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Extermann M, Artz A, Rebollo MA, Klepin HD, Krug U, Loh KP, Mims AS, Neuendorff N, Santini V, Stauder R, Vey N. Treating acute myelogenous leukemia in patients aged 70 and above: Recommendations from the International Society of Geriatric Oncology (SIOG). J Geriatr Oncol 2024; 15:101626. [PMID: 37741771 DOI: 10.1016/j.jgo.2023.101626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 08/28/2023] [Accepted: 09/06/2023] [Indexed: 09/25/2023]
Abstract
Acute myeloid leukemia (AML) treatment is challenging in older patients. There is a lack of evidence-based recommendations for older patients ≥70, a group largely underrepresented in clinical trials. With new treatment options being available in recent years, recommendations are needed for these patients. As such the International Society of Geriatric Oncology (SIOG) assembled a task force to review the evidence specific to treatment and outcomes in this population of patients ≥70 years. Six questions were selected by the expert panel in domains of (1) baseline assessment, (2) frontline therapy, (3) post-remission therapy, (4) treatment for relapse, (5) targeted therapies, and (6) patient reported outcome/function and enhancing treatment tolerance. Information from current literature was extracted, combining evidence from systematic reviews/meta-analyses, decision models, individual trials targeting these patients, and subgroup data. Accordingly, recommendations were generated using a GRADE approach upon reviewing current evidence by consensus of the whole panel. It is our firm recommendation and hope that direct evidence should be generated for patients aged ≥70 as a distinct group in high need of improvement of their survival outcomes. Such studies should integrate information from a geriatric assessment to optimize external validity and outcomes.
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Affiliation(s)
- Martine Extermann
- Senior Adult Oncology Program, Moffitt Cancer Center, Tampa, FL, USA.
| | - Andrew Artz
- Division of Leukemia, Department of Hematology & Hematopoietic Cell Transplantation, City of Hope, Duarte, CA, USA
| | - Maite Antonio Rebollo
- Institut Català d'Oncologia, Oncohematogeriatrics Unit, L'Hospitalet de Llobregat, Spain
| | - Heidi D Klepin
- Wake Forest University School of Medicine, Department of Internal Medicine, Section on Hematology and Oncology, Winston-Salem, NC, USA
| | - Utz Krug
- Klinikum Leverkusen, Department of Medicine 3, Leverkusen, Germany
| | - Kah Poh Loh
- University of Rochester Medical Center, Department of Medicine, Division of Hematology and Oncology, James P. Wilmot Cancer Institute, Rochester, NY, USA
| | - Alice S Mims
- The Ohio State University Wexner Medical Center, Department of Internal Medicine, Columbus, OH, USA
| | - Nina Neuendorff
- University Hospital Essen, Department of Hematology and Stem-Cell Transplantation, Essen, Germany
| | - Valeria Santini
- MDS Unit, AOUC, Hematology, University of Florence, Florence, Italy
| | - Reinhard Stauder
- Department of Internal Medicine V (Hematology Oncology), Innsbruck Medical University, Innsbruck, Austria
| | - Norbert Vey
- Aix-Marseille University, Institut Paoli-Calmettes, Hematology Department, Marseille, France
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Xu X, Liu R, He A, Wang F. Real-world results of venetoclax combined with hypomethylating agents in young adults with relapsed/refractory acute myeloid leukemia. Hematology 2023; 28:2265206. [PMID: 37796109 DOI: 10.1080/16078454.2023.2265206] [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: 07/06/2023] [Accepted: 09/24/2023] [Indexed: 10/06/2023] Open
Abstract
OBJECTIVES Young adults with acute myeloid leukemia (AML) often fail to achieve permanent complete remission (CR) and frequently relapse, indicating an urgent need to explore effective salvage therapies. Recent advances in AML treatment have been attributed to the combination of the B-cell lymphoma 2 (Bcl-2) inhibitor venetoclax (VEN) with hypomethylating agents (HMAs); however, the use of this combination in young adults with relapsed or refractory (R/R) AML has not been reported. METHODS We retrospectively examined 31 young patients with R/R AML treated with VEN plus an HMA. We evaluated the demographic data, cytogenetic characteristics, AML types, response rates, and transplantation-related data for the patients in our cohort. RESULTS The combination of VEN + HMA yielded a CR rate of 48.4%. The most prominent hematologic adverse event was neutropenia, which occurred in all patients, with 90.3% of cases being grade ≥3. Non-hematologic toxicities were relatively mild and infrequent, with an incidence of 45.2%. More than half of the patients with sustained CR had received an allogeneic hematopoietic stem cell transplantation (allo-HSCT), of whom two died of transplant-related complications. CONCLUSION Our results showed that the combination of VEN + HMA appeared to be a highly effective and well-tolerated salvage therapy option for young patients with R/R AML, enabling more young patients to proceed to potentially curative allo-HSCT. However, additional, well-designed studies with larger numbers of patients are required to confirm the advantages of VEN + HMA in this population.
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Affiliation(s)
- Xuezhu Xu
- Department of Hematology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, People's Republic of China
| | - Rui Liu
- Department of Hematology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, People's Republic of China
| | - Aili He
- Department of Hematology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, People's Republic of China
| | - Fangxia Wang
- Department of Hematology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, People's Republic of China
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Jeha S, Goto H, Baruchel A, Boëlle-Le Corfec E, Geffriaud-Ricouard C, Pieters R, Shin HY. Patient-Level Meta-analysis of Clofarabine in Acute Lymphoblastic Leukemia. Adv Ther 2023; 40:5447-5463. [PMID: 37819554 PMCID: PMC10611855 DOI: 10.1007/s12325-023-02696-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 09/22/2023] [Indexed: 10/13/2023]
Abstract
INTRODUCTION Clofarabine monotherapy at a dose of 52 mg/m2 per day was approved in the USA in 2004 for the treatment of relapsed or refractory acute lymphoblastic leukemia (R/R ALL) in patients aged 1-21 years after at least two prior regimens. To address a post-marketing requirement for additional evidence of the clinical benefit of clofarabine in its approved indication, a meta-analysis of patient-level data was conducted. METHODS A systematic literature review was conducted, using the Dr.Evidence software platform, DOC Search, and Embase, to identify clinical trials with patients with R/R ALL who received clofarabine monotherapy at 52 mg/m2. The primary endpoint was complete remission (CR). Secondary endpoints were overall remission (OR, defined by CR or CR with either incomplete platelet recovery or incomplete neutrophil and platelet recovery), duration of response, overall survival (OS), and safety. RESULTS A total of 754 patients in 12 clinical studies were analyzed including 682 patients with R/R ALL treated with clofarabine monotherapy at 52 mg/m2; of them, 374 were aged < 22 years (pediatric population). Rates of CR and OR were 16% (95% confidence interval [CI] 7, 26) and 28% (95% CI 20, 37), respectively, in the pediatric population and 12% (95% CI 5, 21) and 21% (95% CI 13, 31) in the overall population. Median OS (evaluable in three studies in pediatric patients) was 3.7 months (95% CI 0.1, 31.4), reaching 10.1 months (95% CI 0.3, 68.9) for those achieving OR. Sensitivity analyses supported these findings. The most frequent grade 3-4 adverse events were liver abnormalities, anemia, diarrhea, and febrile neutropenia. CONCLUSION In this meta-analysis, CR duration and median OS in pediatric patients with R/R ALL appeared to be slightly longer than in the phase II study. No new safety signals were identified. Results support the use of clofarabine monotherapy in its approved indication.
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Affiliation(s)
- Sima Jeha
- St Jude Children's Hospital Research, 262 Danny Thomas Place, Memphis, TN, 38105-3678, USA.
| | - Hiroaki Goto
- Division of Hematology/Oncology, Kanagawa Children's Medical Center, Minami-ku, Yokohama, Kanagawa, Japan
| | - André Baruchel
- Department of Pediatric Hemato-Immunology, Hôpital Universitaire Robert Debré (APHP and Université Paris Cité), Paris, France
| | | | | | - Rob Pieters
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Hee Young Shin
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
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4
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Pal S, Sharma A, Mathew SP, Jaganathan BG. Targeting cancer-specific metabolic pathways for developing novel cancer therapeutics. Front Immunol 2022; 13:955476. [PMID: 36618350 PMCID: PMC9815821 DOI: 10.3389/fimmu.2022.955476] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 10/20/2022] [Indexed: 12/24/2022] Open
Abstract
Cancer is a heterogeneous disease characterized by various genetic and phenotypic aberrations. Cancer cells undergo genetic modifications that promote their proliferation, survival, and dissemination as the disease progresses. The unabated proliferation of cancer cells incurs an enormous energy demand that is supplied by metabolic reprogramming. Cancer cells undergo metabolic alterations to provide for increased energy and metabolite requirement; these alterations also help drive the tumor progression. Dysregulation in glucose uptake and increased lactate production via "aerobic glycolysis" were described more than 100 years ago, and since then, the metabolic signature of various cancers has been extensively studied. However, the extensive research in this field has failed to translate into significant therapeutic intervention, except for treating childhood-ALL with amino acid metabolism inhibitor L-asparaginase. Despite the growing understanding of novel metabolic alterations in tumors, the therapeutic targeting of these tumor-specific dysregulations has largely been ineffective in clinical trials. This chapter discusses the major pathways involved in the metabolism of glucose, amino acids, and lipids and highlights the inter-twined nature of metabolic aberrations that promote tumorigenesis in different types of cancer. Finally, we summarise the therapeutic interventions which can be used as a combinational therapy to target metabolic dysregulations that are unique or common in blood, breast, colorectal, lung, and prostate cancer.
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Affiliation(s)
- Soumik Pal
- Stem Cells and Cancer Biology Research Group, Department of Biosciences and Bioengineering, Indian Institute of Technology Guwahati, Guwahati, Assam, India
| | - Amit Sharma
- Stem Cells and Cancer Biology Research Group, Department of Biosciences and Bioengineering, Indian Institute of Technology Guwahati, Guwahati, Assam, India
| | - Sam Padalumavunkal Mathew
- Stem Cells and Cancer Biology Research Group, Department of Biosciences and Bioengineering, Indian Institute of Technology Guwahati, Guwahati, Assam, India
| | - Bithiah Grace Jaganathan
- Stem Cells and Cancer Biology Research Group, Department of Biosciences and Bioengineering, Indian Institute of Technology Guwahati, Guwahati, Assam, India,Jyoti and Bhupat Mehta School of Health Sciences and Technology, Indian Institute of Technology Guwahati, Guwahati, Assam, India,*Correspondence: Bithiah Grace Jaganathan,
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Pandya BJ, Chen CC, McGuiness CB, Sullivan L, Feng Q, Walsh E, Borate U. Burden of chemotherapy in patients with relapsed/refractory acute myeloid leukemia in the United States: a retrospective claims database study. Expert Rev Hematol 2022; 15:857-866. [PMID: 35924860 DOI: 10.1080/17474086.2022.2104709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Real-world estimates of relapsed or refractory (R/R) acute myeloid leukemia (AML) chemotherapy episode costs are scarce. We quantified chemotherapy episode-related costs and healthcare resource use (HRU) in R/R AML. RESEARCH DESIGN AND METHODS This real-world, retrospective analysis of United States claims from IQVIA's PharMetrics® Plus database (October 2008-September 2019) identified adults with R/R AML and ≥1 chemotherapy episode. Chemotherapy episode (ie, low- [LIC] or high-intensity [HIC] chemotherapy) costs and HRU were determined using inpatient, outpatient, and pharmacy claims. RESULTS Mean (SD) and median total all-cause healthcare costs per R/R AML chemotherapy episode were $230,799 ($300,770) and $129,117. Mean (SD) and median adjusted direct R/R AML chemotherapy episode costs were $116,384 ($151,425) and $63,298, with increases noted from the first to the second and subsequent episodes and with HIC. Hospitalizations were the major cost driver; 64.1% of patients had ≥1 hospitalization and 36% required an intensive care unit stay. CONCLUSIONS R/R AML chemotherapy episode costs were high, with higher costs reported with HIC and increasing lines of chemotherapy. Hospitalizations were a main cost driver. Novel therapies with comparable or improved effectiveness and decreased need for hospitalizations versus chemotherapy may help alleviate the clinical and economic burden of R/R AML.
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Affiliation(s)
- Bhavik J Pandya
- Health Economics and Clinical Outcomes Research-Oncology, Astellas Pharma, Inc, Northbrook, IL, USA
| | - Chi-Chang Chen
- Health Economics and Outcomes Research, Real-World Evidence, IQVIA, Plymouth Meeting, PA, USA
| | - Catherine B McGuiness
- Health Economics and Outcomes Research, Real-World Evidence, IQVIA, Plymouth Meeting, PA, USA
| | - Loretta Sullivan
- Health Economics and Clinical Outcomes Research-Oncology, Astellas Pharma, Inc, Northbrook, IL, USA
| | - Qi Feng
- Health Economics and Clinical Outcomes Research-Oncology, Astellas Pharma, Inc, Northbrook, IL, USA
| | - Elise Walsh
- Health Economics and Outcomes Research, Real-World Evidence, IQVIA, Plymouth Meeting, PA, USA
| | - Uma Borate
- Oncology, Oregon Health and Science University, Portland, OR, USA
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Ali SS, Raj R, Kaur T, Weadick B, Nayak D, No M, Protos J, Odom H, Desai K, Persaud AK, Wang J, Govindarajan R. Solute Carrier Nucleoside Transporters in Hematopoiesis and Hematological Drug Toxicities: A Perspective. Cancers (Basel) 2022; 14:cancers14133113. [PMID: 35804885 PMCID: PMC9264962 DOI: 10.3390/cancers14133113] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 06/18/2022] [Accepted: 06/22/2022] [Indexed: 02/04/2023] Open
Abstract
Simple Summary Anticancer nucleoside analogs are promising treatments that often result in damaging toxicities and therefore ineffective treatment. Mechanisms of this are not well-researched, but cellular nucleoside transport research in mice might provide additional insight given transport’s role in mammalian hematopoiesis. Cellular nucleoside transport is a notable component of mammalian hematopoiesis due to how mutations within it relate to hematological abnormities. This review encompasses nucleoside transporters, focusing on their inherent properties, hematopoietic role, and their interplay in nucleoside drug treatment side effects. We then propose potential mechanisms to explain nucleoside transport involvement in blood disorders. Finally, we point out and advocate for future research areas that would improve therapeutic outcomes for patients taking nucleoside analog therapies. Abstract Anticancer nucleoside analogs produce adverse, and at times, dose-limiting hematological toxicities that can compromise treatment efficacy, yet the mechanisms of such toxicities are poorly understood. Recently, cellular nucleoside transport has been implicated in normal blood cell formation with studies from nucleoside transporter-deficient mice providing additional insights into the regulation of mammalian hematopoiesis. Furthermore, several idiopathic human genetic disorders have revealed nucleoside transport as an important component of mammalian hematopoiesis because mutations in individual nucleoside transporter genes are linked to various hematological abnormalities, including anemia. Here, we review recent developments in nucleoside transporters, including their transport characteristics, their role in the regulation of hematopoiesis, and their potential involvement in the occurrence of adverse hematological side effects due to nucleoside drug treatment. Furthermore, we discuss the putative mechanisms by which aberrant nucleoside transport may contribute to hematological abnormalities and identify the knowledge gaps where future research may positively impact treatment outcomes for patients undergoing various nucleoside analog therapies.
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Affiliation(s)
- Syed Saqib Ali
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, OH 43210, USA; (S.S.A.); (R.R.); (T.K.); (B.W.); (D.N.); (M.N.); (J.P.); (H.O.); (K.D.); (A.K.P.)
| | - Ruchika Raj
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, OH 43210, USA; (S.S.A.); (R.R.); (T.K.); (B.W.); (D.N.); (M.N.); (J.P.); (H.O.); (K.D.); (A.K.P.)
| | - Tejinder Kaur
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, OH 43210, USA; (S.S.A.); (R.R.); (T.K.); (B.W.); (D.N.); (M.N.); (J.P.); (H.O.); (K.D.); (A.K.P.)
| | - Brenna Weadick
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, OH 43210, USA; (S.S.A.); (R.R.); (T.K.); (B.W.); (D.N.); (M.N.); (J.P.); (H.O.); (K.D.); (A.K.P.)
| | - Debasis Nayak
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, OH 43210, USA; (S.S.A.); (R.R.); (T.K.); (B.W.); (D.N.); (M.N.); (J.P.); (H.O.); (K.D.); (A.K.P.)
| | - Minnsung No
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, OH 43210, USA; (S.S.A.); (R.R.); (T.K.); (B.W.); (D.N.); (M.N.); (J.P.); (H.O.); (K.D.); (A.K.P.)
| | - Jane Protos
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, OH 43210, USA; (S.S.A.); (R.R.); (T.K.); (B.W.); (D.N.); (M.N.); (J.P.); (H.O.); (K.D.); (A.K.P.)
| | - Hannah Odom
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, OH 43210, USA; (S.S.A.); (R.R.); (T.K.); (B.W.); (D.N.); (M.N.); (J.P.); (H.O.); (K.D.); (A.K.P.)
| | - Kajal Desai
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, OH 43210, USA; (S.S.A.); (R.R.); (T.K.); (B.W.); (D.N.); (M.N.); (J.P.); (H.O.); (K.D.); (A.K.P.)
| | - Avinash K. Persaud
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, OH 43210, USA; (S.S.A.); (R.R.); (T.K.); (B.W.); (D.N.); (M.N.); (J.P.); (H.O.); (K.D.); (A.K.P.)
| | - Joanne Wang
- Department of Pharmaceutics, College of Pharmacy, University of Washington, Seattle, WA 98195, USA;
| | - Rajgopal Govindarajan
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, OH 43210, USA; (S.S.A.); (R.R.); (T.K.); (B.W.); (D.N.); (M.N.); (J.P.); (H.O.); (K.D.); (A.K.P.)
