplant (HCT) patients conditioned with intravenous (IV) or oral busulfan to lower rates of rejection, nonrelapse mortality, and relapse. Using the candidate gene approach, the authors evaluated whether busulfan clearance was associated with polymorphisms in the genes regulating the predominant metabolizing enzymes involved in busulfan conjugation, specifically glutathione S-transferase (GST) isoenzymes A1 (GSTA1) and M1 (GSTM1). Busulfan clearance was estimated after the morning dose on days 1, 2, and 3; each patient's average clearance was used for analyses. The average (± standard deviation) busulfan clearance was 3.2 ± 0.56 mL/min/kg in the separate population of 95 patients who received oral busulfan and 103 ± 24 ml/min/m(2) in the 57 patients who received IV busulfan. Oral busulfan clearance was associated with GSTA1 (P = .008) but not GSTM1 (P = .57) genotypes. However, among the GSTA1 haplotypes (ie, *A*A, *A*B, *B*B), there was significant overlap in the observed oral busulfan clearance and similar rates of achieving the target busulfan exposure. Clearance of IV busulfan was not associated with GSTA1 (P = .21) or GSTM1 (P = .99). These data suggest that personalizing either IV or oral busulfan dosing cannot be simplified on the basis of GSTA1 or GSTM1 genotype.
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Affiliation(s)
- Nissa Abbasi
- University of Washington School of Pharmacy, Seattle, Washington, USA
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Long-term outcomes of HLA-matched sibling compared with mismatched related and unrelated donor hematopoietic stem cell transplantation for chronic phase chronic myelogenous leukemia: a single institution experience in China. Ann Hematol 2010; 90:331-41. [PMID: 20872002 DOI: 10.1007/s00277-010-1081-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2010] [Accepted: 09/08/2010] [Indexed: 12/28/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HSCT) remains the only curative therapy for chronic myelogenous leukemia (CML). In this study, the long-term outcomes of HLA-matched sibling donor (MSD) with mismatched related donor (MRD) and unrelated donor (URD) transplantation for CML in the first chronic phase (CML-CP1) using different graft vs. host disease (GVHD) prophylaxis regimens according to donor source and the degree of HLA matching were compared. The data of 91 patients with CML-CP1 were analyzed with respect to GVHD, overall survival (OS), and transplant-related mortality (TRM). The incidence of grade II-IV acute GVHD was 25.5% in the MSD and 40.5% in the MRD/URD group (P = 0.133). The 1-year cumulative incidence of chronic GVHD was not different between the MSD and the MRD/URD groups, while extensive chronic GVHD was different between the two groups (31.9% vs. 10.8%, P = 0.023). The 5-year cumulative relapse rate was not different between the MSD and the MRD/URD groups, while TRM was different between the two groups (6.6% vs. 26.3%, P = 0.010). The 5-year cumulative OS was 90.9%, 71.5%, and 85.4% in the MSD, the MRD/URD, and the HLA allele-matched URD transplantation, respectively (MSD vs. MRD/URD, P = 0.013; MSD vs. HLA allele-matched URD, P = 0.437). In conclusion, survival in HLA allele-matched URD is equivalent to MSD, but in MRD and mismatched URD is inferior to MSD in patients with CML-CP1 undergoing allo-HSCT using different GVHD prophylaxis regimens according to donor source and degree of HLA matching. Patients undergoing MRD/URD transplantation have an equal quality of life as patients undergoing MSD transplantation.
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Tumor necrosis factor polymorphism affects transplantation outcome in patients with myelodysplastic syndrome but not in those with chronic myelogenous leukemia, independent of the presence of HLA-DR15. Biol Blood Marrow Transplant 2010; 16:1700-6. [PMID: 20541027 DOI: 10.1016/j.bbmt.2010.06.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2010] [Accepted: 06/01/2010] [Indexed: 10/19/2022]
Abstract
Both the presence of HLA-DR15 and tumor necrosis factor (TNF)-α levels have been reported to affect outcome after hematopoietic cell transplantation (HCT). Patients with a myelodysplastic syndrome (MDS) show a high prevalence of HLA-DR15 and express high levels of TNF-α in the bone marrow. The present analysis involving 7950 patients showed an HLA-DR15 frequency of 31% in patients with MDS, compared with only 23% in patients with chronic myelogenous leukemia (CML). HLA-DR15 was more prevalent in Caucasian patients than in non-Caucasian patients (P = .01). The numbers of patients in the non-Caucasian subgroups were too small to allow further analysis. Among Caucasian patients with MDS and CML, the presence of HLA-DR15 did not significantly affect the occurrence of graft-versus-host disease, relapse, nonrelapse mortality (NRM), or survival. However, there was a significant correlation between DR15 and TNF polymorphisms at position -308 among patients with MDS, and the TNF-308 AG genotype conferred an increased risk of NRM compared with the GG genotype (hazard ratio [HR], 1.49; P = .02), even after adjusting for DR15. Conversely, the TNF-863 AA genotype was correlated with decreased overall mortality and NRM compared with the CC genotype (HR, 0.36, P = .04 vs HR, 0.13, P = .04), even after adjusting for DR15. There was no significant association between TNF-308 or -863 polymorphisms and transplantation outcome in CML patients. These results suggest that TNF polymorphisms, but not DR15, affect transplantation outcome in a disease-dependent manner.
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Venepalli N, Rezvani K, Mielke S, Savani BN. Role of allo-SCT for CML in 2010. Bone Marrow Transplant 2010; 45:1579-86. [DOI: 10.1038/bmt.2010.138] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Radich JP. Molecular monitoring of patients with chronic myeloid leukemia: clinical examples from a non-trial setting. ACTA ACUST UNITED AC 2010; 9 Suppl 4:S391-4. [PMID: 20007108 DOI: 10.3816/clm.2009.s.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The molecular monitoring of chronic myeloid leukemia allows the clinician a minimally invasive method to judge response to tyrosine kinase therapy and to predict outcome and relapse. Because there are several treatment options for patients with suboptimal response, the ability to proactively predict and respond to relapse makes the "personalization" of treatment a realizable goal. There are practical issues with molecular monitoring, however, including availability of assays, standardization of tests, and the learning curve as doctors and patients learn to follow BCR-ABL levels with interest and reason. This review will examine the use of molecular monitoring in the non-trial setting, concentrating on pitfalls that can occur in the real-world delivery of complex medical care.
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Affiliation(s)
- Jerald P Radich
- Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA.
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Takamatsu Y, Sasaki N, Ogata K, Yukawa E, Jimi S, Hara S, Tamura K. Population pharmacokinetic study of a test dose oral busulfan in Japanese adult patients undergoing hematopoietic stem cell transplantation. Cancer Chemother Pharmacol 2010; 65:1203-7. [DOI: 10.1007/s00280-010-1263-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2009] [Accepted: 02/01/2010] [Indexed: 11/30/2022]
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