1
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Versluis J, Metzner M, Wang A, Gradowska P, Thomas A, Jakobsen NA, Kennedy A, Moore R, Boertjes E, Vonk CM, Kavelaars FG, Rijken M, Gilkes A, Schwab C, Beverloo HB, Manz M, Visser O, Van Elssen CHMJ, de Weerdt O, Tick LW, Biemond BJ, Vekemans MC, Freeman SD, Harrison CJ, Cook JA, Dennis M, Knapper S, Thomas I, Craddock C, Ossenkoppele GJ, Löwenberg B, Russell N, Valk PJM, Vyas P. Risk Stratification in Older Intensively Treated Patients With AML. J Clin Oncol 2024:JCO2302631. [PMID: 39231389 DOI: 10.1200/jco.23.02631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 05/17/2024] [Accepted: 07/09/2024] [Indexed: 09/06/2024] Open
Abstract
PURPOSE AML is a genetically heterogeneous disease, particularly in older patients. In patients older than 60 years, survival rates are variable after the most important curative approach, intensive chemotherapy followed by allogeneic hematopoietic cell transplantation (allo-HCT). Thus, there is an urgent need in clinical practice for a prognostic model to identify older patients with AML who benefit from curative treatment. METHODS We studied 1,910 intensively treated patients older than 60 years with AML and high-risk myelodysplastic syndrome (HR-MDS) from two cohorts (NCRI-AML18 and HOVON-SAKK). The median patient age was 67 years. Using a random survival forest, clinical, molecular, and cytogenetic variables were evaluated in an AML development cohort (n = 1,204) for association with overall survival (OS). Relative weights of selected variables determined the prognostic model, which was validated in AML (n = 491) and HR-MDS cohorts (n = 215). RESULTS The complete cohort had a high frequency of poor-risk features, including 2022 European LeukemiaNet adverse-risk (57.3%), mutated TP53 (14.4%), and myelodysplasia-related genetic features (65.1%). Nine variables were used to construct four groups with highly distinct 4-year OS in the (1) AML development, (2) AML validation, and (3) HR-MDS test cohorts ([1] favorable: 54% ± 4%, intermediate: 38% ± 2%, poor: 21% ± 2%, very poor: 4% ± 1%; [2] 54% ± 9%, 43% ± 4%, 27% ± 4%, 4% ± 3%; and [3] 54% ± 10%, 33% ± 6%, 14% ± 5%, 0% ± 3%, respectively). This new AML60+ classification improves current prognostic classifications. Importantly, patients within the AML60+ intermediate- and very poor-risk group significantly benefited from allo-HCT, whereas the poor-risk patients showed an indication, albeit nonsignificant, for improved outcome after allo-HCT. CONCLUSION The new AML60+ classification provides prognostic information for intensively treated patients 60 years and older with AML and HR-MDS and identifies patients who benefit from intensive chemotherapy and allo-HCT.
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Affiliation(s)
- Jurjen Versluis
- Department of Hematology, Erasmus University Medical Center Cancer Institute, Rotterdam, the Netherlands
| | - Marlen Metzner
- MRC Molecular Haematology Unit, Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, United Kingdom
| | - Ariel Wang
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Patrycja Gradowska
- Department of Hematology, Erasmus University Medical Center Cancer Institute, Rotterdam, the Netherlands
- HOVON Foundation, Rotterdam, the Netherlands
| | - Abin Thomas
- Centre for Trials Research, College of Biomedical & Life Sciences, Cardiff University, Cardiff, United Kingdom
| | - Niels Asger Jakobsen
- MRC Molecular Haematology Unit, Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, United Kingdom
| | - Alison Kennedy
- MRC Molecular Haematology Unit, Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, United Kingdom
| | - Rachel Moore
- MRC Molecular Haematology Unit, Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, United Kingdom
| | - Emma Boertjes
- Department of Hematology, Erasmus University Medical Center Cancer Institute, Rotterdam, the Netherlands
| | - Christian M Vonk
- Department of Hematology, Erasmus University Medical Center Cancer Institute, Rotterdam, the Netherlands
| | - Francois G Kavelaars
- Department of Hematology, Erasmus University Medical Center Cancer Institute, Rotterdam, the Netherlands
| | - Melissa Rijken
- Department of Hematology, Erasmus University Medical Center Cancer Institute, Rotterdam, the Netherlands
| | - Amanda Gilkes
- School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Claire Schwab
- Leukaemia Research Cytogenetics Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - H Berna Beverloo
- Department of Clinical Genetics, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Markus Manz
- Department of Hematology, University Hospital Zurich, Zurich, Switzerland
| | - Otto Visser
- Department of Hematology, Isala Hospital, Zwolle, the Netherlands
| | | | | | | | - Bart J Biemond
- Amsterdam UMC, Location AMC, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | | | - Sylvie D Freeman
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Christine J Harrison
- Leukaemia Research Cytogenetics Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Jonathan A Cook
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Mike Dennis
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Steven Knapper
- School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Ian Thomas
- Centre for Trials Research, College of Biomedical & Life Sciences, Cardiff University, Cardiff, United Kingdom
| | - Charles Craddock
- Warwick Clinical Trials Unit, University of Warwick, Warwick, United Kingdom
| | - Gert J Ossenkoppele
- Amsterdam UMC, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Bob Löwenberg
- Department of Hematology, Erasmus University Medical Center Cancer Institute, Rotterdam, the Netherlands
| | - Nigel Russell
- Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Peter J M Valk
- Department of Hematology, Erasmus University Medical Center Cancer Institute, Rotterdam, the Netherlands
| | - Paresh Vyas
- MRC Molecular Haematology Unit, Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, United Kingdom
- Department of Haematology, Oxford University Hospitals NHS Trust and Oxford Biomedical Centre, Oxford, United Kingdom
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2
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Gibson A, Dickson S, McCall D, Garcia M, Connors J, He J, Roth M, Nunez C, Cuglievan B. Venetoclax for pediatric patients with newly diagnosed acute myeloid leukemia. Pediatr Blood Cancer 2024:e31286. [PMID: 39152634 DOI: 10.1002/pbc.31286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 08/07/2024] [Accepted: 08/08/2024] [Indexed: 08/19/2024]
Abstract
This retrospective study at the University of Texas MD Anderson Cancer Center evaluated frontline venetoclax combination therapy in 11 pediatric/adolescent patients with acute myeloid leukemia (AML). Despite the small sample size and retrospective nature, the treatment demonstrated safety and potential efficacy, with most patients achieving early complete remission. Adverse events were consistent with other AML therapies, and no discontinuations due to toxicity occurred. While acknowledging study limitations, including selection bias and diverse concurrent therapies, this research underscores the promising role of venetoclax in pediatric AML. Further investigation is crucial to validate its long-term efficacy in this population.