- Translational Therapeutics, The Ohio State University Comprehensive Cancer Center, Columbus, OH 43210, USA
- Correspondence: ; Tel.: +1-614-247-8269; Fax: +1-614-292-2588
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Genthon A, Dragoi D, Memoli M, Hirsch P, Favale F, Suner L, Chaquin M, Boncoeur P, Marjanovic Z, Bonnin A, Sestili S, Dulery R, Malard F, Brissot E, Banet A, van de Wyngaert Z, Vekhoff A, Delhommeau F, Mohty M, Legrand O. Isocitrate dehydrogenase inhibitors as a bridge to allogeneic stem cell transplant in relapsed or refractory acute myeloid leukaemia. Br J Haematol 2022; 198:780-784. [PMID: 35615877 DOI: 10.1111/bjh.18290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 05/09/2022] [Accepted: 05/18/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Alexis Genthon
- Service d'hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint-Antoine, AP-HP, INSERM UMRs 938, Sorbonne Université, Paris, France
| | - Diana Dragoi
- Service d'hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint-Antoine, AP-HP, INSERM UMRs 938, Sorbonne Université, Paris, France
| | - Mara Memoli
- Service d'hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint-Antoine, AP-HP, INSERM UMRs 938, Sorbonne Université, Paris, France
| | - Pierre Hirsch
- Service d'Hématologie Biologique, Hôpital Saint Antoine, AP-HP, Centre de Recherche Saint-Antoine (CRSA), INSERM UMR938, Sorbonne Université, Paris, France
| | - Fabrizia Favale
- Service d'Hématologie Biologique, Hôpital Saint Antoine, AP-HP, Centre de Recherche Saint-Antoine (CRSA), INSERM UMR938, Sorbonne Université, Paris, France
| | - Ludovic Suner
- Service d'Hématologie Biologique, Hôpital Saint Antoine, AP-HP, Centre de Recherche Saint-Antoine (CRSA), INSERM UMR938, Sorbonne Université, Paris, France
| | - Michael Chaquin
- Service d'Hématologie Biologique, Hôpital Saint Antoine, AP-HP, Centre de Recherche Saint-Antoine (CRSA), INSERM UMR938, Sorbonne Université, Paris, France
| | - Pierre Boncoeur
- Service d'Hématologie Biologique, Hôpital Saint Antoine, AP-HP, Centre de Recherche Saint-Antoine (CRSA), INSERM UMR938, Sorbonne Université, Paris, France
| | - Zora Marjanovic
- Service d'hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint-Antoine, AP-HP, INSERM UMRs 938, Sorbonne Université, Paris, France
| | - Agnès Bonnin
- Service d'hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint-Antoine, AP-HP, INSERM UMRs 938, Sorbonne Université, Paris, France
| | - Simona Sestili
- Service d'hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint-Antoine, AP-HP, INSERM UMRs 938, Sorbonne Université, Paris, France
| | - Remy Dulery
- Service d'hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint-Antoine, AP-HP, INSERM UMRs 938, Sorbonne Université, Paris, France
| | - Florent Malard
- Service d'hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint-Antoine, AP-HP, INSERM UMRs 938, Sorbonne Université, Paris, France
| | - Eolia Brissot
- Service d'hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint-Antoine, AP-HP, INSERM UMRs 938, Sorbonne Université, Paris, France
| | - Anne Banet
- Service d'hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint-Antoine, AP-HP, INSERM UMRs 938, Sorbonne Université, Paris, France
| | - Zoe van de Wyngaert
- Service d'hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint-Antoine, AP-HP, INSERM UMRs 938, Sorbonne Université, Paris, France
| | - Anne Vekhoff
- Service d'hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint-Antoine, AP-HP, INSERM UMRs 938, Sorbonne Université, Paris, France
| | - Francois Delhommeau
- Service d'Hématologie Biologique, Hôpital Saint Antoine, AP-HP, Centre de Recherche Saint-Antoine (CRSA), INSERM UMR938, Sorbonne Université, Paris, France
| | - Mohamad Mohty
- Service d'hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint-Antoine, AP-HP, INSERM UMRs 938, Sorbonne Université, Paris, France
| | - Ollivier Legrand
- Service d'hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint-Antoine, AP-HP, INSERM UMRs 938, Sorbonne Université, Paris, France
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Targeting nucleotide metabolism: a promising approach to enhance cancer immunotherapy. J Hematol Oncol 2022; 15:45. [PMID: 35477416 PMCID: PMC9044757 DOI: 10.1186/s13045-022-01263-x] [Citation(s) in RCA: 46] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 04/18/2022] [Indexed: 12/12/2022] Open
Abstract
Targeting nucleotide metabolism can not only inhibit tumor initiation and progression but also exert serious side effects. With in-depth studies of nucleotide metabolism, our understanding of nucleotide metabolism in tumors has revealed their non-proliferative effects on immune escape, indicating the potential effectiveness of nucleotide antimetabolites for enhancing immunotherapy. A growing body of evidence now supports the concept that targeting nucleotide metabolism can increase the antitumor immune response by (1) activating host immune systems via maintaining the concentrations of several important metabolites, such as adenosine and ATP, (2) promoting immunogenicity caused by increased mutability and genomic instability by disrupting the purine and pyrimidine pool, and (3) releasing nucleoside analogs via microbes to regulate immunity. Therapeutic approaches targeting nucleotide metabolism combined with immunotherapy have achieved exciting success in preclinical animal models. Here, we review how dysregulated nucleotide metabolism can promote tumor growth and interact with the host immune system, and we provide future insights into targeting nucleotide metabolism for immunotherapeutic treatment of various malignancies.
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Park S, Kwag D, Kim TY, Lee JH, Lee JY, Min GJ, Park SS, Yahng SA, Jeon YW, Shin SH, Yoon JH, Lee SE, Cho BS, Eom KS, Kim YJ, Lee S, Min CK, Cho SG, Lee JW, Kim HJ. A retrospective comparison of salvage intensive chemotherapy versus venetoclax-combined regimen in patients with relapsed/refractory acute myeloid leukemia (AML). Ther Adv Hematol 2022; 13:20406207221081637. [PMID: 35340720 PMCID: PMC8949776 DOI: 10.1177/20406207221081637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 01/31/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Evidence that a venetoclax (VEN)-combined regimen is effective in relapsed/refractory acute myeloid leukemia (R/R AML) is emerging. However, it is unknown how VEN-combined low intensity treatment compares to intensive chemotherapy (IC) in medically fit patients with R/R AML. Methods: We compared AML patients who received IC (n = 89) to those who received a VEN in combination with hypomethylating agents or low dose cytarabine (VEN combination) (n = 54) as their first- or second-line salvage after failing anthracycline-containing intensive chemotherapy. Results: The median age was 49 years, and significantly more patients in the VEN combination group were in their second salvage and had received prior stem cell transplantation (SCT). Overall response rates including CR, CRi, and MLFS were comparable (44.0% for IC vs. 59.3% for VEN combination, p = 0.081), but VEN combination group compared to IC group tended to show lower treatment related mortality. The rate of bridging to SCT was the same (68.5%), but the percentage of SCT at blast clearance was significantly higher in the VEN-combined group (62.3% vs. 86.5%, p = 0.010). After median follow-up periods of 22.5 (IC) and 11.3 months (VEN combination), the median overall survival was 8.9 (95% CI, 5.4-12.4) and 12.4 months (95% CI, 9.5-15.2) (p = 0.724), respectively. Conclusion: VEN combination provides a comparable anti-leukemic response and survival to salvage IC, and provide a bridge to SCT with better disease control in medically-fit patients with R/R AML.
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Affiliation(s)
- Silvia Park
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Daehun Kwag
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Tong Yoon Kim
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Jong Hyuk Lee
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Joon Yeop Lee
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Gi June Min
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Sung Soo Park
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Seung-Ah Yahng
- Department of Hematology, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, South Korea
| | - Young-Woo Jeon
- Department of Hematology, Yeoido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Seung-Hwan Shin
- Department of Hematology, Catholic Hematology Hospital, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Jae-Ho Yoon
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Sung-Eun Lee
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Byung Sik Cho
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Ki-Seong Eom
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Yoo-Jin Kim
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Seok Lee
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Chang-Ki Min
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Seok-Goo Cho
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Jong Wook Lee
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Hee-Je Kim
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
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10
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DeAngelo DJ, Jonas BA, Liesveld JL, Bixby DL, Advani AS, Marlton P, Magnani JL, Thackray HM, Feldman EJ, O'Dwyer ME, Becker PS. Phase 1/2 study of uproleselan added to chemotherapy in patients with relapsed or refractory acute myeloid leukemia. Blood 2022; 139:1135-1146. [PMID: 34543383 PMCID: PMC11017789 DOI: 10.1182/blood.2021010721] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 09/01/2021] [Indexed: 11/20/2022] Open
Abstract
Uproleselan (GMI-1271) is a novel E-selectin antagonist that disrupts cell survival pathways, enhances chemotherapy response, improves survival in mouse xenograft and syngeneic models, and decreases chemotherapy toxicity in vivo. A phase 1/2 study evaluated the safety, tolerability, and antileukemic activity of uproleselan (5-20 mg/kg) with MEC (mitoxantrone, etoposide, and cytarabine) among patients with relapsed/refractory (R/R) acute myeloid leukemia (AML). Among the first 19 patients, no dose-limiting toxicities were observed. The recommended phase 2 dose (RP2D) was 10 mg/kg twice daily. An additional 47 patients with R/R AML were treated with uproleselan at the RP2D plus MEC. At the RP2D, the remission rate (complete response [CR]/CR with incomplete count recovery [CRi]) was 41% (CR, 35%), and the median overall survival (OS) was 8.8 months. In a separate cohort, 25 newly diagnosed patients age ≥60 years received uproleselan at the RP2D plus cytarabine and idarubicin (7 + 3). In these frontline patients, the CR/CRi rate was 72% (CR, 52%), and the median OS was 12.6 months. The addition of uproleselan was associated with low rates of oral mucositis. E-selectin ligand expression on leukemic blasts was higher in patients with relapsed vs primary refractory AML and in newly diagnosed older patients with high-risk cytogenetics and secondary AML. In the R/R cohort, E-selectin expression >10% was associated with a higher response rate and improved survival. The addition of uproleselan to chemotherapy was well tolerated, with high remission rates, low induction mortality, and low rates of mucositis, providing a strong rationale for phase 3 randomized confirmatory studies. This trial was registered at www.clinicaltrials.gov as #NCT02306291.
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Affiliation(s)
- Daniel J. DeAngelo
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | | | - Jane L. Liesveld
- Department of Medicine, Hematology/Oncology, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Dale L. Bixby
- Department of Hematology/Oncology, University of Michigan, Ann Arbor, MI
| | | | - Paula Marlton
- Princess Alexandra Hospital, University of Queensland School of Medicine, Brisbane, QLD, Australia
| | | | | | | | - Michael E. O'Dwyer
- Department of Haematology, National University of Ireland Galway, Galway, Ireland
| | - Pamela S. Becker
- University of Washington/Fred Hutchinson Cancer Research Center, Seattle, WA
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11
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Gadaud N, Leroy H, Bérard E, Tavitian S, Leguay T, Dimicoli-Salazar S, Rieu JB, Luquet I, Largeaud L, Bidet A, Delabesse E, Klein E, Sarry A, de Grande AC, Bories P, Pigneux A, Récher C, Dumas PY, Bertoli S. Azacitidine, intensive chemotherapy or best supportive care in relapsed or refractory acute myeloid leukemia, a DATAML registry study. Leuk Lymphoma 2022; 63:1398-1406. [DOI: 10.1080/10428194.2021.2022140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Noémie Gadaud
- Service d’Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
| | - Harmony Leroy
- Centre Hospitalier Universitaire de Bordeaux, Service d’Hématologie Clinique et de Thérapie Cellulaire, Bordeaux, France
| | - Emilie Bérard
- Service d’Epidémiologie, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
- CERPOP, Université de Toulouse, Inserm, UPS, Toulouse, France
| | - Suzanne Tavitian
- Service d’Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
| | - Thibaut Leguay
- Centre Hospitalier Universitaire de Bordeaux, Service d’Hématologie Clinique et de Thérapie Cellulaire, Bordeaux, France
| | - Sophie Dimicoli-Salazar
- Centre Hospitalier Universitaire de Bordeaux, Service d’Hématologie Clinique et de Thérapie Cellulaire, Bordeaux, France
| | - Jean-Baptiste Rieu
- Laboratoire d’Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
| | - Isabelle Luquet
- Laboratoire d’Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
| | - Laetitia Largeaud
- Laboratoire d’Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
- Université Toulouse III Paul Sabatier, Toulouse, France
- Cancer Research Center of Toulouse, UMR1037 INSERM, ERL5294 CNRS, Toulouse, France
| | - Audrey Bidet
- Laboratoire d’Hématologie Biologique, CHU Bordeaux, Bordeaux, France
| | - Eric Delabesse
- Laboratoire d’Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
- Université Toulouse III Paul Sabatier, Toulouse, France
- Cancer Research Center of Toulouse, UMR1037 INSERM, ERL5294 CNRS, Toulouse, France
| | - Emilie Klein
- Laboratoire d’Hématologie Biologique, CHU Bordeaux, Bordeaux, France
| | - Audrey Sarry
- Service d’Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
| | - Anne-Charlotte de Grande
- Centre Hospitalier Universitaire de Bordeaux, Service d’Hématologie Clinique et de Thérapie Cellulaire, Bordeaux, France
| | - Pierre Bories
- Service d’Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
| | - Arnaud Pigneux
- Centre Hospitalier Universitaire de Bordeaux, Service d’Hématologie Clinique et de Thérapie Cellulaire, Bordeaux, France
- Université de Bordeaux, Bordeaux, France
- Institut National de la Santé et de la Recherche Médicale, Bordeaux, France
| | - Christian Récher
- Service d’Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
- Université Toulouse III Paul Sabatier, Toulouse, France
- Cancer Research Center of Toulouse, UMR1037 INSERM, ERL5294 CNRS, Toulouse, France
| | - Pierre-Yves Dumas
- Centre Hospitalier Universitaire de Bordeaux, Service d’Hématologie Clinique et de Thérapie Cellulaire, Bordeaux, France
- Université de Bordeaux, Bordeaux, France
- Institut National de la Santé et de la Recherche Médicale, Bordeaux, France
| | - Sarah Bertoli
- Service d’Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
- Université Toulouse III Paul Sabatier, Toulouse, France
- Cancer Research Center of Toulouse, UMR1037 INSERM, ERL5294 CNRS, Toulouse, France
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12
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Bakunina K, Putter H, Versluis J, Koster EAS, van der Holt B, Manz MG, Breems DA, Gjertsen BT, Cloos J, Valk PJM, Passweg J, Pabst T, Ossenkoppele GJ, Löwenberg B, Cornelissen JJ, de Wreede LC. The added value of multi-state modelling in a randomized controlled trial: The HOVON 102 study re-analyzed. Cancer Med 2021; 11:630-640. [PMID: 34953042 PMCID: PMC8817075 DOI: 10.1002/cam4.4392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 09/20/2021] [Accepted: 09/23/2021] [Indexed: 11/07/2022] Open
Abstract
Clofarabine is an active antileukemic drug for subgroups of patients with acute myeloid leukemia (AML). Multi-state models can provide additional insights to supplement the original intention-to-treat analysis of randomized controlled trials (RCT). We re-analyzed the HOVON102/SAKK30/09 phase III RCT for newly diagnosed AML patients, which randomized between standard induction chemotherapy with or without clofarabine. Using multi-state models, we evaluated the effects of induction chemotherapy outcomes (complete remission [CR], measurable residual disease [MRD]), and post-remission therapy with allogeneic stem cell transplantation [alloSCT] on relapse and death. Through the latter a consistent reduction in the hazard of relapse in the clofarabine arm compared to the standard arm was found, which occurred irrespective of MRD status or post-remission treatment with alloSCT, demonstrating a strong and persistent antileukemic effect of clofarabine. During the time period between achieving CR and possible post-remission treatment with alloSCT, non-relapse mortality was higher in patients receiving clofarabine. An overall net benefit of treatment with clofarabine was identified using the composite endpoint current leukemia-free survival (CLFS). In conclusion, these results enforce and extend the earlier reported beneficial effect of clofarabine in AML and show that multi-state models further detail the effect of treatment on competing and series of events.
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Affiliation(s)
- Katerina Bakunina
- Department of Hematology, HOVON Data Center, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Hein Putter
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Jurjen Versluis
- Department of Hematology, Erasmus University Medical Center Cancer Institute, Rotterdam, The Netherlands
| | - Eva A S Koster
- Department of Hematology, Leiden University Medical Center, Leiden, The Netherlands
| | - Bronno van der Holt
- Department of Hematology, HOVON Data Center, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Markus G Manz
- Department of Medical Oncology and Hematology, University Hospital Zurich, Zurich, Switzerland
| | - Dimitri A Breems
- Department of Hematology, Hospital Network Antwerp Stuivenberg/Middelheim, Antwerp, Belgium
| | - Bjorn T Gjertsen
- Department of Internal Medicine, Hematology section, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Jacqueline Cloos
- Department of Hematology, Amsterdam UMC, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Peter J M Valk
- Department of Hematology, Erasmus University Medical Center Cancer Institute, Rotterdam, The Netherlands
| | - Jakob Passweg
- Department of Hematology, University Hospital Basel, Basel, Switzerland
| | - Thomas Pabst
- Department of Medical Oncology, University Hospital/Inselspital, Bern, Switzerland
| | - Gert J Ossenkoppele
- Department of Hematology, 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
| | - Jan J Cornelissen
- Department of Hematology, Erasmus University Medical Center Cancer Institute, Rotterdam, The Netherlands
| | - Liesbeth C de Wreede
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
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13
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Michaelis LC. Is there an optimal adjunct therapy to traditional cytotoxic induction? Best Pract Res Clin Haematol 2021; 34:101326. [PMID: 34865698 DOI: 10.1016/j.beha.2021.101326] [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: 10/20/2022]
Abstract
The traditional cytotoxic induction regimen for acute myeloid leukemia (AML) is seven days of standard-dose cytarabine and three days of an anthracycline antibiotic (such as daunorubicin or idarubicin), commonly known as "7 + 3." Many studies have been conducted to find an additional agent that might improve efficacy. Data from select studies has shown, in certain populations, benefit to adding cladribine, clofarabine and lomustine to a traditional backbone. For mutation-based chemotherapy regimens, midostaurin with 7 + 3 is the current standard of care for FLT3-mutant, younger AML patients. As we learn more about the synergism of molecular agents and traditional anti-cancer treatments, we can hopefully develop novel regimens without abandoning some of the benefits of these mutation agnostic historical therapies.
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14
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Zeidner JF, Vincent BG, Ivanova A, Moore D, McKinnon KP, Wilkinson AD, Mukhopadhyay R, Mazziotta F, Knaus HA, Foster MC, Coombs CC, Jamieson K, Van Deventer H, Webster JA, Prince GT, DeZern AE, Smith BD, Levis MJ, Montgomery ND, Luznik L, Serody JS, Gojo I. Phase II Trial of Pembrolizumab after High-Dose Cytarabine in Relapsed/Refractory Acute Myeloid Leukemia. Blood Cancer Discov 2021; 2:616-629. [PMID: 34778801 DOI: 10.1158/2643-3230.bcd-21-0070] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 07/12/2021] [Accepted: 08/25/2021] [Indexed: 12/17/2022] Open
Abstract
Immune suppression, exhaustion, and senescence are frequently seen throughout disease progression in acute myeloid leukemia (AML). We conducted a phase II study of high-dose cytarabine followed by pembrolizumab 200 mg i.v. on day 14 to examine whether PD-1 inhibition improves clinical responses in relapsed/refractory (R/R) AML. Overall responders could receive pembrolizumab maintenance up to 2 years. Among 37 patients enrolled, the overall response rate, composite complete remission (CRc) rate (primary endpoint), and median overall survival (OS) were 46%, 38%, and 11.1 months, respectively. Patients with refractory/early relapse and those receiving treatment as first salvage had encouraging outcomes (median OS, 13.2 and 11.3 months, respectively). Grade ≥3 immune-related adverse events were rare (14%) and self-limiting. Patients who achieved CRc had a higher frequency of progenitor exhausted CD8+ T cells expressing TCF-1 in the bone marrow prior to treatment. A multifaceted correlative approach of genomic, transcriptomic, and immunophenotypic profiling offers insights on molecular correlates of response and resistance to pembrolizumab. Significance Immune-checkpoint blockade with pembrolizumab was tolerable and feasible after high-dose cytarabine in R/R AML, with encouraging clinical activity, particularly in refractory AML and those receiving treatment as first salvage regimen. Further study of pembrolizumab and other immune-checkpoint blockade strategies after cytotoxic chemotherapy is warranted in AML.See related commentary by Wei et al., p. 551. This article is highlighted in the In This Issue feature, p. 549.
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Affiliation(s)
- Joshua F Zeidner
- University of North Carolina School of Medicine, Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina.,Division of Hematology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Benjamin G Vincent
- University of North Carolina School of Medicine, Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina.,Division of Hematology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina.,University of North Carolina, Department of Microbiology and Immunology, Chapel Hill, North Carolina.,Program in Computational Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Anastasia Ivanova
- University of North Carolina School of Medicine, Department of Biostatistics, Chapel Hill, North Carolina
| | - Dominic Moore
- University of North Carolina School of Medicine, Department of Biostatistics, Chapel Hill, North Carolina
| | - Karen P McKinnon
- University of North Carolina School of Medicine, Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina.,University of North Carolina, Department of Microbiology and Immunology, Chapel Hill, North Carolina
| | - Alec D Wilkinson
- University of North Carolina School of Medicine, Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
| | - Rupkatha Mukhopadhyay
- Johns Hopkins School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland
| | - Francesco Mazziotta
- Johns Hopkins School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland.,University of Siena, Department of Medical Biotechnologies, Siena, Italy
| | - Hanna A Knaus
- Johns Hopkins School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland
| | - Matthew C Foster
- University of North Carolina School of Medicine, Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina.,Division of Hematology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Catherine C Coombs
- University of North Carolina School of Medicine, Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina.,Division of Hematology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Katarzyna Jamieson
- University of North Carolina School of Medicine, Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina.,Division of Hematology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Hendrik Van Deventer
- University of North Carolina School of Medicine, Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina.,Division of Hematology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Jonathan A Webster
- Johns Hopkins School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland.,Department of Oncology, Division of Hematological Malignancies, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Gabrielle T Prince
- Johns Hopkins School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland.,Department of Oncology, Division of Hematological Malignancies, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Amy E DeZern
- Johns Hopkins School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland.,Department of Oncology, Division of Hematological Malignancies, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - B Douglas Smith
- Johns Hopkins School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland.,Department of Oncology, Division of Hematological Malignancies, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Mark J Levis
- Johns Hopkins School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland.,Department of Oncology, Division of Hematological Malignancies, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Nathan D Montgomery
- University of North Carolina School of Medicine, Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina.,Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Leo Luznik
- Johns Hopkins School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland.,Department of Oncology, Division of Hematological Malignancies, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jonathan S Serody
- University of North Carolina School of Medicine, Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina.,Division of Hematology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina.,University of North Carolina, Department of Microbiology and Immunology, Chapel Hill, North Carolina.,Program in Computational Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Ivana Gojo
- Johns Hopkins School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland.,University of Siena, Department of Medical Biotechnologies, Siena, Italy
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15
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Weigert N, Rowe JM, Lazarus HM, Salman MY. Consolidation in AML: Abundant opinion and much unknown. Blood Rev 2021; 51:100873. [PMID: 34483002 DOI: 10.1016/j.blre.2021.100873] [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: 05/12/2021] [Revised: 06/24/2021] [Accepted: 08/01/2021] [Indexed: 11/25/2022]
Abstract
Consolidation therapy forms the backbone of post-remission therapy for AML and is uniformly accepted as an integral part of therapy designed to achieve long-term survival. The need for post-remission therapy was initially described over four decades ago and has since undergone many variations in terms of dosage, number of cycles and intensity of therapy. There is much empiricism in the current understanding of consolidation therapy and much that has not been rigorously studied. This review will consider the many aspects of consolidation therapy, focusing on the number of cycles, differences between young and older adults, first and subsequent remission as well as therapy prior to an allogeneic transplant. Emphasis will be given to differentiate strategies that are clearly evidence-based from those that have been incorporated into standard of care while bypassing the need for rigorous data-driven approaches. Finally, consideration will be given to the current ability to assess the minimal measureable residual disease and the impact that this may have on therapeutic paradigms, including superseding many of the time-honored prognostic features.
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Affiliation(s)
- Nir Weigert
- Department of Hematology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Jacob M Rowe
- Department of Hematology, Shaare Zedek Medical Center, Jerusalem, Israel; Department of Hematology and Bone Marrow Transplantation, Rambam Medical Center, Haifa, Israel; Technion, Israel Institute of Technology, Haifa, Israel.
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16
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Su Q, Fan Z, Huang F, Xu N, Nie D, Lin D, Guo Z, Shi P, Wang Z, Jiang L, Sun J, Jiang Z, Liu Q, Xuan L. Comparison of Two Strategies for Prophylactic Donor Lymphocyte Infusion in Patients With Refractory/Relapsed Acute Leukemia. Front Oncol 2021; 11:554503. [PMID: 33747904 PMCID: PMC7966710 DOI: 10.3389/fonc.2021.554503] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 01/11/2021] [Indexed: 11/27/2022] Open
Abstract
Prophylactic donor lymphocyte infusion (pDLI) could reduce relapse in patients with refractory/relapsed acute leukemia (RRAL) undergoing allogeneic hematopoietic stem cell transplantation (allo-HSCT), but optimal timing of pDLI remains uncertain. We compared the outcomes of two strategies for pDLI based on time from transplant and minimal residual disease (MRD) status in patients with RRAL. For patients without grade II–IV acute graft-versus-host disease (aGVHD) on day +60, pDLI was given on day +60 regardless of MRD in cohort 1, and was given on day +90 unless MRD was positive on day +60 in cohort 2. A total of 161 patients with RRAL were enrolled, including 83 in cohort 1 and 78 in cohort 2. The extensive chronic GVHD (cGVHD) incidence in cohort 2 was lower than that in cohort 1 (10.3% vs. 27.9%, P = 0.006) and GVHD-free/relapse-free survival (GRFS) in cohort 2 was superior to that in cohort 1 (55.1% vs. 41.0%, P = 0.042). The 2-year relapse rate, overall and leukemia-free survival were comparable between the two cohorts (29.0% vs. 28.2%, P = 0.986; 63.9% vs. 64.1%, P = 0.863; 57.8% vs. 61.5%, P = 0.666). Delaying pDLI to day +90 based on MRD for patients with RRAL undergoing allo-HSCT could lower extensive cGVHD incidence and improve GRFS without increasing incidence of leukemia relapse compared with pDLI on day +60.
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Affiliation(s)
- Qiongqiong Su
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhiping Fan
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Fen Huang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Na Xu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Danian Nie
- Department of Hematology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Dongjun Lin
- Department of Hematology, The Third Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Ziwen Guo
- Department of Hematology, Zhongshan People's Hospital, Zhongshan, China
| | - Pengcheng Shi
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhixiang Wang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Ling Jiang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jing Sun
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zujun Jiang
- Department of Hematology, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, China
| | - Qifa Liu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Li Xuan
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
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17
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Ye L, Gao L, Cheng Q, Guo F, He L, Yuan T, Zhu M, Ma Y, Pan M, Chu X, Ding M, Yu G. Intermediate dose cytarabine improves survival and relapse-free rate compared with standard-dose cytarabine as post-remission treatment for acute myeloid leukemia: A retrospection study. Medicine (Baltimore) 2021; 100:e24273. [PMID: 33546048 PMCID: PMC7837979 DOI: 10.1097/md.0000000000024273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 12/11/2020] [Indexed: 11/25/2022] Open
Abstract
The exact dose of cytarabine still remain controversial for the management of patients with acute myeloid leukemia (AML) after complete remission (CR), but recent studies favor lower doses. This study aimed to investigate the toxic effects of single-intermediate dose (ID) cytarabine in patients with AML after achieving CR, compared with standard-dose cytarabine.In this retrospective study, AML patients who achieved CR after consolidation therapy before enrollment between 07/2008 and 05/2019 were included. All patients were divided into single-ID cytarabine and standard-dose cytarabine. The Kaplan-Meier method was used to compare overall survival (OS) and relapse-free time (RFS). Cox regression models were used to assess factors independently associated with OS and RFS. The toxic side effects of hematology and non-hematology were observed.52 patients were enrolled. There were 33 in ID group, 19 in Standard dose group. The 3-year RFS rate (40.4% vs 22.2%, P = .031) was better in the ID group than in the standard-dose group, while the 3-year OS rate was not different between the 2 groups (50.2% vs 27.8%, P = .074). Treatment stratage of ID cytarabine chemotherapy significantly improve the prognosis of AML regardless of patient age, risk grade, WBC count. There were no significant differences between the 2 groups in grade 3 to 4 bone marrow suppression, gastrointestinal symptoms, blood transfusion, infections.Patients with AML receiving ID cytarabine showed better survival and similar toxicity profiles compared with patients who received standard-dose cytarabine.
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18
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Bewersdorf JP, Giri S, Wang R, Williams RT, Tallman MS, Zeidan AM, Stahl M. Venetoclax as monotherapy and in combination with hypomethylating agents or low dose cytarabine in relapsed and treatment refractory acute myeloid leukemia: a systematic review and meta-analysis. Haematologica 2020; 105:2659-2663. [PMID: 33131256 PMCID: PMC7604631 DOI: 10.3324/haematol.2019.242826] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Jan Philipp Bewersdorf
- Department of Internal Medicine, Section of Hematology, Yale School of Medicine, New Haven, CT
| | - Smith Giri
- Division of Hematology and Oncology, University of Alabama at Birmingham School of Medicine, Birmingham, AL
| | - Rong Wang
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT
- Department of Chronic Disease Epidemiology, School of Public Health, Yale University, New Haven, CT
| | | | - Martin S. Tallman
- Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Amer M. Zeidan
- Department of Internal Medicine, Section of Hematology, Yale School of Medicine, New Haven, CT
- Department of Chronic Disease Epidemiology, School of Public Health, Yale University, New Haven, CT
| | - Maximilian Stahl
- Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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19
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A Rare Case of Coexisting Breast Cancer and Refractory Acute Myeloid Leukemia. Case Rep Hematol 2020; 2020:8893185. [PMID: 32908731 PMCID: PMC7468610 DOI: 10.1155/2020/8893185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 07/18/2020] [Accepted: 08/10/2020] [Indexed: 11/17/2022] Open
Abstract
The occurrence of acute myeloid leukemia (AML) within six months from a diagnosis of breast cancer (BC) is rarely reported in the literature, and it is associated with a poor prognosis. We report herein the case of a 40-year-old woman referred to our centre affected by BC and simultaneous AML. The patient proved refractory to first line therapy and achieved complete remission (CR) with a clofarabine-based regimen followed by allogeneic stem cell transplantation (ASCT). Both during salvage chemotherapy and after ASCT, the patient presented severe infectious complications ( acute cholecistytis and Nocardia pneumonia, respectively) treated with surgery, and currently she is alive in CR for both diseases after 29 months of follow-up. The case highlights the importance of a diagnostic assessment of any unexplained cytopenia in association with solid neoplasia under treatment, underlining the feasibility and priority of a timely treatment of the haematological neoplasm in order to achieve long-term survival.