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Affiliation(s)
- Amber Gibson
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Samantha Dickson
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - David McCall
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Miriam Garcia
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jeremy Connors
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jiasen He
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Michael Roth
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Cesar Nunez
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Branko Cuglievan
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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3
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Tiong IS, Hiwase DK, Abro E, Bajel A, Palfreyman E, Beligaswatte A, Reynolds J, Anstee N, Nguyen T, Loo S, Chua CC, Ashby M, Wiltshire KM, Fleming S, Fong CY, Teh TC, Blombery P, Dillon R, Ivey A, Wei AH. Targeting Molecular Measurable Residual Disease and Low-Blast Relapse in AML With Venetoclax and Low-Dose Cytarabine: A Prospective Phase II Study (VALDAC). J Clin Oncol 2024; 42:2161-2173. [PMID: 38427924 PMCID: PMC11191043 DOI: 10.1200/jco.23.01599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 11/21/2023] [Accepted: 12/18/2023] [Indexed: 03/03/2024] Open
Abstract
PURPOSE A prospective phase II study examined the safety and efficacy of venetoclax combined with low-dose cytarabine (LDAC) in AML at first measurable residual disease (MRD) or oligoblastic relapse. METHODS Patients with either MRD (≥1 log10 rise) or oligoblastic relapse (blasts 5%-15%) received venetoclax 600 mg once daily D1-28 plus LDAC once daily D1-10 in 28-day cycles. The primary objective was MRD response in the MRD relapse cohort or complete remission (CR/CRh/CRi) in the oligoblastic relapse cohort. RESULTS Forty-eight adults with either MRD (n = 26) or oligoblastic (n = 22) relapse were enrolled. Median age was 67 years (range, 18-80) and 94% had received previous intensive chemotherapy. Patients received a median of four cycles of therapy; 17% completed ≥12 cycles. Patients with oligoblastic relapse had more grade ≥3 anemia (32% v 4%; P = .02) and infections (36% v 8%; P = .03), whereas grade 4 neutropenia (32 v 23%) or thrombocytopenia (27 v 15%) were comparable with the MRD relapse cohort. Markers of molecular MRD relapse included mutant NPM1 (77%), CBFB::MYH11 (4%), RUNX1::RUNX1T1 (4%), or KMT2A::MLLT3 (4%). Three patients with a log10 rise in IDH1/2 (12%) were included. By cycle 2 in the MRD relapse cohort, a log10 reduction in MRD was observed in 69%; 46% achieved MRD negative remission. In the oligoblastic relapse cohort, 73% achieved CR/CRh/CRi. Overall, 21 (44%) underwent hematopoietic cell transplantation. Median overall survival (OS) was not reached in either cohort. Estimated 2-year OS rate was 67% (95% CI, 50 to 89) in the MRD and 53% (95% CI, 34 to 84) in the oligoblastic relapse cohorts. CONCLUSION For AML in first remission and either MRD or oligoblastic relapse, venetoclax plus LDAC is well tolerated and highly effective.
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MESH Headings
- Humans
- Aged
- Middle Aged
- Leukemia, Myeloid, Acute/drug therapy
- Leukemia, Myeloid, Acute/mortality
- Leukemia, Myeloid, Acute/genetics
- Leukemia, Myeloid, Acute/pathology
- Neoplasm, Residual
- Cytarabine/administration & dosage
- Sulfonamides/administration & dosage
- Sulfonamides/adverse effects
- Adult
- Female
- Male
- Bridged Bicyclo Compounds, Heterocyclic/administration & dosage
- Bridged Bicyclo Compounds, Heterocyclic/adverse effects
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/adverse effects
- Aged, 80 and over
- Prospective Studies
- Nucleophosmin
- Young Adult
- Adolescent
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Affiliation(s)
- Ing Soo Tiong
- The Alfred Hospital and Monash University, Melbourne, Australia
- Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Melbourne, Australia
| | - Devendra K. Hiwase
- Royal Adelaide Hospital, Adelaide, Australia
- University of Adelaide, Adelaide, Australia
- South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Emad Abro
- Princess Alexandra Hospital, Queensland, Australia
| | - Ashish Bajel
- Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Melbourne, Australia
- The University of Melbourne, Melbourne, Australia
| | | | - Ashanka Beligaswatte
- University of Adelaide, Adelaide, Australia
- Flinders Medical Centre, Bedford Park, Australia
| | - John Reynolds
- The Alfred Hospital and Monash University, Melbourne, Australia
| | - Natasha Anstee
- The University of Melbourne, Melbourne, Australia
- Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
| | - Tamia Nguyen
- Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Melbourne, Australia
- The University of Melbourne, Melbourne, Australia
| | - Sun Loo
- Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Melbourne, Australia
- The University of Melbourne, Melbourne, Australia
- Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
- The Northern Hospital, Melbourne, Australia
| | - Chong Chyn Chua
- The Alfred Hospital and Monash University, Melbourne, Australia
- The University of Melbourne, Melbourne, Australia
- Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
- The Northern Hospital, Melbourne, Australia
| | - Michael Ashby
- The Alfred Hospital and Monash University, Melbourne, Australia
| | | | - Shaun Fleming
- The Alfred Hospital and Monash University, Melbourne, Australia
| | - Chun Y. Fong
- Austin Health and Olivia Newton John Cancer Research Institute, Melbourne, Australia
| | - Tse-Chieh Teh
- The Alfred Hospital and Monash University, Melbourne, Australia
- Box Hill Hospital, Melbourne, Australia
| | - Piers Blombery
- Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Melbourne, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Richard Dillon
- Department of Medical and Molecular Genetics, King's College, London, United Kingdom
- Guy's Hospital, London, United Kingdom
| | - Adam Ivey
- The Alfred Hospital and Monash University, Melbourne, Australia
| | - Andrew H. Wei
- Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Melbourne, Australia
- The University of Melbourne, Melbourne, Australia
- Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
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4
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Palmieri R, Billio A, Ferrara F, Galimberti S, Lemoli RM, Todisco E, Moretti F, Venditti A. Literature review and expert opinion on the treatment of high-risk acute myeloid leukemia in patients who are eligible for intensive chemotherapy. Front Oncol 2024; 14:1367393. [PMID: 38444680 PMCID: PMC10912626 DOI: 10.3389/fonc.2024.1367393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 02/06/2024] [Indexed: 03/07/2024] Open
Abstract
In patients with Acute Myeloid Leukemia (AML), the assessment of disease risk plays a central role in the era of personalized medicine. Indeed, integrating baseline clinical and biological features on a case-by-case basis is not only essential to select which treatment would likely result in a higher probability of achieving complete remission, but also to dynamically customize any subsequent therapeutic intervention. For young high-risk patients with low comorbidities burden and in good general conditions (also called "fit" patients), intensive chemotherapy followed by allogeneic stem cell transplantation still represents the backbone of any therapeutic program. However, with the approval of novel promising agents in both the induction/consolidation and the maintenance setting, the algorithms for the management of AML patients considered eligible for intensive chemotherapy are in constant evolution. In this view, we selected burning issues regarding the identification and management of high-risk AML, aiming to provide practical advice to facilitate their daily clinical management in patients considered eligible for intensive chemotherapy.