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20
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Naoe T. <Editors' Choice> How to improve outcomes of elderly patients with acute myeloid leukemia: era of excitement. NAGOYA JOURNAL OF MEDICAL SCIENCE 2020; 82:151-160. [PMID: 32581396 PMCID: PMC7276402 DOI: 10.18999/nagjms.82.2.151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Among elderly patients with acute myeloid leukemia (AML), especially those who are unfit for intensive chemotherapy, a policy of reduced-intensity chemotherapy or conservative observation has been chosen, resulting in unmet medical needs. Clinical trials using anticancer drugs including antimetabolites or drugs targeted to cell cycle-related molecules failed to show superiority over conventional treatments. Recently, drugs targeted to Bcl-2, SMO, FLT3, and IDH1/2 have been shown to prolong overall survival alone or in combination with reduced-intensity chemotherapy. These treatments are likely to reshape the therapeutic landscape of AML, which will be personalized for individual patients based on leukemia genetics.
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Affiliation(s)
- Tomoki Naoe
- National Hospital Organization Nagoya Medical Center, Nagoya, Japan
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21
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Canaani J, Nagar M, Heering G, Gefen C, Yerushalmi R, Shem-Tov N, Volchek Y, Merkel D, Avigdor A, Shimoni A, Amariglio N, Rechavi G, Nagler A. Reassessing the role of high dose cytarabine and mitoxantrone in relapsed/refractory acute myeloid leukemia. Oncotarget 2020; 11:2233-2245. [PMID: 32577167 PMCID: PMC7289527 DOI: 10.18632/oncotarget.27618] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 05/14/2020] [Indexed: 01/04/2023] Open
Abstract
A substantial segment of patients with acute myeloid leukemia (AML) will relapse following an initial response to induction therapy or will prove to be primary refractory. High-dose cytarabine and mitoxantrone (HiDAC/MITO) is an established salvage therapy for these patients. We studied all adult patients with relapsed/refractory (R/R) AML who were treated with HiDAC/MITO in our center between the years 2008-2017. To determine whether responding patients harbored a unique molecular signature, we performed targeted next-generation sequencing (NGS) on a subset of patients. The study cohort consisted of 172 patients with a median age of 54 years (range 18–77). The composite complete remission rate was 58%; 11 patients (6%) died during salvage therapy. Median survival was 11.4 months with a 1-year survival rate of 48%. In multivariate analysis favorable risk cytogenetics [Odds ratio (OR)=0.34, confidence interval (CI) 95%, 0.17–0.68; P = 0.002], and de-novo AML (OR = 0.4, CI 95%, 0.16–0.98; P = 0.047) were independently associated with a favorable response. Patients who attained a complete remission had a median survival of 43.7 months compared with 5.2 months for refractory patients (p < 0.0001). Neither the FLT3-ITD and NPM1 mutational status nor the indication for salvage therapy significantly impacted on the response to HiDAC/MITO salvage. NGS analysis identified 20 different mutations across the myeloid gene spectrum with a distinct TP53 signature detected in non-responding patients. HiDAC/MITO is an effective salvage regimen in R/R AML, however patients with adverse cytogenetics or secondary disease may not benefit as much from this approach.
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Affiliation(s)
- Jonathan Canaani
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Meital Nagar
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Gabriel Heering
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Chen Gefen
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Ronit Yerushalmi
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Noga Shem-Tov
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Yulia Volchek
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Drorit Merkel
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Abraham Avigdor
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Avichai Shimoni
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Ninette Amariglio
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Gidi Rechavi
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Arnon Nagler
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
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22
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Burnett A, Stone R. AML: New Drugs but New Challenges. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 20:341-350. [DOI: 10.1016/j.clml.2020.02.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 01/30/2020] [Accepted: 02/05/2020] [Indexed: 12/20/2022]
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23
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Capelli D, Saraceni F, Fiorentini A, Chiarucci M, Menotti D, Poloni A, Discepoli G, Leoni P, Olivieri A. Feasibility and Outcome of a Phase II Study of Intensive Induction Chemotherapy in 91 Elderly Patients with AML Evaluated Using a Simplified Multidimensional Geriatric Assessment. Adv Ther 2020; 37:2288-2302. [PMID: 32297279 PMCID: PMC7467471 DOI: 10.1007/s12325-020-01310-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Indexed: 12/04/2022]
Abstract
Introduction We prospectively tested in a phase II study high-dose aracytin and idarubicin plus amifostine as induction regimen in 149 patients with acute myeloid leukaemia (AML) aged ≥ 60 years, evaluated by a simplified multidimensional geriatric assessment (MGA). Methods Ninety-one fully or partially fit patients (61%) were allocated to intensive chemotherapy and 58 (39%) frail patients to best supportive care (BSC). Intensively treated patients, showing early death and complete response (CR) rate respectively of 5.5% and 73.6%, received 61 consolidations, followed by autologous transplant (ASCT), stem cell transplantation (SCT) or gemtuzumab ozogamicin, depending on mobilization outcome and donor availability. Results The 8-year overall survival (OS) of these patients was 20.4%, with median duration of 11.4 months significantly superior to the 1.5 months of BSC arm (p < 0.001). Hyperleukocytosis and cytogenetics were predictors of survival with a relative risk of 1.8 in patients with poor karyotype without hyperleukocytosis (p = 0.02) and 3 in those with hyperleukocytosis (≥ 50,000/μl) (p = 0.002). Conclusion MGA allowed tailored post-consolidation in 53.8% of patients after high-dose aracytin induction, with long-term survival doubling that reported in the literature after standard-dose cytarabine regimens. Trial Registration The study was registered with the Umin Clinical Trial Registry (www.umin.ac.jp/ctr), number R000014052. Electronic Supplementary Material The online version of this article (10.1007/s12325-020-01310-4) contains supplementary material, which is available to authorized users.
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24
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Marconi G, Talami A, Abbenante MC, Sartor C, Parisi S, Nanni J, Bertamini L, Ragaini S, Olivi M, de Polo S, Cristiano G, Fontana MC, Bochicchio MT, Ottaviani E, Arpinati M, Sessa M, Baldazzi C, Caso L, Testoni N, Baccarani M, Bonifazi F, Martinelli G, Paolini S, Cavo M, Papayannidis C, Curti A. MEC (mitoxantrone, etoposide, and cytarabine) induces complete remission and is an effective bridge to transplant in acute myeloid leukemia. Eur J Haematol 2020; 105:47-55. [DOI: 10.1111/ejh.13406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 03/02/2020] [Accepted: 03/04/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Giovanni Marconi
- Department of Experimental, Diagnostic and Specialty Medicine Institute of Hematology "L. and A. Seràgnoli" University of Bologna Bologna Italy
| | - Annalisa Talami
- Department of Experimental, Diagnostic and Specialty Medicine Institute of Hematology "L. and A. Seràgnoli" University of Bologna Bologna Italy
| | - Maria Chiara Abbenante
- Department of Experimental, Diagnostic and Specialty Medicine Institute of Hematology "L. and A. Seràgnoli" University of Bologna Bologna Italy
- Department of Haematology and Stem Cell Transplantation Unit IRCCS “Casa Sollievo della Sofferenza” Hospital San Giovanni Rotondo Italy
| | - Chiara Sartor
- Department of Experimental, Diagnostic and Specialty Medicine Institute of Hematology "L. and A. Seràgnoli" University of Bologna Bologna Italy
| | - Sarah Parisi
- Department of Experimental, Diagnostic and Specialty Medicine Institute of Hematology "L. and A. Seràgnoli" University of Bologna Bologna Italy
| | - Jacopo Nanni
- Department of Experimental, Diagnostic and Specialty Medicine Institute of Hematology "L. and A. Seràgnoli" University of Bologna Bologna Italy
| | - Luca Bertamini
- Department of Experimental, Diagnostic and Specialty Medicine Institute of Hematology "L. and A. Seràgnoli" University of Bologna Bologna Italy
- Division of Hematology AOU Città della Salute e della Scienza di Torino Torino Italy
| | - Simone Ragaini
- Department of Experimental, Diagnostic and Specialty Medicine Institute of Hematology "L. and A. Seràgnoli" University of Bologna Bologna Italy
| | - Matteo Olivi
- Department of Experimental, Diagnostic and Specialty Medicine Institute of Hematology "L. and A. Seràgnoli" University of Bologna Bologna Italy
| | - Stefano de Polo
- Department of Experimental, Diagnostic and Specialty Medicine Institute of Hematology "L. and A. Seràgnoli" University of Bologna Bologna Italy
| | - Gianluca Cristiano
- Department of Experimental, Diagnostic and Specialty Medicine Institute of Hematology "L. and A. Seràgnoli" University of Bologna Bologna Italy
| | - Maria Chiara Fontana
- Department of Experimental, Diagnostic and Specialty Medicine Institute of Hematology "L. and A. Seràgnoli" University of Bologna Bologna Italy
| | - Maria Teresa Bochicchio
- Department of Experimental, Diagnostic and Specialty Medicine Institute of Hematology "L. and A. Seràgnoli" University of Bologna Bologna Italy
- Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS Meldola Italy
| | - Emanuela Ottaviani
- Department of Experimental, Diagnostic and Specialty Medicine Institute of Hematology "L. and A. Seràgnoli" University of Bologna Bologna Italy
| | - Mario Arpinati
- Department of Hematology and Oncology Institute of Hematology L. e A. Seràgnoli Azienda Ospedaliero‐Universitaria S. Orsola Malpighi Bologna Italy
| | - Mariarosaria Sessa
- Department of Experimental, Diagnostic and Specialty Medicine Institute of Hematology "L. and A. Seràgnoli" University of Bologna Bologna Italy
| | - Carmen Baldazzi
- Department of Experimental, Diagnostic and Specialty Medicine Institute of Hematology "L. and A. Seràgnoli" University of Bologna Bologna Italy
| | - Lucia Caso
- Department of Hematology and Oncology Institute of Hematology L. e A. Seràgnoli Azienda Ospedaliero‐Universitaria S. Orsola Malpighi Bologna Italy
| | - Nicoletta Testoni
- Department of Experimental, Diagnostic and Specialty Medicine Institute of Hematology "L. and A. Seràgnoli" University of Bologna Bologna Italy
| | - Michele Baccarani
- Department of Experimental, Diagnostic and Specialty Medicine Institute of Hematology "L. and A. Seràgnoli" University of Bologna Bologna Italy
| | - Francesca Bonifazi
- Department of Hematology and Oncology Institute of Hematology L. e A. Seràgnoli Azienda Ospedaliero‐Universitaria S. Orsola Malpighi Bologna Italy
| | - Giovanni Martinelli
- Department of Experimental, Diagnostic and Specialty Medicine Institute of Hematology "L. and A. Seràgnoli" University of Bologna Bologna Italy
- Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS Meldola Italy
| | - Stefania Paolini
- Department of Experimental, Diagnostic and Specialty Medicine Institute of Hematology "L. and A. Seràgnoli" University of Bologna Bologna Italy
| | - Michele Cavo
- Department of Experimental, Diagnostic and Specialty Medicine Institute of Hematology "L. and A. Seràgnoli" University of Bologna Bologna Italy
| | - Cristina Papayannidis
- Department of Experimental, Diagnostic and Specialty Medicine Institute of Hematology "L. and A. Seràgnoli" University of Bologna Bologna Italy
| | - Antonio Curti
- Department of Hematology and Oncology Institute of Hematology L. e A. Seràgnoli Azienda Ospedaliero‐Universitaria S. Orsola Malpighi Bologna Italy
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25
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Gill H, Yim R, Pang HH, Lee P, Chan TSY, Hwang YY, Leung GMK, Ip HW, Leung RYY, Yip SF, Kho B, Lee HKK, Mak V, Chan CC, Lau JSM, Lau CK, Lin SY, Wong RSM, Li W, Ma ESK, Li J, Panagiotou G, Sim JPY, Lie AKW, Kwong YL. Clofarabine, cytarabine, and mitoxantrone in refractory/relapsed acute myeloid leukemia: High response rates and effective bridge to allogeneic hematopoietic stem cell transplantation. Cancer Med 2020; 9:3371-3382. [PMID: 32187883 PMCID: PMC7221314 DOI: 10.1002/cam4.2865] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 12/23/2019] [Accepted: 12/26/2019] [Indexed: 12/15/2022] Open
Abstract
Clofarabine is active in refractory/relapsed acute myeloid leukemia (AML). In this phase 2 study, we treated 18‐ to 65‐year‐old AML patients refractory to first‐line 3 + 7 daunorubicin/cytarabine induction or relapsing after 3 + 7 induction and high‐dose cytarabine consolidation, with clofarabine (30 mg/m2/d, Days 1‐5), cytarabine (750 mg/m2/d, Days 1‐5), and mitoxantrone (12 mg/m2/d, Days 3‐5) (CLAM). Patients achieving remission received up to two consolidation cycles of 50% CLAM, with eligible cases bridged to allogeneic hematopoietic stem cell transplantation (allo‐HSCT). The mutational profile of a 69‐gene panel was evaluated. Twenty‐six men and 26 women at a median age of 46 (22‐65) years were treated. The overall response rate after the first cycle of CLAM was 90.4% (complete remission, CR: 69.2%; CR with incomplete hematologic recovery, CRi: 21.2%). Twenty‐two CR/CRi patients underwent allo‐HSCT. The 2‐year overall survival (OS), relapse‐free survival (RFS), and event‐free survival (EFS) were 65.8%, 45.7%, and 40.2%, respectively. Multivariate analyses showed that superior OS was associated with CR after CLAM (P = .005) and allo‐HSCT (P = .005), and superior RFS and EFS were associated with allo‐HSCT (P < .001). Remarkably, CR after CLAM and allo‐HSCT resulted in 2‐year OS of 84.3% and 90%, respectively. Karyotypic aberrations and genetic mutations did not influence responses or survivals. Grade 3/4 neutropenia/thrombocytopenia and grade 3 febrile neutropenia occurred in all cases. Other nonhematologic toxicities were mild and uncommon. There was no treatment‐related mortality and the performance of allo‐HSCT was not compromised. Clofarabine, cytarabine, and mitoxantrone was highly effective and safe in refractory/relapsed AML. This study was registered at ClinicalTrials.gov (NCT02686593).
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Affiliation(s)
- Harinder Gill
- Department of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Rita Yim
- Department of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Herbert H Pang
- School of Public Health, The University of Hong Kong, Hong Kong SAR, China
| | - Paul Lee
- Department of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Thomas S Y Chan
- Department of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Yu-Yan Hwang
- Department of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Garret M K Leung
- Department of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Ho-Wan Ip
- Department of Pathology, Queen Mary Hospital, Hong Kong SAR, China
| | - Rock Y Y Leung
- Department of Pathology, Queen Mary Hospital, Hong Kong SAR, China
| | - Sze-Fai Yip
- Department of Medicine, Tuen Mun Hospital, Hong Kong SAR, China
| | - Bonnie Kho
- Department of Medicine, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR, China
| | - Harold K K Lee
- Department of Medicine, Princess Margaret Hospital, Hong Kong SAR, China
| | - Vivien Mak
- Department of Medicine, Princess Margaret Hospital, Hong Kong SAR, China
| | - Chi-Chung Chan
- Department of Medicine, Queen Elizabeth Hospital, Hong Kong SAR, China
| | - June S M Lau
- Department of Medicine, Queen Elizabeth Hospital, Hong Kong SAR, China
| | - Chi-Kuen Lau
- Department of Medicine, Tseung Kwan O Hospital, Hong Kong SAR, China
| | - Shek-Yin Lin
- Department of Medicine, United Christian Hospital, Hong Kong SAR, China
| | - Raymond S M Wong
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong SAR, China
| | - Wa Li
- Department of Clinical Oncology, Prince of Wales Hospital, Hong Kong SAR, China
| | - Edmond S K Ma
- Department of Pathology, Hong Kong Sanatorium and Hospital, Hong Kong SAR, China
| | - Jun Li
- Department of Infectious Diseases and Public Health, The City University of Hong Kong, Hong Kong SAR, China.,School of Biological Sciences, The University of Hong Kong, Hong Kong SAR, China
| | - Gianni Panagiotou
- School of Biological Sciences, The University of Hong Kong, Hong Kong SAR, China.,Department of Microbiology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.,Department of Systems Biology and Bioinformatics, Leibniz Institute for Natural Product Research and Infection Biology, Hans Knöll Institute (HKI), Jena, Germany
| | - Joycelyn P Y Sim
- Department of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Albert K W Lie
- Department of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Yok-Lam Kwong
- Department of Medicine, The University of Hong Kong, Hong Kong SAR, China
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26
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Shallis RM, Boddu PC, Bewersdorf JP, Zeidan AM. The golden age for patients in their golden years: The progressive upheaval of age and the treatment of newly-diagnosed acute myeloid leukemia. Blood Rev 2020; 40:100639. [DOI: 10.1016/j.blre.2019.100639] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 10/29/2019] [Accepted: 11/05/2019] [Indexed: 12/25/2022]
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27
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Walchack R, Cumpston A, Vos J, Kanate AS. Delayed-onset effect of clofarabine in the treatment of an adult patient with acute myeloid leukemia. Am J Health Syst Pharm 2020; 76:349-352. [PMID: 31361841 DOI: 10.1093/ajhp/zxy055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE A delayed-onset effect of clofarabine in the treatment of an adult patient with acute myeloid leukemia (AML) is reported. SUMMARY A 44-year-old African-American man with pancytopenia was transferred to an academic medical center for evaluation. His medical history included bipolar depression, gynecomastia, and HIV infection (diagnosed 5 years prior) for which he was being treated with atazanavir, emtricitabine-tenofovir, and ritonavir. He was diagnosed with AML with 60% myeloblasts found during bone marrow biopsy. He had primary refractory disease after induction chemotherapy treatment. His disease was refractory to subsequent therapy with high-dose cytarabine and then etoposide and mitoxantrone. The patient then underwent treatment with granulocyte-colony stimulating factor-primed clofarabine and cytarabine (G-CLAC). At blood count recovery, he was diagnosed with refractory disease, with 17% blasts in peripheral blood and was subsequently discharged home on hospice 38 days after G-CLAC and 19 days after the last dose of filgrastim. He arrived at the outpatient clinic 79 days after G-CLAC chemotherapy with significantly improved blood counts. Two weeks later, a bone marrow biopsy confirmed complete remission with incomplete hematologic recovery. CONCLUSION A patient with relapsed AML achieved a delayed response to clofarabine at least 38 days after treatment.
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Affiliation(s)
- Robert Walchack
- Department of Pharmacy, West Virginia University Medicine, Morgantown, WV
| | - Aaron Cumpston
- Department of Pharmacy, West Virginia University Medicine, Morgantown, WV.,Osborn Hematopoietic Malignancy and Transplantation Program, West Virginia University, Morgantown, WV
| | - Jeffrey Vos
- Department of Pathology, West Virginia University, Morgantown, WV
| | - Abraham S Kanate
- Osborn Hematopoietic Malignancy and Transplantation Program, West Virginia University, Morgantown, WV
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28
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Marcault C, Venton G, Gastaud L, Mannone L, Rey J, D'Incan E, Saillard C, Charbonnier A, Raynaud S, Vey N, Cluzeau T. Alternative Effective and Safe Induction Regimens for Newly Diagnosed Acute Myeloid Leukemia in Patients With Cardiac Contraindication to Anthracyclines. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2019; 20:e76-e81. [PMID: 31865004 DOI: 10.1016/j.clml.2019.11.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 11/04/2019] [Accepted: 11/19/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION The standard first-line treatment for acute myeloid leukemia (AML) is a combination of cytarabine and anthracyclines. To date, there is no commonly agreed-on regimen for patients who are ineligible for this therapy because of cardiac comorbidities or prior exposure to anthracyclines. We compared 3 anthracycline-free regimens currently used in France. PATIENTS AND METHODS Two patients with newly diagnosed or relapsed/refractory AML were treated intensively in 3 French centers. All patients had at least one contraindication to the receipt of anthracyclines. Three regimen types were used: fludarabine, cytarabine, and granulocyte-colony stimulating factor (FLAG); clofarabine and cytarabine (CLARA); and topotecan plus cytarabine (TA). RESULTS Thirty patients (58%) had de novo AML. The European LeukemiaNet 2013 risk categories were favorable, intermediate, and adverse in 4 (8%), 27 (52%), and 20 (39%) patients, respectively. Twenty-four patients received TA and 28 FLAG/CLARA regimens. Fifty percent of patients had cardiac dysfunction, and 50% had prior anthracycline exposure above the maximum tolerated dose. The rate of cardiac events was similar after TA (17%) and FLAG/CLARA (25%) (P = .78). The 5-year nonrelapse mortality was 17.9% and 12.5% in the TA and FLAG/CLARA groups, respectively (P = .59). In patients with previously untreated AML, complete response occurred in 18 (72%) of 25, but median overall survival was only 9.7 months. CONCLUSION TA, FLAG, and CLARA regimens are efficient and are associated with acceptable toxicity in AML patients ineligible for the 3 + 7 regimen as a result of cardiac comorbidities. However, long-term outcome remains disappointing, thereby highlighting the need for the development of less toxic regimens.
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Affiliation(s)
- Clemence Marcault
- CHU of Nice, Hematology Department, Cote D'Azur University, Nice Sophia Antipolis University, Nice, France; CHU of Nice, Oncohematology Laboratory, Cote D'Azur University, Nice Sophia Antipolis University, Nice, France
| | - Geoffroy Venton
- Hematology Department, Paoli-Calmettes Institute, Marseille, France
| | - Lauris Gastaud
- Oncology Department, Antoine Lacassagne Center, Nice, France
| | - Lionel Mannone
- CHU of Nice, Hematology Department, Cote D'Azur University, Nice Sophia Antipolis University, Nice, France
| | - Jerome Rey
- Hematology Department, Paoli-Calmettes Institute, Marseille, France
| | - Evelyne D'Incan
- Hematology Department, Paoli-Calmettes Institute, Marseille, France
| | - Colombe Saillard
- Hematology Department, Paoli-Calmettes Institute, Marseille, France
| | - Aude Charbonnier
- Hematology Department, Paoli-Calmettes Institute, Marseille, France
| | - Sophie Raynaud
- CHU of Nice, Oncohematology Laboratory, Cote D'Azur University, Nice Sophia Antipolis University, Nice, France
| | - Norbert Vey
- Department of Clinical Hematology, Paoli-Calmettes Institute, Marseille, France
| | - Thomas Cluzeau
- CHU of Nice, Hematology Department, Cote D'Azur University, Nice Sophia Antipolis University, Nice, France; INSERM U1065, Mediterranean Center of Molecular Medecine, Cote D'Azur University, Nice, France.
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29
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Largeaud L, Bertoli S, Bérard E, Dufrechou S, Prade N, Gadaud N, Tavitian S, Bories P, Luquet I, Sarry A, Mas VD, Huguet F, Delabesse E, Récher C. Outcome of relapsed/refractory AML patients with IDH1 R132 mutations in real life before the era of IDH1 inhibitors. Leuk Lymphoma 2019; 61:473-476. [PMID: 31566052 DOI: 10.1080/10428194.2019.1668937] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Laetitia Largeaud
- Laboratoire D'Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France.,Université Toulouse III Paul Sabatier, Toulouse, France.,UMR1037-INSERM, ERL5294 CNRS, Cancer Research Center of Toulouse, Toulouse, France
| | - Sarah Bertoli
- Université Toulouse III Paul Sabatier, Toulouse, France.,UMR1037-INSERM, ERL5294 CNRS, Cancer Research Center of Toulouse, Toulouse, France.,Service D'Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France
| | - Emilie Bérard
- Service D'Epidémiologie, Centre Hospitalier Universitaire de Toulouse, Toulouse, France.,UMR 1027, INSERM-Université de Toulouse III, Toulouse, France
| | - Stéphanie Dufrechou
- Laboratoire D'Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France
| | - Naïs Prade
- Laboratoire D'Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France
| | - Noémie Gadaud
- Service D'Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France
| | - Suzanne Tavitian
- Service D'Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France
| | - Pierre Bories
- Réseau Onco-Occitanie, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France
| | - Isabelle Luquet
- Laboratoire D'Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France
| | - Audrey Sarry
- Service D'Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France
| | - Véronique De Mas
- Laboratoire D'Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France.,Université Toulouse III Paul Sabatier, Toulouse, France.,UMR1037-INSERM, ERL5294 CNRS, Cancer Research Center of Toulouse, Toulouse, France
| | - Françoise Huguet
- Service D'Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France
| | - Eric Delabesse
- Laboratoire D'Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France.,Université Toulouse III Paul Sabatier, Toulouse, France.,UMR1037-INSERM, ERL5294 CNRS, Cancer Research Center of Toulouse, Toulouse, France
| | - Christian Récher
- Université Toulouse III Paul Sabatier, Toulouse, France.,UMR1037-INSERM, ERL5294 CNRS, Cancer Research Center of Toulouse, Toulouse, France.,Service D'Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France
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30
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Rufibach K, Heinzmann D, Monnet A. Integrating phase 2 into phase 3 based on an intermediate endpoint while accounting for a cure proportion—With an application to the design of a clinical trial in acute myeloid leukemia. Pharm Stat 2019; 19:44-58. [DOI: 10.1002/pst.1969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 06/13/2019] [Accepted: 07/11/2019] [Indexed: 01/05/2023]
Affiliation(s)
- Kaspar Rufibach
- Methods, Collaboration, and Outreach Group (MCO), Department of BiostatisticsHoffmann‐La Roche Ltd Basel Switzerland
| | - Dominik Heinzmann
- Oncology Biostatistics, Department of BiostatisticsHoffmann‐La Roche Ltd Basel Switzerland
| | - Annabelle Monnet
- Oncology Biostatistics, Department of BiostatisticsHoffmann‐La Roche Ltd Basel Switzerland
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31
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Krauter J, Fiedler W, Schlenk RF, Paschka P, Thol F, Lübbert M, Wattad M, Verbeek M, Könecke C, Neuhaus B, Papkalla A, Kebenko M, Janning M, Döhner K, Gaidzik VI, Becker H, Greil C, Reimer P, Götze KS, Döhner H, Ganser A, Heuser M. Phase I/II study on cytarabine and idarubicin combined with escalating doses of clofarabine in newly diagnosed patients with acute myeloid leukaemia and high risk for induction failure (AMLSG 17-10 CIARA trial). Br J Haematol 2019; 183:235-241. [PMID: 30378121 DOI: 10.1111/bjh.15546] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Accepted: 07/05/2018] [Indexed: 11/28/2022]
Abstract
This open-label, multicentre phase I/II study determined the maximum tolerated dose (MTD), safety and efficacy of clofarabine administered with cytarabine and idarubicin in newly diagnosed acute myeloid leukaemia (AML) patients lacking favourable genetic aberrations. The MTD was 30 mg/m2 clofarabine for patients below and above 60 years. The most frequently reported grade 3-4 non-haematological adverse events were infectious and gastrointestinal toxicities. Complete remission (CR)/CR with incomplete recovery rate was 67%. Allogeneic haematopoietic cell transplantation in first remission was feasible in a high proportion of younger AML patients and probably contributed to the favourable outcome compared to historical controls.
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Affiliation(s)
- Jürgen Krauter
- Department of Haematology, Haemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Walter Fiedler
- Department of Oncology, Haematology and Bone Marrow Transplantation with section Pneumology, Hubertus Wald University Comprehensive Cancer Centre Hamburg, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Richard F Schlenk
- NCT-Trial Centre, National Centre for Tumour Diseases, Heidelberg, Germany
| | - Peter Paschka
- Department of Internal Medicine III, University of Ulm, Ulm, Germany
| | - Felicitas Thol
- Department of Haematology, Haemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Michael Lübbert
- Department of Haematology-Oncology, Faculty of Medicine Freiburg, University of Freiburg Medical Centre, Freiburg, Germany
| | | | - Mareike Verbeek
- Department of Internal Medicine III, Technical University of Munich, Munich, Germany
| | - Christian Könecke
- Department of Haematology, Haemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Barbara Neuhaus
- Hannover Clinical Trial Centre, Hannover Medical School, Hannover, Germany
| | - Armin Papkalla
- Hannover Clinical Trial Centre, Hannover Medical School, Hannover, Germany
| | - Maxim Kebenko
- Department of Oncology, Haematology and Bone Marrow Transplantation with section Pneumology, Hubertus Wald University Comprehensive Cancer Centre Hamburg, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Melanie Janning
- Department of Oncology, Haematology and Bone Marrow Transplantation with section Pneumology, Hubertus Wald University Comprehensive Cancer Centre Hamburg, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Konstanze Döhner
- Department of Internal Medicine III, University of Ulm, Ulm, Germany
| | - Verena I Gaidzik
- Department of Internal Medicine III, University of Ulm, Ulm, Germany
| | - Heiko Becker
- Department of Haematology-Oncology, Faculty of Medicine Freiburg, University of Freiburg Medical Centre, Freiburg, Germany
| | - Christine Greil
- Department of Haematology-Oncology, Faculty of Medicine Freiburg, University of Freiburg Medical Centre, Freiburg, Germany
| | - Peter Reimer
- Evangelisches Krankenhaus Essen-Werden, Essen, Germany
| | - Katharina S Götze
- Department of Internal Medicine III, Technical University of Munich, Munich, Germany
| | - Hartmut Döhner
- Department of Internal Medicine III, University of Ulm, Ulm, Germany
| | - Arnold Ganser
- Department of Haematology, Haemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Michael Heuser
- Department of Haematology, Haemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
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32
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Rubnitz JE, Lacayo NJ, Inaba H, Heym K, Ribeiro RC, Taub J, McNeer J, Degar B, Schiff D, Yeoh AEJ, Coustan-Smith E, Wang L, Triplett B, Raimondi SC, Klco J, Choi J, Pounds S, Pui CH. Clofarabine Can Replace Anthracyclines and Etoposide in Remission Induction Therapy for Childhood Acute Myeloid Leukemia: The AML08 Multicenter, Randomized Phase III Trial. J Clin Oncol 2019; 37:2072-2081. [PMID: 31246522 DOI: 10.1200/jco.19.00327] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
PURPOSE To identify effective and less toxic therapy for children with acute myeloid leukemia, we introduced clofarabine into the first course of remission induction to reduce exposure to daunorubicin and etoposide. PATIENTS AND METHODS From 2008 through 2017, 285 patients were enrolled at eight centers; 262 were randomly assigned to receive clofarabine and cytarabine (Clo+AraC, n = 129) or high-dose cytarabine, daunorubicin, and etoposide (HD-ADE, n = 133) as induction I. Induction II consisted of low-dose ADE given alone or combined with sorafenib or vorinostat. Consolidation therapy comprised two or three additional courses of chemotherapy or hematopoietic cell transplantation. Genetic abnormalities and the level of minimal residual disease (MRD) at day 22 of initial remission induction determined final risk classification. The primary end point was MRD at day 22. RESULTS Complete remission was induced after two courses of therapy in 263 (92.3%) of the 285 patients; induction failures included four early deaths and 15 cases of resistant leukemia. Day 22 MRD was positive in 57 of 121 randomly assigned evaluable patients (47%) who received Clo+AraC and 42 of 121 patients (35%) who received HD-ADE (odds ratio, 1.86; 95% CI, 1.03 to 3.41; P = .04). Despite this result, the 3-year event-free survival rate (52.9% [44.6% to 62.8%] for Clo+AraC v 52.4% [44.0% to 62.4%] for HD-ADE, P = .94) and overall survival rate (74.8% [67.1% to 83.3%] for Clo+AraC v 64.6% [56.2% to 74.2%] for HD-ADE, P = .1) did not differ significantly across the two arms. CONCLUSION Our findings suggest that the use of clofarabine with cytarabine during remission induction might reduce the need for anthracycline and etoposide in pediatric patients with acute myeloid leukemia and may reduce rates of cardiomyopathy and treatment-related cancer.