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Affiliation(s)
- Raffaele Palmieri
- Hematology, Department of Biomedicine and Prevention, University Tor Vergata, Rome, Italy
| | - Atto Billio
- Division of Hematology and Bone Marrow Transplant (BMT), Hospital S. Maurizio, Bolzano, Italy
| | | | - Sara Galimberti
- Hematology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Roberto M. Lemoli
- Cattedra di Ematologia, Dipartimento di Medicina Interna (DiMI), Università di Genova, Genova, Italy
- Clinica Ematologica, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Martino, Genova, Italy
| | - Elisabetta Todisco
- Struttura Complessa (SC) Ematologia, Ospedale Busto Arsizio, Azienda Socio Sanitaria Territoriale (ASST) Valle Olona, Varese, Italy
| | - Federico Moretti
- Hematology, Department of Biomedicine and Prevention, University Tor Vergata, Rome, Italy
| | - Adriano Venditti
- Hematology, Department of Biomedicine and Prevention, University Tor Vergata, Rome, Italy
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5
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Lopes LM, Nucci M, Portugal RD. Toxicity and outcome of adults with acute myeloid leukemia receiving consolidation with high-dose cytarabine. Hematol Transfus Cell Ther 2023:S2531-1379(23)00161-X. [PMID: 37684163 DOI: 10.1016/j.htct.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 12/15/2022] [Accepted: 07/20/2023] [Indexed: 09/10/2023] Open
Abstract
INTRODUCTION High-dose cytarabine is considered standard of care as consolidation chemotherapy in adults with acute myeloid leukemia (AML) who are not eligible for allogeneic hematopoietic cell transplantation, but may be associated with significant toxicity. We evaluated the toxicity associated with high-dose cytarabine given as consolidation in AML patients treated at a Brazilian public hospital. METHODS We retrospectively reviewed the charts of all patients with AML treated between 2008 and 2020 who obtained complete remission (CR) after one cycle of induction chemotherapy and received consolidation with at least one cycle of high-dose cytarabine (defined as 3 g/m2 every 12 h days 1, 3 and 5). RESULTS Among 61 patients who received induction remission, 32 obtained CR and 28 received at least one cycle of high-dose cytarabine, for a total of 67 cycles (median 2 cycles per patient, range 1 - 4). In 45 cycles (67.2%) the patient was discharged after the end of chemotherapy, with a median of 6 days at home (range 3 - 8). Readmission occurred in 31 of the 45 cycles (68.9%). The most frequent toxicities were febrile neutropenia (56.7%), nausea and vomiting (23.9%), oral mucositis (14.9%) and diarrhea (11.9%). Bacteremia was documented in 13 cycles (34.2%). There were three cases of typhlitis and two of invasive fungal disease (aspergillosis and candidemia). Four patients died (14.3%), with two deaths considered treatment-related (candidemia and typhlitis). CONCLUSION In the setting of a Brazilian public hospital, high-dose cytarabine as consolidation therapy is feasible, with manageable toxicity profile.
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Affiliation(s)
- Lais Moreira Lopes
- Universidade Federal do Rio de Janeiro (URFJ), Rio de Janeiro, RJ, Brazil
| | - Marcio Nucci
- Universidade Federal do Rio de Janeiro (URFJ), Rio de Janeiro, RJ, Brazil; Grupo Oncoclínicas, São Paulo, SP, Brazil.
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6
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Tomasoni C, Pievani A, Rambaldi B, Biondi A, Serafini M. A Question of Frame: The Role of the Bone Marrow Stromal Niche in Myeloid Malignancies. Hemasphere 2023; 7:e896. [PMID: 37234820 PMCID: PMC10208717 DOI: 10.1097/hs9.0000000000000896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 04/18/2023] [Indexed: 05/28/2023] Open
Abstract
Until a few years ago, the onset of acute myeloid leukemia (AML) was entirely ascribed to genetic lesions in hematopoietic stem cells. These mutations generate leukemic stem cells, which are known to be the main ones responsible for chemoresistance and relapse. However, in the last years, increasing evidence demonstrated that dynamic interplay between leukemic cells and bone marrow (BM) niche is of paramount relevance in the pathogenesis of myeloid malignancies, including AML. Specifically, BM stromal niche components, such as mesenchymal stromal cells (MSCs) and their osteoblastic cell derivatives, play a key role not only in supporting normal hematopoiesis but also in the manifestation and progression of myeloid malignancies. Here, we reviewed recent clinical and experimental findings about how genetic and functional alterations in MSCs and osteolineage progeny can contribute to leukemogenesis and how leukemic cells in turn generate a corrupted niche able to support myeloid neoplasms. Moreover, we discussed how the newest single-cell technologies may help dissect the interactions between BM stromal cells and malignant hematopoiesis. The deep comprehension of the tangled relationship between stroma and AML blasts and their modulation during disease progression may have a valuable impact on the development of new microenvironment-directed therapeutic strategies, potentially useful for a wide cohort of patients.