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Affiliation(s)
- Jeffrey E Rubnitz
- 1St Jude Children's Research Hospital and the University of Tennessee Health Science Center, College of Medicine, Memphis, TN
| | - Norman J Lacayo
- 2Lucile Packard Children's Hospital and Stanford Cancer Center, Palo Alto, CA
| | - Hiroto Inaba
- 1St Jude Children's Research Hospital and the University of Tennessee Health Science Center, College of Medicine, Memphis, TN
| | | | - Raul C Ribeiro
- 1St Jude Children's Research Hospital and the University of Tennessee Health Science Center, College of Medicine, Memphis, TN
| | | | | | | | | | | | | | - Lei Wang
- 1St Jude Children's Research Hospital and the University of Tennessee Health Science Center, College of Medicine, Memphis, TN
| | - Brandon Triplett
- 1St Jude Children's Research Hospital and the University of Tennessee Health Science Center, College of Medicine, Memphis, TN
| | - Susana C Raimondi
- 1St Jude Children's Research Hospital and the University of Tennessee Health Science Center, College of Medicine, Memphis, TN
| | - Jeffery Klco
- 1St Jude Children's Research Hospital and the University of Tennessee Health Science Center, College of Medicine, Memphis, TN
| | - John Choi
- 1St Jude Children's Research Hospital and the University of Tennessee Health Science Center, College of Medicine, Memphis, TN
| | - Stanley Pounds
- 1St Jude Children's Research Hospital and the University of Tennessee Health Science Center, College of Medicine, Memphis, TN
| | - Ching-Hon Pui
- 1St Jude Children's Research Hospital and the University of Tennessee Health Science Center, College of Medicine, Memphis, TN
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33
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Mondesir J, Alary AS, Sibon D, Willems L, Deau B, Suarez F, Hermine O, Fontenay M, Bouscary D, Kosmider O, Tamburini J. Impact of genotype in relapsed and refractory acute myeloid leukaemia patients treated with clofarabine and cytarabine: a retrospective study. Br J Haematol 2019; 187:65-72. [PMID: 31215036 DOI: 10.1111/bjh.16045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 04/16/2019] [Indexed: 12/01/2022]
Abstract
The treatment of relapsed/refractory (R/R) acute myeloid leukaemia (AML) remains a challenge. Among salvage chemotherapy regimens, the clofarabine and cytarabine (CLARA) combination has been widely evaluated and has a favourable safety/efficacy balance. Predictive factors of efficacy in patients with R/R AML are unclear, particularly the impact of AML-related gene mutations. We report our single-centre experience on 34 R/R AML patients treated with CLARA, with a focus on the genetic characterization of our cohort. CLARA yielded a 47% response rate among this poor-prognosis AML population, while two patients (5·8%) died due to treatment-related toxicity. The two-year progression-free survival and overall survival rates were 29·4% and 35·3%, respectively. Nine patients (26%) had long-term response with a median follow-up of 39·5 months among the responders, of whom six underwent haematopoietic stem cell transplantation. Adverse karyotype did not correlate with response or survival, and secondary AML were more frequent among responders to CLARA, suggesting that this combination may successfully salvage R/R AML patients regardless of adverse prognostic markers. We also observed that a low mutational burden and absence of splice mutations correlated with prolonged survival after CLARA, suggesting that extensive genotyping may have prognostic implications in R/R AML.
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Affiliation(s)
- Johanna Mondesir
- Faculté de Médecine Sorbonne Paris Cité, Université Paris Descartes, Paris, France.,Haematology Department, Cochin Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
| | - Anne-Sophie Alary
- Faculté de Médecine Sorbonne Paris Cité, Université Paris Descartes, Paris, France.,Haematology Laboratory, Cochin Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
| | - David Sibon
- Faculté de Médecine Sorbonne Paris Cité, Université Paris Descartes, Paris, France.,Haematology Department, Necker Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
| | - Lise Willems
- Faculté de Médecine Sorbonne Paris Cité, Université Paris Descartes, Paris, France.,Haematology Department, Cochin Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
| | - Benedicte Deau
- Faculté de Médecine Sorbonne Paris Cité, Université Paris Descartes, Paris, France.,Haematology Department, Cochin Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
| | - Felipe Suarez
- Faculté de Médecine Sorbonne Paris Cité, Université Paris Descartes, Paris, France.,Haematology Department, Necker Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
| | - Olivier Hermine
- Faculté de Médecine Sorbonne Paris Cité, Université Paris Descartes, Paris, France.,Haematology Department, Necker Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
| | - Michaela Fontenay
- Faculté de Médecine Sorbonne Paris Cité, Université Paris Descartes, Paris, France.,Haematology Laboratory, Cochin Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
| | - Didier Bouscary
- Faculté de Médecine Sorbonne Paris Cité, Université Paris Descartes, Paris, France.,Haematology Department, Cochin Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
| | - Olivier Kosmider
- Faculté de Médecine Sorbonne Paris Cité, Université Paris Descartes, Paris, France.,Haematology Laboratory, Cochin Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
| | - Jerome Tamburini
- Faculté de Médecine Sorbonne Paris Cité, Université Paris Descartes, Paris, France.,Haematology Laboratory, Cochin Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
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Ye P, Pei R, Jin J, Sun J, Li K, Cao J, Zhou D, Lu Y. Modified cladribine, cytarabine, and G-CSF as a salvage regimen in patients with relapsed/refractory acute myeloid leukemia: a bridge to myeloablative allogeneic hematopoietic stem cell transplantation. Ann Hematol 2019; 98:2073-2080. [PMID: 31201514 DOI: 10.1007/s00277-019-03723-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Accepted: 05/28/2019] [Indexed: 12/27/2022]
Abstract
Patients with primary refractory or early relapsed acute myeloid leukemia (AML) have a dismal prognosis, and the treatment options for these patients are limited. The present study retrospectively examined the efficacy and toxicities of the combination of cladribine 5 mg/m2 per day and intermediate-dose cytarabine 1 g/m2 per day for 5 days and granulocyte colony-stimulating factor (G-CSF) as a salvage treatment in 36 patients with relapsed/refractory AML. Among these, 32 patients had de novo AML, and the remaining 4 patients had secondary AML. The median age for the study cohort was 45.8 years. According to the European LeukemiaNet prognostic index, 5 patients had favorable risk, 18 had intermediate risk, and 11 had poor risk. The complete remission was achieved in 58% of the patients with tolerable toxicities. Fifteen patients underwent stem cell transplantation later. Patients who underwent allogeneic hematopoietic stem cell transplantation had a significantly improved 1-year overall survival compared with those who did not (73% vs. 29%, P < 0.001). The results suggested that, as a salvage regimen, modified cladribine, cytarabine, and G-CSF were effective and well tolerated for patients with relapsed/refractory AML, especially for patients who underwent subsequent stem cell transplantation.
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Affiliation(s)
- Peipei Ye
- Department of Hematology, Yinzhou Hospital Affiliated to Medical School of Ningbo University, No. 251, East Baizhang Road, Yinzhou District, Ningbo, 315040, Zhejiang, China
| | - Renzhi Pei
- Department of Hematology, Yinzhou Hospital Affiliated to Medical School of Ningbo University, No. 251, East Baizhang Road, Yinzhou District, Ningbo, 315040, Zhejiang, China
| | - Jie Jin
- Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Jie Sun
- Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Kongfei Li
- Department of Hematology, Yinzhou Hospital Affiliated to Medical School of Ningbo University, No. 251, East Baizhang Road, Yinzhou District, Ningbo, 315040, Zhejiang, China
| | - Junjie Cao
- Department of Hematology, Yinzhou Hospital Affiliated to Medical School of Ningbo University, No. 251, East Baizhang Road, Yinzhou District, Ningbo, 315040, Zhejiang, China
| | - Dandan Zhou
- Department of Hematology, Yinzhou Hospital Affiliated to Medical School of Ningbo University, No. 251, East Baizhang Road, Yinzhou District, Ningbo, 315040, Zhejiang, China
| | - Ying Lu
- Department of Hematology, Yinzhou Hospital Affiliated to Medical School of Ningbo University, No. 251, East Baizhang Road, Yinzhou District, Ningbo, 315040, Zhejiang, China.
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35
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Cortes JE, Khaled S, Martinelli G, Perl AE, Ganguly S, Russell N, Krämer A, Dombret H, Hogge D, Jonas BA, Leung AYH, Mehta P, Montesinos P, Radsak M, Sica S, Arunachalam M, Holmes M, Kobayashi K, Namuyinga R, Ge N, Yver A, Zhang Y, Levis MJ. Quizartinib versus salvage chemotherapy in relapsed or refractory FLT3-ITD acute myeloid leukaemia (QuANTUM-R): a multicentre, randomised, controlled, open-label, phase 3 trial. Lancet Oncol 2019; 20:984-997. [PMID: 31175001 DOI: 10.1016/s1470-2045(19)30150-0] [Citation(s) in RCA: 294] [Impact Index Per Article: 58.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 03/13/2019] [Accepted: 03/15/2019] [Indexed: 01/22/2023]
Abstract
BACKGROUND Patients with relapsed or refractory FLT3 internal tandem duplication (FLT3-ITD)-positive acute myeloid leukaemia have a poor prognosis, including high frequency of relapse, poorer response to salvage therapy, and shorter overall survival than those with FLT3 wild-type disease. We aimed to assess whether single-agent quizartinib, an oral, highly potent and selective type II FLT3 inhibitor, improves overall survival versus salvage chemotherapy. METHODS QuANTUM-R is a randomised, controlled, phase 3 trial done at 152 hospitals and cancer centres in 19 countries. Eligible patients aged 18 years or older with ECOG performance status 0-2 with relapsed or refractory (duration of first composite complete remission ≤6 months) FLT3-ITD acute myeloid leukaemia after standard therapy with or without allogeneic haemopoietic stem-cell transplantation were randomly assigned (2:1; permuted block size of 6; stratified by response to previous therapy and choice of chemotherapy via a phone-based and web-based interactive response system) to quizartinib (60 mg [30 mg lead-in] orally once daily) or investigator's choice of preselected chemotherapy: subcutaneous low-dose cytarabine (subcutaneous injection of cytarabine 20 mg twice daily on days 1-10 of 28-day cycles); intravenous infusions of mitoxantrone (8 mg/m2 per day), etoposide (100 mg/m2 per day), and cytarabine (1000 mg/m2 per day on days 1-5 of up to two 28-day cycles); or intravenous granulocyte colony-stimulating factor (300 μg/m2 per day or 5 μg/kg per day subcutaneously on days 1-5), fludarabine (intravenous infusion 30 mg/m2 per day on days 2-6), cytarabine (intravenous infusion 2000 mg/m2 per day on days 2-6), and idarubicin (intravenous infusion 10 mg/m2 per day on days 2-4 in up to two 28-day cycles). Patients proceeding to haemopoietic stem-cell transplantation after quizartinib could resume quizartinib after haemopoietic stem-cell transplantation. The primary endpoint was overall survival in the intention-to-treat population. This trial is registered with ClinicalTrials.gov, number NCT02039726, and follow-up is ongoing. FINDINGS Between May 7, 2014, and Sept 13, 2017, 367 patients were enrolled, of whom 245 were randomly allocated to quizartinib and 122 to chemotherapy. Four patients in the quizartinib group and 28 in the chemotherapy group were not treated. Median follow-up was 23·5 months (IQR 15·4-32·3). Overall survival was longer for quizartinib than for chemotherapy (hazard ratio 0·76 [95% CI 0·58-0·98; p=0·02]). Median overall survival was 6·2 months (5·3-7·2) in the quizartinib group and 4·7 months (4·0-5·5) in the chemotherapy group. The most common non-haematological grade 3-5 treatment-emergent adverse events (within ≤30 days of last dose or >30 days if suspected to be a treatment-related event) for quizartinib (241 patients) and chemotherapy (94 patients) were sepsis or septic shock (46 patients [19%] for quizartinib vs 18 [19%] for chemotherapy), pneumonia (29 [12%] vs eight [9%]), and hypokalaemia (28 [12%] vs eight [9%]). The most frequent treatment-related serious adverse events were febrile neutropenia (18 patients [7%]), sepsis or septic shock (11 [5%]), QT prolongation (five [2%]), and nausea (five [2%]) in the quizartinib group, and febrile neutropenia (five [5%]), sepsis or septic shock (four [4%]), pneumonia (two [2%]), and pyrexia (two [2%]) in the chemotherapy group. Grade 3 QT prolongation in the quizartinib group was uncommon (eight [3%] by central reading, ten [4%] by investigator report); no grade 4 events occurred. There were 80 (33%) treatment-emergent deaths in the quizartinib group (31 [13%] of which were due to adverse events) and 16 (17%) in the chemotherapy group (nine [10%] of which were due to adverse events). INTERPRETATION Treatment with quizartinib had a survival benefit versus salvage chemotherapy and had a manageable safety profile in patients with rapidly proliferative disease and very poor prognosis. Quizartinib could be considered a new standard of care. Given that there are only a few available treatment options, this study highlights the value of targeting the FLT3-ITD driver mutation with a highly potent and selective FLT3 inhibitor. FUNDING Daiichi Sankyo.
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Affiliation(s)
- Jorge E Cortes
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Samer Khaled
- City of Hope National Medical Center, Duarte, CA, USA
| | - Giovanni Martinelli
- Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori IRCCS, Meldola FC, Italy
| | - Alexander E Perl
- Abramson Center of the University of Pennsylvania, Philadelphia, PA, USA
| | | | | | - Alwin Krämer
- Universität Heidelberg and German Cancer Research Center, Heidelberg, Germany
| | | | - Donna Hogge
- Vancouver General Hospital, Vancouver, BC, Canada
| | - Brian A Jonas
- University of California Davis Comprehensive Cancer Center, Sacramento, CA, USA
| | | | | | - Pau Montesinos
- Hospital Universitari I Politècnic La Fe, València, Spain; CIBERONC, Instituto de Salud Carlos III, Madrid, Spain
| | - Markus Radsak
- University Medical Center of Johannes Gutenberg University, Mainz, Germany
| | - Simona Sica
- Fondazione Policlinico Universitario A Gemelli-IRCCS, Istituto di Ematologia Università Cattolica Sacro Cuore, Rome, Italy
| | | | | | | | | | | | | | | | - Mark J Levis
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA
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Largeaud L, Bérard E, Bertoli S, Dufrechou S, Prade N, Gadaud N, Tavitian S, Bories P, Luquet I, Sarry A, De Mas V, Huguet F, Delabesse E, Récher C. Outcome of AML patients with IDH2 mutations in real world before the era of IDH2 inhibitors. Leuk Res 2019; 81:82-87. [PMID: 31055247 DOI: 10.1016/j.leukres.2019.04.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 04/22/2019] [Accepted: 04/23/2019] [Indexed: 11/28/2022]
Abstract
Describing the prognosis of sub-groups of acute myeloid leukemia (AML) patients treated in real world with current therapies is becoming increasingly relevant to estimate the benefit that new targeted drugs will bring in the field. This is particularly the case when novel drugs are registered on the basis of non-randomized studies. IDH2 inhibitors have recently emerged as promising drugs in patients with IDH2R140 or IDH2R172 mutations. Enasidenib, a first-in-class IDH2 inhibitor, has been approved following promising results of a phase 1-2 clinical trial in relapsed or refractory AML patients with IDH2 mutations. In this study, we described the characteristics, treatments and outcome of 75 IDH2 mutated patients both at diagnosis and relapse or refractory disease. Among the 33 relapsed/refractory AML patients with either IDH2R140 or IDH2R172, 28 (84.8%) patients received salvage therapy and 14 achieved a complete response (50%). Median duration of response was 15.2 months. Median, 1-y, 3-y and 5-y OS were 15.1 months (IQR, 4.6-37.7), 53.1% (95% CI, 33.2-69.5), 29.2% (95% CI, 12.6-48.1) and 24.4% (95% CI, 9.3-43.1), respectively. In responding patients, median OS was 37.7 months and 1-y, 3-y and 5-y OS was 85.7%, 57.1% and 47.6%, respectively. In non-responding patients, median OS was 5.0 months (IQR, 4.5-8.6) and 1-y and 3-y OS was 17.9% and 0%, respectively. Thus, a substantial number of R/R AML patients with IDH2 mutations can be salvaged by current treatments and benefit from prolonged survival. It is expected that novel targeted agents such as enasidenib will further improve efficacy and safety in the next future.
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Affiliation(s)
- Laetitia Largeaud
- Laboratoire d'Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France; Université Toulouse III Paul Sabatier, Toulouse, France; Cancer Research Center of Toulouse, UMR1037-INSERM, ERL5294 CNRS, Toulouse, France
| | - Emilie Bérard
- Service d'Epidémiologie, Centre Hospitalier Universitaire de Toulouse, Toulouse, France; UMR 1027, INSERM-Université de Toulouse III, Toulouse, France
| | - Sarah Bertoli
- Université Toulouse III Paul Sabatier, Toulouse, France; Cancer Research Center of Toulouse, UMR1037-INSERM, ERL5294 CNRS, Toulouse, France; Service d'Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France
| | - Stéphanie Dufrechou
- Laboratoire d'Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France
| | - Naïs Prade
- Laboratoire d'Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France
| | - Noémie Gadaud
- Service d'Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France
| | - Suzanne Tavitian
- Service d'Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France
| | - Pierre Bories
- Réseau Onco-occitanie, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France
| | - Isabelle Luquet
- Laboratoire d'Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France
| | - Audrey Sarry
- Service d'Epidémiologie, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Véronique De Mas
- Laboratoire d'Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France; Université Toulouse III Paul Sabatier, Toulouse, France; Cancer Research Center of Toulouse, UMR1037-INSERM, ERL5294 CNRS, Toulouse, France
| | - Françoise Huguet
- Service d'Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France
| | - Eric Delabesse
- Laboratoire d'Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France; Université Toulouse III Paul Sabatier, Toulouse, France; Cancer Research Center of Toulouse, UMR1037-INSERM, ERL5294 CNRS, Toulouse, France
| | - Christian Récher
- Université Toulouse III Paul Sabatier, Toulouse, France; Cancer Research Center of Toulouse, UMR1037-INSERM, ERL5294 CNRS, Toulouse, France; Service d'Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France.
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Hypomethylating agents in relapsed and refractory AML: outcomes and their predictors in a large international patient cohort. Blood Adv 2019; 2:923-932. [PMID: 29685952 DOI: 10.1182/bloodadvances.2018016121] [Citation(s) in RCA: 99] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 03/13/2018] [Indexed: 01/12/2023] Open
Abstract
Although hypomethylating agents (HMAs) are frequently used in the frontline treatment of older acute myeloid leukemia (AML) patients, little is known about their effectiveness in relapsed or primary treatment-refractory (RR)-AML. Using an international multicenter retrospective database, we studied the effectiveness of HMAs in RR-AML and evaluated for predictors of response and overall survival (OS). A total of 655 patients from 12 centers received azacitidine (57%) or decitabine (43%), including 290 refractory (44%) and 365 relapsed (56%) patients. Median age at diagnosis was 65 years. Best response to HMAs was complete remission (CR; 11%) or CR with incomplete count recovery (CRi; 5.3%). Additionally, 8.5% experienced hematologic improvement. Median OS was 6.7 months (95% confidence interval, 6.1-7.3). As expected, OS differed significantly by best response, with patients achieving CR and CRi having a median OS of 25.3 and 14.6 months, respectively. In multivariate analysis, the presence of ≤5% circulating blasts and a 10-day schedule of decitabine were associated with improved response rates, whereas the presence of >5% circulating blasts and >20% bone marrow blasts were associated with decreased OS. A significant subset of RR-AML patients (16%) achieved CR/CRi with HMAs and experienced a median OS of 21 months. Outside of a clinical trial, HMAs represent a reasonable therapeutic option for some patients with RR-AML.
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McBride A, Campen CJ, Camamo J, Maloney M, Persky D, Kurtin SE, Barket NL, Krishnadasan R, Elquza E, Anwer F, Weibel K. Implementation of a pharmacy-managed program for the transition of chemotherapy to the outpatient setting. Am J Health Syst Pharm 2019; 75:e246-e258. [PMID: 29691269 DOI: 10.2146/ajhp170138] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Implementation of a pharmacy-managed program for the transition of chemotherapy to the outpatient setting is described. SUMMARY The University of Arizona Cancer Center and Banner-University Medical Center Tucson are affiliated not-for-profit academic medical centers in Tucson, Arizona, whose facilities include a hospital and ambulatory care clinics that maintain 3 outpatient infusion centers. The cancer center pharmacy currently employs 25 pharmacists, with 4 clinical pharmacists serving both the inpatient and outpatient treatment sites. A multidisciplinary team of staff members was assembled to address the transition of chemotherapy from inpatient to outpatient that included physicians, ambulatory clinical oncology pharmacists, finance, social workers, pharmacy staff, nursing staff, and information technology. The program was initiated in May 2014, with a 2-year postimplementation evaluation of our transition of chemotherapy to the outpatient setting. Chemotherapy order sets were developed in our electronic medical record for transitioning rituximab to the outpatient setting for inpatient chemotherapy orders as well as transitioning leukemia, lymphoma, and solid tumor chemotherapy regimens to be administered in the outpatient setting. Eighteen rituximab-containing regimens and 14 chemotherapy protocols were switched to the outpatient setting, with numerous variants of these regimens also created for outpatient only administration. The realized savings for high-cost chemotherapy transitioned to the outpatient setting with rituximab and clofarabine was $1,902,890. Over 747 inpatient bed days were saved, with an approximated cost savings to the health system of $1,402,866, with a cumulative cost savings to our health system of $3,305,756. CONCLUSION This model for transitioning chemotherapy from the hospital to the outpatient setting enhanced access to care, decreased bed utilization in the hospital, and improved clinical and financial metrics.
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Affiliation(s)
- Ali McBride
- University of Arizona Cancer Center, Tucson, AZ
| | | | - James Camamo
- Banner-University Medical Center Tucson, Tucson, AZ
| | | | | | - Sandra E Kurtin
- Clinical Assistant Professor of Medicine Adjunct Clinical Assistant Professor of Nursing, University of Arizona Cancer Center, Tucson, Arizona
| | | | | | - Emad Elquza
- Department of Medicine, University of Arizona Cancer Center, Tucson, AZ
| | - Faiz Anwer
- Department of Medicine, University of Arizona Cancer Center, Tucson, AZ
| | - Kurt Weibel
- Banner-University Medical Center Tucson, Tucson, AZ
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Norsworthy KJ, Luo L, Hsu V, Gudi R, Dorff SE, Przepiorka D, Deisseroth A, Shen YL, Sheth CM, Charlab R, Williams GM, Goldberg KB, Farrell AT, Pazdur R. FDA Approval Summary: Ivosidenib for Relapsed or Refractory Acute Myeloid Leukemia with an Isocitrate Dehydrogenase-1 Mutation. Clin Cancer Res 2019; 25:3205-3209. [PMID: 30692099 DOI: 10.1158/1078-0432.ccr-18-3749] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 12/21/2018] [Accepted: 01/23/2019] [Indexed: 11/16/2022]
Abstract
The FDA approved ivosidenib (Tibsovo; Agios), a small-molecule inhibitor of isocitrate dehydrogenase (IDH)1 on July 20, 2018, for treatment of adults with relapsed or refractory acute myeloid leukemia (R/R AML) with susceptible IDH1 mutation as detected by an FDA-approved test. The efficacy of ivosidenib was established on the basis of complete remission (CR) + CR with partial hematologic recovery (CRh) rate, duration of CR + CRh, and conversion from transfusion dependence (TD) to transfusion independence (TI) in Study AG120-C-001, a single-arm trial. With median follow-up of 8.3 months for 174 adults with IDH1-mutated R/R AML treated with 500 mg ivosidenib daily, the CR + CRh rate was 33% [95% confidence interval (CI), 26-40], median duration of response was 8.2 (95% CI, 5.6-12) months, and conversion from TD to TI occurred in 37% of patients. These endpoints reflect short-term benefit in patients with an unmet medical need; long-term efficacy outcomes were not assessed. Serious adverse reactions (AR) in ≥5% of patients were differentiation syndrome (10%), leukocytosis (10%), and QT interval prolongation (7%). Common (≥20%) ARs of any grade were fatigue, leukocytosis, arthralgia, diarrhea, dyspnea, edema, nausea, mucositis, QT interval prolongation, rash, pyrexia, cough, and constipation. Assessment of long-term safety of ivosidenib is a condition of this approval.
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Affiliation(s)
- Kelly J Norsworthy
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland.
| | - Lola Luo
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Vicky Hsu
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Ramadevi Gudi
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Sarah E Dorff
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Donna Przepiorka
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Albert Deisseroth
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Yuan-Li Shen
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Christopher M Sheth
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Rosane Charlab
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Gene M Williams
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Kirsten B Goldberg
- Oncology Center of Excellence, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Ann T Farrell
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Richard Pazdur
- Oncology Center of Excellence, U.S. Food and Drug Administration, Silver Spring, Maryland
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Ravandi F, Ritchie EK, Sayar H, Lancet JE, Craig MD, Vey N, Strickland SA, Schiller GJ, Jabbour E, Pigneux A, Horst HA, Récher C, Klimek VM, Cortes JE, Carella AM, Egyed M, Krug U, Fox JA, Craig AR, Ward R, Smith JA, Acton G, Kantarjian HM, Stuart RK. Phase 3 results for vosaroxin/cytarabine in the subset of patients ≥60 years old with refractory/early relapsed acute myeloid leukemia. Haematologica 2018; 103:e514-e518. [PMID: 29794146 PMCID: PMC6278965 DOI: 10.3324/haematol.2018.191361] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Affiliation(s)
- Farhad Ravandi
- University of Texas MD Anderson Cancer Center, Houston, TX, USA,Correspondence:
| | | | - Hamid Sayar
- Indiana University Simon Cancer Center, Indianapolis, IN, USA
| | | | | | - Norbert Vey
- Institut Paoli-Calmettes and Aix-Marseille University, Marseille, France
| | | | - Gary J. Schiller
- David Geffen School of Medicine at University of California, Los Angeles, CA, USA
| | - Elias Jabbour
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Arnaud Pigneux
- Université de Bordeaux, Centre Hospitalier Universitaire de Bordeaux, France
| | | | - Christian Récher
- Institut Universitaire du Cancer de Toulouse Oncopole, Université de Toulouse III, Centre Hospitalier Universitaire de Toulouse, France
| | | | - Jorge E. Cortes
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | | | - Utz Krug
- Universitätsklinikum Münster, Germany
| | - Judith A. Fox
- Sunesis Pharmaceuticals, Inc., South San Francisco, CA, USA
| | - Adam R. Craig
- Sunesis Pharmaceuticals, Inc., South San Francisco, CA, USA
| | - Renee Ward
- Sunesis Pharmaceuticals, Inc., South San Francisco, CA, USA
| | | | - Gary Acton
- Sunesis Pharmaceuticals, Inc., South San Francisco, CA, USA
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Jamy O, Bae S, Costa LJ, Erba HP, Papadantonakis N. Outcomes of fludarabine, high dose cytarabine and granulocyte-colony stimulating factor (FLAG) as re-induction for residual acute myeloid leukemia on day 14 bone marrow. Leuk Res 2018; 74:64-67. [PMID: 30300822 DOI: 10.1016/j.leukres.2018.09.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 09/20/2018] [Accepted: 09/24/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND Patients with acute myeloid leukemia (AML) treated with intensive chemotherapy may require re-induction based on the evaluation of day 14 bone marrow biopsy. METHODS A retrospective chart review was performed to evaluate adult patients with AML who received re-induction with fludarabine, high dose cytarabine and granulocyte colony stimulating factor (FLAG) regimen for residual disease (≥ 5% blasts by morphology) on day 14 bone marrow examination between September 2012 and July 2017 at our institution. RESULTS We identified 27 patients who received FLAG therapy for treatment of residual disease on day 14 marrow examination following initial induction. The median age at diagnosis was 61 years and the majority of patients had poor risk AML. The overall response rate was 78% and 15 patients proceeded to allogeneic hematopoietic stem cell transplantation. CONCLUSION The regimen was well tolerated and is a viable re-induction option for patients with residual disease on a day 14 bone marrow.
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Affiliation(s)
- Omer Jamy
- Division of Hematology/Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sejong Bae
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA; Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Luciano J Costa
- Division of Hematology/Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA; Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Harry P Erba
- Division of Hematology/Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA; Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Nikolaos Papadantonakis
- Division of Hematology/Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA; Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, USA.
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Levin-Epstein R, Oliai C, Schiller G. Allogeneic Hematopoietic Stem Cell Transplantation for Older Patients With Acute Myeloid Leukemia. Curr Treat Options Oncol 2018; 19:63. [PMID: 30362051 DOI: 10.1007/s11864-018-0577-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OPINION STATEMENT Acute myelogenous leukemia (AML) in the elderly is complex and has a poor prognosis, often characterized by higher risk cytogenetic and molecular features compared to that in younger patients. Rates of transplant have been limited by concern related to non-relapse mortality, as older patients have historically been considered medically unfit for the transplantation process. Reduced-intensity conditioning (RIC) for hematopoietic stem cell transplantation (HSCT) has been shown to provide similar efficacy to myeloablative methods, with decreased non-relapse mortality in the elderly and improved efficacy over non-transplant approaches with cytotoxic chemotherapy alone. Targeted non-cytotoxic and modified cytotoxic agents have emerged to further improve transplant outcomes for older AML patients. Validated comorbidity indices are useful tools to assess an individual's fitness for undergoing HSCT rather than chronological age alone. We believe HSCT is the primary curative treatment approach for many older AML patients, taking into account risk and comorbidities, particularly given the tendency of leukemia in this population to harbor an unfavorable disease profile. We use RIC and advocate for the addition of targeted agents if applicable. With continuing data in support of transplant for older AML patients, we anticipate that transplant rates in this population will continue to rise.
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Affiliation(s)
- Rebecca Levin-Epstein
- UCLA Department of Radiation Oncology, 200 Medical Plaza, Suite B265, Los Angeles, CA, 90095, USA.
| | - Caspian Oliai
- UCLA Department of Hematology Oncology, 200 Medical Plaza, Suite 120, Los Angeles, CA, 90095, USA
| | - Gary Schiller
- UCLA Department of Hematology Oncology, 200 Medical Plaza, Suite 120, Los Angeles, CA, 90095, USA
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Veltri L, Rezvani K, Oran B, Mehta R, Rondon G, Kebriaei P, Popat U, Nieto Y, Hosing C, Qazilbash M, Khouri I, Shpall E, Champlin R, Marin D. Allotransplants for Patients 65 Years or Older with High-Risk Acute Myeloid Leukemia. Biol Blood Marrow Transplant 2018; 25:505-514. [PMID: 30308325 DOI: 10.1016/j.bbmt.2018.09.032] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 09/27/2018] [Indexed: 01/09/2023]
Abstract
The outcome of persons > 65 years with acute myeloid leukemia (AML) is poor. A transplant from an HLA-identical sibling or an HLA-matched unrelated donor can cure some of these patients but is associated with a substantial transplant-related mortality and a high relapse risk. We analyzed 185 subjects > 65 years with high-risk AML receiving conventional (n = 42) or reduced-intensity (n = 143) pretransplant conditioning and a transplant from an HLA-identical sibling (n = 66) or a 10/10 loci HLA-matched unrelated donor (n = 119). Two-year survival was 37%. Subjects with serious adverse events during before chemotherapy for their leukemia had a poor outcome after stem cell transplantation. Patients who had active leukemia or measurable residual disease (MRD) before transplantation had a worse outcome. Delayed hematologic recovery after induction or consolidation chemotherapy, high-risk AML genetics, donor-recipient HLA-DRβ3/4/5-DP mismatches, and history of cardiovascular disease were also correlated with survival in multivariate analyses. The 57 MRD-negative patients with few other adverse prognostic factors had an excellent outcome (2-year overall survival, 76%), whereas the 58 patients with detectable leukemia and more than 1 other additional factor fared poorly (2-year overall survival, 8%). These data indicate it is possible to identify persons > 65 years with high-risk AML likely to benefit from an allotransplant. Validation of this prediction is needed.
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Affiliation(s)
- Lauren Veltri
- Department of Stem Cell Transplantation and Cellular Therapy, MD Anderson Cancer Center, University of Texas, Houston, Texas
| | - Katayoun Rezvani
- Department of Stem Cell Transplantation and Cellular Therapy, MD Anderson Cancer Center, University of Texas, Houston, Texas
| | - Betul Oran
- Department of Stem Cell Transplantation and Cellular Therapy, MD Anderson Cancer Center, University of Texas, Houston, Texas
| | - Rohtesh Mehta
- Department of Stem Cell Transplantation and Cellular Therapy, MD Anderson Cancer Center, University of Texas, Houston, Texas
| | - Gabriela Rondon
- Department of Stem Cell Transplantation and Cellular Therapy, MD Anderson Cancer Center, University of Texas, Houston, Texas
| | - Partow Kebriaei
- Department of Stem Cell Transplantation and Cellular Therapy, MD Anderson Cancer Center, University of Texas, Houston, Texas
| | - Uday Popat
- Department of Stem Cell Transplantation and Cellular Therapy, MD Anderson Cancer Center, University of Texas, Houston, Texas
| | - Yago Nieto
- Department of Stem Cell Transplantation and Cellular Therapy, MD Anderson Cancer Center, University of Texas, Houston, Texas
| | - Chitra Hosing
- Department of Stem Cell Transplantation and Cellular Therapy, MD Anderson Cancer Center, University of Texas, Houston, Texas
| | - Muzaffar Qazilbash
- Department of Stem Cell Transplantation and Cellular Therapy, MD Anderson Cancer Center, University of Texas, Houston, Texas
| | - Issa Khouri
- Department of Stem Cell Transplantation and Cellular Therapy, MD Anderson Cancer Center, University of Texas, Houston, Texas
| | - Elizabeth Shpall
- Department of Stem Cell Transplantation and Cellular Therapy, MD Anderson Cancer Center, University of Texas, Houston, Texas
| | - Richard Champlin
- Department of Stem Cell Transplantation and Cellular Therapy, MD Anderson Cancer Center, University of Texas, Houston, Texas
| | - David Marin
- Department of Stem Cell Transplantation and Cellular Therapy, MD Anderson Cancer Center, University of Texas, Houston, Texas.