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Affiliation(s)
- Chiara Tomasoni
- Tettamanti Center, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Alice Pievani
- Tettamanti Center, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Benedetta Rambaldi
- Hematology and Bone Marrow Transplant Unit, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Andrea Biondi
- Pediatrics, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Marta Serafini
- Tettamanti Center, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
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7
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Srinivasan Rajsri K, Roy N, Chakraborty S. Acute Myeloid Leukemia Stem Cells in Minimal/Measurable Residual Disease Detection. Cancers (Basel) 2023; 15:2866. [PMID: 37345204 PMCID: PMC10216329 DOI: 10.3390/cancers15102866] [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: 04/06/2023] [Revised: 05/14/2023] [Accepted: 05/17/2023] [Indexed: 06/23/2023] Open
Abstract
Acute myeloid leukemia (AML) is a hematological malignancy characterized by an abundance of incompletely matured or immature clonally derived hematopoietic precursors called leukemic blasts. Rare leukemia stem cells (LSCs) that can self-renew as well as give rise to leukemic progenitors comprising the bulk of leukemic blasts are considered the cellular reservoir of disease initiation and maintenance. LSCs are widely thought to be relatively resistant as well as adaptive to chemotherapy and can cause disease relapse. Therefore, it is imperative to understand the molecular bases of LSC forms and functions during different stages of disease progression, so we can more accurately identify these cells and design therapies to target them. Irrespective of the morphological, cytogenetic, and cellular heterogeneity of AML, the uniform, singularly important and independently significant prognosticator of disease response to therapy and patient outcome is measurable or minimal residual disease (MRD) detection, defined by residual disease detection below the morphology-based 5% blast threshold. The importance of LSC identification and frequency estimation during MRD detection, in order to make MRD more effective in predicting disease relapse and modifying therapeutic regimen is becoming increasingly apparent. This review focuses on summarizing functional and cellular composition-based LSC identification and linking those studies to current techniques of MRD detection to suggest LSC-inclusive MRD detection as well as outline outstanding questions that need to be addressed to improve the future of AML clinical management and treatment outcomes.
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Affiliation(s)
- Kritika Srinivasan Rajsri
- Department of Pathology, New York University Grossman School of Medicine, New York, NY 10016, USA; (K.S.R.); (N.R.)
- Department of Molecular Pathobiology, New York University College of Dentistry, New York, NY 10010, USA
| | - Nainita Roy
- Department of Pathology, New York University Grossman School of Medicine, New York, NY 10016, USA; (K.S.R.); (N.R.)
| | - Sohini Chakraborty
- Department of Pathology, New York University Grossman School of Medicine, New York, NY 10016, USA; (K.S.R.); (N.R.)
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8
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Karlsson L, Cheuk D, De Moerloose B, Hasle H, Jahnukainen K, Juul-Dam KL, Kaspers G, Kovalova Z, Lausen B, Nyström UN, Palle J, Pronk CJ, Saks K, Tierens A, Zeller B, Abrahamsson J. Characteristics and outcome of primary resistant disease in paediatric acute myeloid leukaemia. Br J Haematol 2023; 201:757-765. [PMID: 36762836 DOI: 10.1111/bjh.18685] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/16/2023] [Accepted: 01/25/2023] [Indexed: 02/11/2023]
Abstract
A significant proportion of events in paediatric acute myeloid leukaemia (AML) are caused by resistant disease (RD). We investigated clinical and biological characteristics in 66 patients with RD from 1013 children with AML registered and treated according to the NOPHO-AML 93, NOPHO-AML 2004, DB AML-01 and NOPHO-DBH AML 2012 protocols. Risk factors for RD were age10 years or older and a white-blood-cell count (WBC) of 100 × 109 /L or more at diagnosis. The five-year overall survival (OS) was 38% (95% confidence interval [CI]: 28%-52%). Of the 63 children that received salvage therapy with chemotherapy, 59% (N = 37) achieved complete remission (CR) with OS 57% (95% CI: 42%-75%) compared to 12% (95% CI: 4%-35%) for children that did not achieve CR. Giving more than two salvage chemotherapy courses did not increase CR rates. OS for all 43 patients receiving allogeneic haematopoietic stem cell transplantation (HSCT) was 49% (95% CI: 36%-66%). Those achieving CR and proceeding to HSCT had an OS of 56% (95% CI: 41%-77%, N = 30). This study showed that almost 40% of children with primary resistant AML can be cured with salvage therapy followed by HSCT. Children that did not achieve CR after two salvage courses with chemotherapy did not benefit from additional chemotherapy.
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Affiliation(s)
- Lene Karlsson
- Department of Pediatrics, Institution for Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Daniel Cheuk
- Department of Pediatrics and Adolescent Medicine, Hong Kong Children's Hospital and Hong Kong Pediatric Hematology and Oncology Study Group (HKPHOSG), Hong Kong, China
| | - Barbara De Moerloose
- Department of Pediatric Hematology-Oncology, Ghent University Hospital, Ghent, Belgium
| | - Henrik Hasle
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Kirsi Jahnukainen
- New Children's hospital, Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | | | - Gertjan Kaspers
- Princess Maxima Center for Pediatric Oncology, Utrecht, The Netherlands.,Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit Amsterdam, Pediatric Oncology, Amsterdam, The Netherlands
| | - Zanna Kovalova
- Department of Paediatric Oncology/Haematology, Children's Clinical University Hospital, Riga, Latvia
| | - Birgitte Lausen
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | - Josefine Palle
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | | | - Kadri Saks
- Department of Paediatrics, SA Tallinna Lastehaigla, Tallinn, Estonia
| | - Anne Tierens
- Department of Pathobiology and Laboratory Medicine, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
| | - Bernward Zeller
- Department of Pediatrics, Oslo University Hospital, Oslo, Norway
| | - Jonas Abrahamsson
- Department of Pediatrics, Institution for Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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9
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Srinivasan S. Optimal dosing of cytarabine in childhood acute myeloid leukemia: do we have the answer yet? Leuk Lymphoma 2022; 63:3015-3017. [PMID: 35913395 DOI: 10.1080/10428194.2022.2105327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Shyam Srinivasan
- Department of Pediatric Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
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10
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Stone RM. Consolidation chemotherapy in AML: Are we playing with a full deck of cards? Best Pract Res Clin Haematol 2022; 35:101408. [DOI: 10.1016/j.beha.2022.101408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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11
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Azenkot T, Jonas BA. Clinical Impact of Measurable Residual Disease in Acute Myeloid Leukemia. Cancers (Basel) 2022; 14:cancers14153634. [PMID: 35892893 PMCID: PMC9330895 DOI: 10.3390/cancers14153634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 07/21/2022] [Indexed: 11/24/2022] Open
Abstract
Simple Summary Advances in immunophenotyping and molecular techniques have allowed for the development of more sensitive diagnostic tests in acute leukemia. These techniques can identify low levels of leukemic cells (quantified as 10−4 to 10−6 ratio to white blood cells) in patient samples. The presence of such low levels of leukemic cells, termed “measurable/minimal residual disease” (MRD), has been shown to be a marker of disease burden and patient outcomes. In acute lymphoblastic leukemia, new agents are highly effective at eliminating MRD for patients whose leukemia progressed despite first line therapies. By comparison, the role of MRD in acute myeloid leukemia is less clear. This commentary reviews select data and remaining questions about the clinical application of MRD to the treatment of patients with acute myeloid leukemia. Abstract Measurable residual disease (MRD) has emerged as a primary marker of risk severity and prognosis in acute myeloid leukemia (AML). There is, however, ongoing debate about MRD-based surveillance and treatment. A literature review was performed using the PubMed database with the keywords MRD or residual disease in recently published journals. Identified articles describe the prognostic value of pre-transplant MRD and suggest optimal timing and techniques to quantify MRD. Several studies address the implications of MRD on treatment selection and hematopoietic stem cell transplant, including patient candidacy, conditioning regimen, and transplant type. More prospective, randomized studies are needed to guide the application of MRD in the treatment of AML, particularly in transplant.