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McMahon CM, Perl AE. Management of primary refractory acute myeloid leukemia in the era of targeted therapies. Leuk Lymphoma 2018; 60:583-597. [PMID: 30234399 DOI: 10.1080/10428194.2018.1504937] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Primary refractory acute myeloid leukemia (AML), or primary induction failure, represents a continued challenge in clinical management. This review presents an overview of primary refractory disease and a discussion of risk factors for induction failure, including current evidence regarding the impact of karyotype and molecular mutation status on responsiveness to chemotherapy. We review the evidence for various treatment options for refractory AML including salvage chemotherapy regimens, allogeneic hematopoietic stem cell transplantation, targeted agents, and non-intensive therapies such as hypomethylating agents. A therapeutic approach to this patient population is presented, and several new and emerging therapies are reviewed.
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Affiliation(s)
- Christine M McMahon
- a Department of Medicine, Division of Hematology and Oncology , Perelman School of Medicine at the University of Pennsylvania , Philadelphia , PA , USA
| | - Alexander E Perl
- a Department of Medicine, Division of Hematology and Oncology , Perelman School of Medicine at the University of Pennsylvania , Philadelphia , PA , USA
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Xu J, Lv TT, Zhou XF, Huang Y, Liu DD, Yuan GL. Efficacy of common salvage chemotherapy regimens in patients with refractory or relapsed acute myeloid leukemia: A retrospective cohort study. Medicine (Baltimore) 2018; 97:e12102. [PMID: 30278488 PMCID: PMC6181529 DOI: 10.1097/md.0000000000012102] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
To assess treatment response and overall survival (OS) in refractory or relapsed acute myeloid leukemia (R/R AML) patients treated by different common salvage chemotherapy regimens.Medical records data from 142 R/R AML patients were reviewed in this retrospective study. Patients were treated with regimens based on the following drugs: cytarabine, granulocyte colony-stimulating factor (G-CSF), and fludarabine (FLAG) (n = 46); cytarabine and G-CSF in addition to aclarubicin or daunorubicin (CAG/DAG) (n = 30); cytarabine, G-CSF, and cladribine (CLAG) (n = 27); cytarabine, etoposide, and mitoxantrone (MEA) (n = 17); cytarabine plus idarubicin, daunorubicin, or mitoxantrone (IA/DA/MA) (n = 12); and homoharringtonine, cytarabine, and aclarubicin or daunorubicin (HAA/HAD) (n = 10).A total of 43 (35.2%) patients achieved complete remission (CR), 60 (49.2%) patients achieved overall remission rate (ORR), and 18 (14.8%) patients received allogeneic hematopoietic stem cell transplantation (allo-HSCT) after CR. Median OS was 8.0 (95% CI 6.6-9.4) months with a 1-year OS rate of (29.9 ± 3.9)% and 3-year OS rate of (11.1 ± 3.6)%. No difference of CR (P = .621), ORR (P = .385), and allo-HSCT (P = .537) achievement was observed among different chemotherapy regimens. Interestingly, we observed that the CLAG-based regimen did not affect CR (P = .165), while it achieved a numerically higher ORR (P = .093) and was an independent factor for prolonged OS (P = .016). No other regimens were determined to be correlated with CR, ORR, or OS.FLAG-, CAG/DAG-, CLAG-, MEA-, IA/DA/MA- and HAA/HAD-based regimens were found to achieve similar CR rates, while the CLAG-based regimen achieved numerically higher ORR rates and significant favorable OS. Therefore, CLAG-based regimens should be a prioritized treatment option for R/R AML patients.
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Aslostovar L, Boyd AL, Almakadi M, Collins TJ, Leong DP, Tirona RG, Kim RB, Julian JA, Xenocostas A, Leber B, Levine MN, Foley R, Bhatia M. A phase 1 trial evaluating thioridazine in combination with cytarabine in patients with acute myeloid leukemia. Blood Adv 2018; 2:1935-1945. [PMID: 30093531 PMCID: PMC6093733 DOI: 10.1182/bloodadvances.2018015677] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 07/04/2018] [Indexed: 12/19/2022] Open
Abstract
We completed a phase 1 dose-escalation trial to evaluate the safety of a dopamine receptor D2 (DRD2) antagonist thioridazine (TDZ), in combination with cytarabine. Thirteen patients 55 years and older with relapsed or refractory acute myeloid leukemia (AML) were enrolled. Oral TDZ was administered at 3 dose levels: 25 mg (n = 6), 50 mg (n = 4), or 100 mg (n = 3) every 6 hours for 21 days. Intermediate-dose cytarabine was administered on days 6 to 10. Dose-limiting toxicities (DLTs) included grade 3 QTc interval prolongation in 1 patient at 25 mg TDZ and neurological events in 2 patients at 100 mg TDZ (gait disturbance, depressed consciousness, and dizziness). At the 50-mg TDZ dose, the sum of circulating DRD2 antagonist levels approached a concentration of 10 μM, a level noted to be selectively active against human AML in vitro. Eleven of 13 patients completed a 5-day lead-in with TDZ, of which 6 received TDZ with hydroxyurea and 5 received TDZ alone. During this period, 8 patients demonstrated a 19% to 55% reduction in blast levels, whereas 3 patients displayed progressive disease. The extent of blast reduction during this 5-day interval was associated with the expression of the putative TDZ target receptor DRD2 on leukemic cells. These preliminary results suggest that DRD2 represents a potential therapeutic target for AML disease. Future studies are required to corroborate these observations, including the use of modified DRD2 antagonists with improved tolerability in AML patients. This trial was registered at www.clinicaltrials.gov as #NCT02096289.
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Affiliation(s)
- Lili Aslostovar
- Stem Cell and Cancer Research Institute and
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, ON, Canada
| | | | - Mohammed Almakadi
- Stem Cell and Cancer Research Institute and
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, ON, Canada
- Division of Malignant Hematology, Department of Oncology, Juravinski Hospital, Hamilton, ON, Canada
| | | | - Darryl P Leong
- Division of Cardiology, Department of Medicine, Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Rommel G Tirona
- Division of Clinical Pharmacology, Department of Medicine, University of Western Ontario, London Health Sciences Centre, London, ON, Canada
| | - Richard B Kim
- Division of Clinical Pharmacology, Department of Medicine, University of Western Ontario, London Health Sciences Centre, London, ON, Canada
| | - Jim A Julian
- Department of Oncology, McMaster University, Juravinski Hospital, Hamilton, ON, Canada
| | - Anargyros Xenocostas
- Division of Hematology, Department of Medicine, University of Western Ontario, London Health Sciences Centre, London, ON, Canada; and
| | - Brian Leber
- Department of Medicine, McMaster University, Juravinski Hospital, Hamilton, ON, Canada
| | - Mark N Levine
- Department of Oncology, McMaster University, Juravinski Hospital, Hamilton, ON, Canada
| | - Ronan Foley
- Department of Pathology and Molecular Medicine, McMaster University, Juravinski Hospital, Hamilton, ON, Canada
| | - Mickie Bhatia
- Stem Cell and Cancer Research Institute and
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, ON, Canada
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Yang M, Zhao J, Liu T, Yang X, Wei H, Xu W, Xiao J. Use of FLT3 inhibitors in acute myeloid leukemia remission induction or salvage therapy: systematic review and meta-analysis. Cancer Manag Res 2018; 10:2635-2652. [PMID: 30147364 PMCID: PMC6097505 DOI: 10.2147/cmar.s166387] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Background Previous studies showed that FLT3 inhibitors played an important role in acute myeloid leukemia (AML) therapy. However, discrepancies remain regarding the association between FLT3 inhibitors use and prognosis of AML patients in clinical trials. Aim The aim of this study was to evaluate the effect of FLT3 inhibitors on the treatment of AML in a systematic review and meta-analysis. Materials and methods PubMed, Embase, and Cochrane Library databases were searched for studies published before August 2017 that used FLT3 inhibitors in AML. Fixed- and random-effect models were used, and between-study heterogeneity was assessed. Results A total of 26 studies fitting our inclusion and exclusion criteria were included. The FLT3 status of patients and main treatment outcomes including overall survival (OS), event-free survival (EFS), relapse-free survival (RFS), complete remission (CR), and overall response rate (ORR) after therapy were extracted. Five studies comparing addition of FLT3 inhibitors and placebo or blank control to chemotherapy were analyzed in Part I, showing improved OS (hazard ratio [HR]=0.86, 95% confidence interval [CI]=0.75–0.99, P=0.03) in the FLT3 inhibitor group but without a significant improvement on EFS (HR=0.86, 95% CI=0.62–1.21, P=0.39) and ORR (odds ratio [OR]=1.10, 95% CI=0.89–1.35, P=0.38). Twenty-one studies evaluating the benefit of using FLT3 inhibitors in different FLT3-type AML patients were analyzed in Part II, showing that FLT3–internal tandem duplication (ITD)-positive patients were more sensitive to FLT3 inhibitor treatment and achieved better CR (OR=1.89, 95% CI=1.06–3.37, P=0.03) and ORR (OR=3.07, 95% CI=2.13–4.43, P<0.001). Conclusion Our study showed that combined use of FLT3 inhibitors improved OS and that the FLT3 status of AML patients could affect their sensitivity to FLT3 inhibitors in terms of CR and ORR.
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Affiliation(s)
- Minglei Yang
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai, 200003, China, ;
| | - Jian Zhao
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai, 200003, China, ;
| | - Tielong Liu
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai, 200003, China, ;
| | - Xinghai Yang
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai, 200003, China, ;
| | - Haifeng Wei
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai, 200003, China, ;
| | - Wei Xu
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai, 200003, China, ;
| | - Jianru Xiao
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai, 200003, China, ;
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Xiao H, Li L, Pang Y, Wu Y, Jiang Z, Liu Z, Wu J, Xiao Y, Huang F, Liu Q, Zhang H, Luo Y, Huang H. Sequential treatment combining cladribine-based re-induction, myeloablative allogeneic HSCT, and prophylactic donor lymphocyte infusion: a promising treatment for refractory acute myeloid leukemia. Ann Hematol 2018; 97:2479-2490. [PMID: 30078144 DOI: 10.1007/s00277-018-3453-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 07/19/2018] [Indexed: 11/26/2022]
Abstract
We describe the first multicenter prospective study to assess the efficacy, safety, and immune reconstitution of a novel sequential transplant approach in 24 patients with primary induction failure/relapsed acute myeloid leukemia (AML). The sequential regimen consisted of cladribine 5 mg/m2/day and cytarabine 2 g/m2/day for 5 days and mitoxantrone 7 mg/m2/day for 3 days, followed by myeloablative allogeneic hematopoietic stem cell transplantation (allo-HSCT) using intravenous busulfan (3.2 mg/kg/day) for 4 days and cyclophosphamide (60 mg/kg/day) for 2 days. Patients in CR without acute graft-versus-host disease at day + 90 received prophylactic donor lymphocyte infusion (pDLI). At the time of transplantation, a marrow blast infiltration > 20% or any level of circulating blasts was found in 62.5% of patients. The cumulative incidence of relapse at 2 years was 29.8%. Overall survival (OS) was 74.5% at 1 year and 56.5% at 2 years. Leukemia-free survival (LFS) at 1 and 2 years was 62.5 and 50.5%, respectively. Multivariate analysis demonstrated that haploidentical related donor, pDLI, and experiencing chronic graft-versus-host disease (cGVHD) were protective from relapse. Total T cells and T cell subsets in peripheral blood recovered at 3 months post-HSCT. The expressions of immune checkpoints (cytotoxic T lymphocyte antigen 4 and programmed death 1) were extremely low in T cells over the first 1 year post-transplantation.
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Affiliation(s)
- Haowen Xiao
- Department of Hematology, Guangzhou General Hospital of Guangzhou Military Command, No. 111 Liuhua Rd., Guangzhou, 510010, Guangdong Province, People's Republic of China.
- Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, People's Republic of China.
| | - Li Li
- Center of Cell-Biological Therapy and Research, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, Guangdong Province, People's Republic of China
| | - Yan Pang
- Department of Hematology, Guangzhou General Hospital of Guangzhou Military Command, No. 111 Liuhua Rd., Guangzhou, 510010, Guangdong Province, People's Republic of China
| | - Yuanbin Wu
- Department of Hematology, Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong Province, People's Republic of China
| | - Zujun Jiang
- Department of Hematology, Guangzhou General Hospital of Guangzhou Military Command, No. 111 Liuhua Rd., Guangzhou, 510010, Guangdong Province, People's Republic of China
| | - Zenghui Liu
- Department of Hematology, Guangzhou General Hospital of Guangzhou Military Command, No. 111 Liuhua Rd., Guangzhou, 510010, Guangdong Province, People's Republic of China
| | - Jiulong Wu
- Center of Cell-Biological Therapy and Research, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, Guangdong Province, People's Republic of China
| | - Yang Xiao
- Department of Hematology, Guangzhou General Hospital of Guangzhou Military Command, No. 111 Liuhua Rd., Guangzhou, 510010, Guangdong Province, People's Republic of China
| | - Fen Huang
- Department of Hematology, Nanfang Hospital of Southern Medical University, Guangzhou, Guangdong Province, People's Republic of China
| | - Qifa Liu
- Department of Hematology, Nanfang Hospital of Southern Medical University, Guangzhou, Guangdong Province, People's Republic of China
| | - Hang Zhang
- Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, People's Republic of China
| | - Yi Luo
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, People's Republic of China
| | - He Huang
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, People's Republic of China
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50
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Kantarjian HM, DiNardo CD, Nogueras-Gonzalez GM, Kadia TM, Jabbour E, Bueso-Ramos CE, O'Brien SM, Konopleva M, Jain NB, Daver NG, Shpall EJ, Champlin RE, Simkins A, Garcia-Manero G, Keating MJ, Huang X, Cortes JE, Pierce SA, Ravandi F, Freireich EJ. Results of second salvage therapy in 673 adults with acute myelogenous leukemia treated at a single institution since 2000. Cancer 2018; 124:2534-2540. [PMID: 29645075 DOI: 10.1002/cncr.31370] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 02/21/2018] [Accepted: 02/22/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND The prognosis is poor for patients who have relapsed-refractory acute myelogenous leukemia (AML). Most published reports analyzed results from therapies in first-salvage AML or in studies that were conducted before 2000. Several novel agents and strategies are being tested for potential approval as treatment for patients with relapsed-refractory AML in second salvage. Therefore, it is important to establish the historic results of anti-AML therapies in this setting in the modern era. The objective of the current study was to analyze the results from second salvage therapies in patients with AML since 2000 with regard to response and survival. METHODS In total, 673 patients who received second salvage therapies for AML since 2000 were analyzed. Their median age was 60 years (range, 18-89 years). Salvage therapy consisted of cytarabine-based regimens in 267 patients, noncytarabine combinations in 37, hypomethylating agent-based regimens in 136, and phase 1 and 2 single agents in 233. RESULTS Eighty-six of the 673 patients (13%) achieved a complete response (CR) or a CR with low platelet count (CRp). The median duration of CR-CRp was 7.2 months. The median survival was 4.4 months (95% confidence interval, 4.0-4.8 months), and the 1-year survival rate was 16% (95% confidence interval, 14%-19%). Multivariate analysis identified the following as independent adverse factors for achievement of CR-CRp: platelets < 50 × 109 /L (P < .001), complex karyotype with ≥3 chromosomal abnormalities (P = .02), regimens that did not include cytarabine or hypomethylating agents (P = .014), and no prior CR lasting ≥12 months with frontline or salvage 1 therapies (P < .001). The independent adverse factors associated with worse survival were age ≥60 years (P = .01), platelets < 50 × 109 /L (P = .02), peripheral blasts ≥ 20% (P = .03), albumin ≤ 3 g/dL (P = .04), and complex karyotype (P = .003). The authors also applied and validated, in the current population, the 2 multivariate-derived prognostic models for CR and survival developed in their previous study of 594 patients who received treatment for second salvage AML from the previous 2 decades. CONCLUSIONS This large-scale analysis establishes the modern historic results of second salvage therapy in AML and validates the prognostic models associated with outcome. These data could be used to analyze the differential benefits of current or future investigational strategies under evaluation in this setting and for the purpose of potential approval of new agents in the United States and the world. Cancer 2018;124:2534-40. © 2018 American Cancer Society.
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Affiliation(s)
- Hagop M Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Courtney D DiNardo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Tapan M Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Carlos E Bueso-Ramos
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Susan M O'Brien
- Chao Family Comprehensive Cancer Center, University of California at Irvine, Irvine, California
| | - Marina Konopleva
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Nitin B Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Naval G Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Elizabeth J Shpall
- Department of Cellular Therapy and Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Richard E Champlin
- Department of Cellular Therapy and Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Aron Simkins
- Department of Internal Medicine, University of Texas Health Science Center, Houston, Texas
| | | | - Michael J Keating
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Xuelin Huang
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jorge E Cortes
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sherry A Pierce
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Emil J Freireich
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
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