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Affiliation(s)
- Tali Azenkot
- Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, CA 95817, USA;
| | - Brian A. Jonas
- Division of Cellular Therapy, Bone Marrow Transplant, and Malignant Hematology, Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, CA 95817, USA
- Correspondence: ; Tel.: +1-916-734-3772
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12
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Ochs MA, Marini BL, Perissinotti AJ, Foucar CE, Pettit K, Burke P, Bixby DL, Benitez LL. Oncology stewardship in acute myeloid leukemia. Ann Hematol 2022; 101:1627-1644. [PMID: 35618780 DOI: 10.1007/s00277-022-04872-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 05/13/2022] [Indexed: 11/25/2022]
Abstract
In recent years, an explosion of novel agents has shifted the treatment paradigm for patients with acute myeloid leukemia. The optimal place in therapy for many of these novel agents remains unknown due to limited guidance from national guidelines and the way these agents were studied prior to entering the market. A critical evaluation of the literature and incorporation of oncology stewardship principles can be helpful in determining an optimal place for these agents while being mindful of the overall cost that is associated with therapies. The purpose of this review is to critically evaluate the efficacy and safety data for five controversial agents and provide examples of the use of stewardship practices in determining their place in the treatment of acute myeloid leukemia.
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Affiliation(s)
- Madeleine A Ochs
- Department of Pharmacy Services and Clinical Pharmacy, Michigan Medicine, 1540 E. Hospital Dr, Ann Arbor, MI, 48109, USA
| | - Bernard L Marini
- Department of Pharmacy Services and Clinical Pharmacy, Michigan Medicine, 1540 E. Hospital Dr, Ann Arbor, MI, 48109, USA
- University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Anthony J Perissinotti
- Department of Pharmacy Services and Clinical Pharmacy, Michigan Medicine, 1540 E. Hospital Dr, Ann Arbor, MI, 48109, USA
| | - Charles E Foucar
- Department of Internal Medicine and Division of Hematology and Oncology, Michigan Medicine, Ann Arbor, MI, USA
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Kristen Pettit
- Department of Internal Medicine and Division of Hematology and Oncology, Michigan Medicine, Ann Arbor, MI, USA
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Patrick Burke
- Department of Internal Medicine and Division of Hematology and Oncology, Michigan Medicine, Ann Arbor, MI, USA
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Dale L Bixby
- Department of Internal Medicine and Division of Hematology and Oncology, Michigan Medicine, Ann Arbor, MI, USA
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Lydia L Benitez
- Department of Pharmacy Services and Clinical Pharmacy, Michigan Medicine, 1540 E. Hospital Dr, Ann Arbor, MI, 48109, USA.
- University of Michigan College of Pharmacy, Ann Arbor, MI, USA.
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13
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Lachowiez CA, Reville PK, Kantarjian H, Jabbour E, Borthakur G, Daver N, Loghavi S, Furudate K, Xiao L, Pierce S, Short NJ, Maiti A, Yilmaz M, Sasaki K, Takahashi K, Konopleva M, Pemmaraju N, Popat U, Shpall E, Garcia-Manero G, Ravandi F, DiNardo CD, Kadia TM. Venetoclax combined with induction chemotherapy in patients with newly diagnosed acute myeloid leukaemia: a post-hoc, propensity score-matched, cohort study. Lancet Haematol 2022; 9:e350-e360. [PMID: 35483396 PMCID: PMC9946440 DOI: 10.1016/s2352-3026(22)00076-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 03/03/2022] [Accepted: 03/08/2022] [Indexed: 01/29/2023]
Abstract
BACKGROUND Venetoclax combined with intensive chemotherapy has been shown to be safe with promising activity in fit patients with newly diagnosed acute myeloid leukaemia. The aim of this study was to compare the activity of venetoclax plus intensive chemotherapy with intensive chemotherapy alone. METHODS This was a post-hoc propensity score matched analysis of prospective clinical trials (NCT03214562, NCT02115295, and NCT01289457) in patients at The University of Texas MD Anderson Cancer Center, Texas, USA between March 29, 2010, and June 15, 2021. Eligible patients were aged 18 years and older, and had newly diagnosed acute myeloid leukaemia or high-risk myelodysplastic syndrome, and were treated within trials incorporating purine analogues with an anthracycline and cytarabine either with venetoclax plus intensive chemotherapy or with intensive chemotherapy alone. Patients in the venetoclax plus intensive chemotherapy cohort were matched with patients in the intensive chemotherapy cohort. Morphological response and measurable residual disease (MRD) was assessed using bone marrow aspiration and biopsy and eight-colour multiparameter flow cytometry. The primary objectives were rate of MRD negative composite complete response and cumulative incidence of transition to allogeneic haematopoietic stem-cell transplantation (HSCT). All patients who had response within two treatment cycles (induction and re-induction) were included in the analyses. Secondary objectives included assessment of event-free and overall survival. FINDINGS The propensity matched cohort included 279 patients (median age 49 years [IQR 39-57]; 131 [47%] were men and 148 [53%] were women); 85 in the venetoclax plus intensive chemotherapy cohort and 194 in the intensive chemotherapy cohort. After a median follow up of 30 months (95% CI 26-36), 64 (86%) of 74 patients in the venetoclax plus intensive chemotherapy cohort had an MRD-negative composite complete response rate compared with 86 [61%] of 140 patients in the intensive chemotherapy cohort (odd ratio 3·2 [95% CI 1·5-6·7]; p=0·0028). The overall cumulative incidence of allogeneic HSCT in responding patients was higher with venetoclax plus intensive chemotherapy than intensive chemotherapy (79% [95% CI 67-88] vs 57% [49-65]; hazard ratio [HR] 1·52 [95% CI 1·11-2·08]; p=0·012). Venetoclax plus intensive chemotherapy improved event-free survival (median not reached [NR; 95% CI NR-NR] vs 14·3 months [10·7-33·5]; HR 0·57 [95% CI 0·34-0·95]; p=0·030), but overall survival did not significantly differ between the two cohorts (median NR [95% CI 24-NR] vs 32 months [19-NR]; HR 0·63 [95% CI 0·35-1·1], p=0·13). INTERPRETATIONS Venetoclax combined with intensive induction chemotherapy induced deep MRD-negative remissions, allowing transition to allogeneic HSCT in first remission, and improvement in event-free survival. These results highlight the incremental benefit of venetoclax added to intensive induction chemotherapy across European LeukemiaNet risk groups, and serve as a benchmark to inform enrolment on future confirmatory prospective clinical trials. FUNDING None.
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Affiliation(s)
- Curtis A Lachowiez
- Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Patrick K Reville
- Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gautam Borthakur
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naval Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sanam Loghavi
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ken Furudate
- Department of Bioinformatics and Computational Biology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lianchun Xiao
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sherry Pierce
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Abhishek Maiti
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Musa Yilmaz
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Koji Sasaki
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Koichi Takahashi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Marina Konopleva
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naveen Pemmaraju
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Uday Popat
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elizabeth Shpall
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Courtney D DiNardo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tapan M Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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14
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Kimura SI, Nakamura Y, Kawamura M, Takeshita J, Kawamura S, Yoshino N, Misaki Y, Yoshimura K, Matsumi S, Gomyo A, Okada Y, Akahoshi Y, Tamaki M, Kusuda M, Kameda K, Wada H, Sato M, Tanihara A, Nakasone H, Kako S, Kanda Y. Neutropenia in the First Cycle of Consolidation Chemotherapy with High-Dose Cytarabine Is Not Associated with the Incidence of Relapse in Adult Acute Myeloid Leukemia Patients in First Complete Remission. Acta Haematol 2022; 145:404-411. [PMID: 35045423 DOI: 10.1159/000522037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 01/15/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND It has been reported that prolonged neutropenia during post-remission chemotherapy is associated with a reduced risk of disease relapse in pediatric acute myeloid leukemia (AML) patients. METHODS We retrospectively reviewed the charts of adult AML patients in first complete remission (CR1) who underwent consolidation chemotherapy with high-dose cytarabine. Those receiving allogeneic hematopoietic cell transplantation in CR1 were excluded. We calculated the D-index, which is an area-based neutropenia index. The patients were divided into 2 groups using the median value of the D-index during the first cycle of consolidation chemotherapy (C#1). RESULTS Fifty-six patients were included. The 2-year cumulative incidence of relapse was 54.8% (95% confidence interval (CI): 37.5-73.8) in patients with a D-index < 5,118 and 62.0% (95%CI: 42.7-81.4) in those with a D-index ≥ 5,118 (P = 0.56). In a multivariate analysis, intermediate / adverse cytogenetic risk (HR 2.76), performance status ≥ 2 (HR 5.55) and 2 cycles of induction chemotherapy required to achieve CR1 (HR 4.29) were identified as significant factors associated with relapse. The D-index at C#1 did not have a significant impact. CONCLUSIONS In contrast to pediatric patients, the severity of neutropenia is not associated with a risk of disease relapse in adult AML patients.
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Affiliation(s)
- Shun-Ichi Kimura
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Yuhei Nakamura
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Masakatsu Kawamura
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Junko Takeshita
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Shunto Kawamura
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Nozomu Yoshino
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Yukiko Misaki
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Kazuki Yoshimura
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Shimpei Matsumi
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Ayumi Gomyo
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Yosuke Okada
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Yu Akahoshi
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Masaharu Tamaki
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Machiko Kusuda
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Kazuaki Kameda
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Hidenori Wada
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Miki Sato
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Aki Tanihara
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Hideki Nakasone
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Shinichi Kako
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Yoshinobu Kanda
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
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15
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Cenfra N, Lapietra G, Perrone S, Voso MT, Divona M, Mecarocci S, La Barbera EO, Cimino G. Azacitidine to Consolidate and Deepen the Therapeutic Response Achieved by Intensive Induction Treatment in a Young Patient Affected by NPM1mut-AML Who Has Become Ineligible for High-Dose Consolidation. Chemotherapy 2022; 67:24-28. [PMID: 35021172 DOI: 10.1159/000520205] [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: 09/14/2021] [Accepted: 10/13/2021] [Indexed: 11/19/2022]
Abstract
Acute myeloid leukemia (AML) is the most common leukemia in adults. In spite of the most recent discoveries about the molecular landscape of this disease, the treatment of elderly and unfit young patients continues to be a great challenge. The hypomethylating agents (HMA) still represent an effective therapeutic option for these categories, especially for the low-risk subgroups. We report the case of a young patient with NPM1mut-AML who underwent a first cycle of intensive induction treatment, achieving a complete remission, but suffered from a serious life-threatening neurologic toxicity. Due to the ineligibility to further lines of intensive chemotherapy, we decided to consolidate the response with azacitidine, administered according to the regular schedule. The minimal residual disease (MRD), monitored through the NPM1 mutation at diagnosis, progressively decreased and became undetectable after 36 cycles of hypomethylating therapy. After 1 year from discontinuation of azacitidine, MRD remains undetectable. Therefore, HMA might still represent a feasible and effective option for patients with low-risk AML, especially when the standard chemotherapy is not indicated, or as maintenance therapy in nontransplantable patients.
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Affiliation(s)
- Natalia Cenfra
- Hematology Polo Universitario Pontino, S.M. Goretti Hospital, Latina, Italy
| | - Gianfranco Lapietra
- Department of Translational and Precision Medicine University "La Sapienza", Rome, Italy
| | - Salvatore Perrone
- Hematology Polo Universitario Pontino, S.M. Goretti Hospital, Latina, Italy
| | - Maria Teresa Voso
- Department of Biomedicine and Prevention, Tor Vergata University, Rome, Italy
| | | | - Sergio Mecarocci
- Hematology Polo Universitario Pontino, S.M. Goretti Hospital, Latina, Italy
| | | | - Giuseppe Cimino
- Hematology Polo Universitario Pontino, S.M. Goretti Hospital, Latina, Italy.,Department of Translational and Precision Medicine University "La Sapienza", Rome, Italy
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16
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Getz KD, Alonzo TA, Sung L, Meshinchi S, Gerbing RB, Raimondi S, Hirsch B, Loken M, Brodersen LE, Kahwash S, Choi J, Kolb EA, Gamis A, Aplenc R. Cytarabine dose reduction in patients with low-risk acute myeloid leukemia: A report from the Children's Oncology Group. Pediatr Blood Cancer 2022; 69:e29313. [PMID: 34472213 PMCID: PMC8919970 DOI: 10.1002/pbc.29313] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 08/09/2021] [Accepted: 08/14/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND The optimal number of chemotherapy courses for low-risk (LR) pediatric acute myeloid leukemia (AML) is not known. OBJECTIVE To compare outcomes for four (21.6 g/m2 cytarabine) versus five (45.6 g/m2 cytarabine) chemotherapy courses for LR-AML using data from Children's Oncology Group (COG) AAML0531 and AAML1031. METHODS We compared relapse risk (RR), disease-free survival (DFS), and overall survival (OS), and the differential impact in LR subgroups for patients receiving four versus five chemotherapy courses. Cox (OS and DFS) and risk (RR) regressions were used to estimate hazard ratios (HR) to compare outcomes. RESULTS A total of 923 LR-AML patients were included; 21% received five courses. Overall, LR-AML patients who received four courses had higher RR (40.9% vs. 31.4%; HR = 1.40, 95% confidence interval [CI]: 1.06-1.85), and worse DFS (56.0% vs. 67.0%; HR = 1.45, 95% CI: 1.10-1.91). There was a similar decrement in OS though it was not statistically significant (77.0% vs. 83.5%; HR = 1.45, 95% CI: 0.97-2.17). Stratified analyses revealed the detrimental effects of cytarabine dose de-escalation to be most pronounced in the LR-AML subgroup with uninformative cytogenetic/molecular features who were minimal residual disease (MRD) negative after the first induction course (EOI1). The absolute decrease in DFS with four courses for patients with favorable cytogenetic/molecular features and positive MRD was similar to that observed for patients with uninformative cytogenetic/molecular features and negative MRD at EOI1, though not statistically significant. CONCLUSIONS Our results support de-escalation of cytarabine exposure through the elimination of a fifth chemotherapy course only for LR-AML patients who have both favorable cytogenetic/molecular features and negative MRD after the first induction cycle.
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Affiliation(s)
- Kelly D. Getz
- Children’s Hospital of Philadelphia, Division of Oncology, Philadelphia, Pennsylvania, USA,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Todd A. Alonzo
- University of Southern California, Los Angeles, California, USA
| | - Lillian Sung
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Soheil Meshinchi
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | | | - Susana Raimondi
- St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Betsy Hirsch
- University of Minnesota, Minneapolis, Minnesota, USA
| | | | | | | | - John Choi
- St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - E. Anders Kolb
- Alfred I. duPont Hospital for Children, Wilmington, Delaware, USA
| | - Alan Gamis
- Children’s Mercy Hospital and Clinics, Kansas City, Missouri, USA
| | - Richard Aplenc
- Children’s Hospital of Philadelphia, Division of Oncology, Philadelphia, Pennsylvania, USA,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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17
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Heuser M, Freeman SD, Ossenkoppele GJ, Buccisano F, Hourigan CS, Ngai LL, Tettero JM, Bachas C, Baer C, Béné MC, Bücklein V, Czyz A, Denys B, Dillon R, Feuring-Buske M, Guzman ML, Haferlach T, Han L, Herzig JK, Jorgensen JL, Kern W, Konopleva MY, Lacombe F, Libura M, Majchrzak A, Maurillo L, Ofran Y, Philippe J, Plesa A, Preudhomme C, Ravandi F, Roumier C, Subklewe M, Thol F, van de Loosdrecht AA, van der Reijden BA, Venditti A, Wierzbowska A, Valk PJM, Wood BL, Walter RB, Thiede C, Döhner K, Roboz GJ, Cloos J. 2021 Update on MRD in acute myeloid leukemia: a consensus document from the European LeukemiaNet MRD Working Party. Blood 2021; 138:2753-2767. [PMID: 34724563 PMCID: PMC8718623 DOI: 10.1182/blood.2021013626] [Citation(s) in RCA: 316] [Impact Index Per Article: 105.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 10/15/2021] [Indexed: 11/20/2022] Open
Abstract
Measurable residual disease (MRD) is an important biomarker in acute myeloid leukemia (AML) that is used for prognostic, predictive, monitoring, and efficacy-response assessments. The European LeukemiaNet (ELN) MRD Working Party evaluated standardization and harmonization of MRD in an ongoing manner and has updated the 2018 ELN MRD recommendations based on significant developments in the field. New and revised recommendations were established during in-person and online meetings, and a 2-stage Delphi poll was conducted to optimize consensus. All recommendations are graded by levels of evidence and agreement. Major changes include technical specifications for next-generation sequencing-based MRD testing and integrative assessments of MRD irrespective of technology. Other topics include use of MRD as a prognostic and surrogate end point for drug testing; selection of the technique, material, and appropriate time points for MRD assessment; and clinical implications of MRD assessment. In addition to technical recommendations for flow- and molecular-MRD analysis, we provide MRD thresholds and define MRD response, and detail how MRD results should be reported and combined if several techniques are used. MRD assessment in AML is complex and clinically relevant, and standardized approaches to application, interpretation, technical conduct, and reporting are of critical importance.
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Affiliation(s)
- Michael Heuser
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Sylvie D Freeman
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Gert J Ossenkoppele
- Department of Hematology, Amsterdam University Medical Center (UMC), Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Francesco Buccisano
- Department of Biomedicine and Prevention, Hematology, University Tor Vergata, Rome, Italy
| | - Christopher S Hourigan
- Laboratory of Myeloid Malignancy, Hematology Branch, National Heart, Lung, and Blood Institute, Bethesda, MD
| | - Lok Lam Ngai
- Department of Hematology, Amsterdam University Medical Center (UMC), Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Jesse M Tettero
- Department of Hematology, Amsterdam University Medical Center (UMC), Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Costa Bachas
- Department of Hematology, Amsterdam University Medical Center (UMC), Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | | | - Marie-Christine Béné
- Department of Hematology and Biology, Centre Hospitalier Universitaire (CHU) Nantes, Nantes, France
| | - Veit Bücklein
- Department of Medicine III, University Hospital, Ludwig Maximilian University Munich, Munich, Germany
| | - Anna Czyz
- Department of Hematology, Blood Neoplasms, and Bone Marrow Transplantation, Wrocław Medical University, Wrocław, Poland
| | - Barbara Denys
- Department of Diagnostic Sciences, Faculty of Medicine and Health Sciences, Ghent University
| | - Richard Dillon
- Department of Medical and Molecular Genetics, King's College, London, United Kingdom
| | | | - Monica L Guzman
- Department of Medicine, Division of Hematology and Oncology, Weill Cornell Medicine, New York, NY
| | | | | | - Julia K Herzig
- Department of Internal Medicine III, University Hospital of Ulm, Ulm, Germany
| | | | | | | | - Francis Lacombe
- Hematology Biology, Flow Cytometry, Bordeaux University Hospital, Pessac, France
| | | | - Agata Majchrzak
- Department of Experimental Hematology, Copernicus Memorial Hospital, Lodz, Poland
| | - Luca Maurillo
- Department of Biomedicine and Prevention, Hematology, University Tor Vergata, Rome, Italy
| | - Yishai Ofran
- Department of Hematology, Shaare Zedek Medical Center Faculty of Medicine Hebrew University, Jerusalem Israel
| | - Jan Philippe
- Department of Diagnostic Sciences, Faculty of Medicine and Health Sciences, Ghent University
| | - Adriana Plesa
- Department of Hematology Laboratory, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Lyon, France
| | | | | | | | - Marion Subklewe
- Department of Medicine III, University Hospital, Ludwig Maximilian University Munich, Munich, Germany
| | - Felicitas Thol
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Arjan A van de Loosdrecht
- Department of Hematology, Amsterdam University Medical Center (UMC), Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Bert A van der Reijden
- Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Adriano Venditti
- Department of Biomedicine and Prevention, Hematology, University Tor Vergata, Rome, Italy
| | | | - Peter J M Valk
- Department of Hematology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Brent L Wood
- Department of Hematopathology, Children's Hospital Los Angeles, CA
| | - Roland B Walter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Christian Thiede
- Department of Medicine I, University Hospital Carl Gustav Carus, Dresden, Germany; and
- AgenDix GmbH, Dresden, Germany
| | - Konstanze Döhner
- Department of Internal Medicine III, University Hospital of Ulm, Ulm, Germany
| | - Gail J Roboz
- Department of Medicine, Division of Hematology and Oncology, Weill Cornell Medicine, New York, NY
| | - Jacqueline Cloos
- Department of Hematology, Amsterdam University Medical Center (UMC), Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
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Luger SM. Is the current consolidation regimen for AML evidence-based? Best Pract Res Clin Haematol 2021; 34:101334. [PMID: 34865706 DOI: 10.1016/j.beha.2021.101334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Current standard of care for consolidation therapy for AML varies based on age and induction regimen, among other factors. Many trials have sought to determine the optimal dose, number of cycles, and schedule for consolidation with cytarabine. For AML patients under age 60, mid-dose cytarabine is as effective as high-dose cytarabine, results after 3 or 4 cycles of cytarabine in consolidation are comparable but are both superior to only one cycle, and giving cytarabine every 12 h on days 1, 2, and 3 appears to have the same benefit but less toxicity than cytarabine given on days 1, 3, and 5. For those over age 60, the best dose of cytarabine is unknown, but post-remission therapy appears to improve survival for some patients who achieve remission after standard induction, depending on induction regimen used and MRD status at time of remission.
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Affiliation(s)
- Selina M Luger
- Abramson Cancer Center, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, USA.
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Lopes LM, Nucci MLM, Portugal RD. CITARABINA 3G/M2 NA INTENSIFICAÇÃO DE ADULTOS COM LEUCEMIA MIELOIDE AGUDA. Hematol Transfus Cell Ther 2021. [DOI: 10.1016/j.htct.2021.10.258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Jaramillo S, Schlenk RF. Post-Induction Treatment for Acute Myeloid Leukemia: Something Change? Curr Oncol Rep 2021; 23:109. [PMID: 34272619 PMCID: PMC8285306 DOI: 10.1007/s11912-021-01092-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2021] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW Until recently, improvement in terms of survival for patients with acute myeloid leukemia (AML) was achieved mostly in younger patients with dose intensification of conventional chemotherapy and a broadening use of allogeneic hematopoietic cell transplantation (allo-HCT) whereas the results remained dismal and very stable in patients older than 60 years. The current review highlights the recent developments in standard intensive post-remission chemotherapy, evidence for the use of recently approved agents, and discusses the relevance of measurable residual disease (MRD) measurement in treatment adaptation. RECENT FINDINGS Current approvals of midostaurin, venetoclax, gemtuzumab ozogamicin, VYXEOS, ivosidenib, enasidenib, glasdegib, and CC-486 have changed the structure, aim, and schedule of consolidation therapy, and new, well-tolerated agents are being evaluated as maintenance therapies. Furthermore, MRD assessment has been implemented to guide the duration and type of consolidation and maintenance therapy as well as indicate the optimal timing of allo-HCT. Novel therapies have changed the structure and perspective of post-remission therapy in AML for both young and elderly patients. In addition, MRD assessment could guide the type, duration, and intensity of consolidation and maintenance therapy.
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Affiliation(s)
- Sonia Jaramillo
- Department of Hematology, Oncology, and Rheumatology at Heidelberg University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Richard F. Schlenk
- Department of Hematology, Oncology, and Rheumatology at Heidelberg University Hospital, University of Heidelberg, Heidelberg, Germany
- NCT-Trial Center, NCT Heidelberg, DKFZ and Heidelberg University Hospital, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
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