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Heiblig M, Labussière-Wallet H, Nicolini FE, Michallet M, Hayette S, Sujobert P, Plesa A, Balsat M, Paubelle E, Barraco F, Tigaud I, Ducastelle S, Wattel E, Salles G, Thomas X. Prognostic Value of Genetic Alterations in Elderly Patients with Acute Myeloid Leukemia: A Single Institution Experience. Cancers (Basel) 2019; 11:cancers11040570. [PMID: 31013658 PMCID: PMC6520979 DOI: 10.3390/cancers11040570] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 03/23/2019] [Accepted: 04/08/2019] [Indexed: 12/15/2022] Open
Abstract
Although the outcome in younger adults with acute myeloid leukemia (AML) has improved, the benefit associated with standard intensive chemotherapy in older patients remains debatable. In this study, we investigated the incidence and the prognostic significance of genetic characteristics according to treatment intensity in patients aged 60 years or older. On the 495 patients of our cohort, DNMT3AR882 (25.2%), NPM1 (23.7%) and FLT3-ITD (16.8%) were the most frequent molecular mutations found at diagnosis. In this elderly population, intensive chemotherapy seemed to be a suitable option in terms of early death and survival, except for normal karyotype (NK) NPM1−FLT3-ITD+ patients and those aged over 70 within the adverse cytogenetic/molecular risk group. The FLT3-ITD mutation was systematically associated with an unfavorable outcome, independently of the ratio. NK NPM1+/FLT3-TKD+ genotype tends to confer a good prognosis in patients treated intensively. Regarding minimal residual disease prognostic value, overall survival was significantly better for patients achieving a 4 log NPM1 reduction (median OS: 24.4 vs. 12.8 months, p = 0.013) but did not reach statistical significance for progression free survival. This retrospective study highlights that intensive chemotherapy may not be the most appropriate option for each elderly patient and that molecular markers may help treatment intensity decision-making.
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Affiliation(s)
- Maël Heiblig
- Department of Hematology, Lyon-Sud Hospital, Hospices Civils de Lyon, 69495 Pierre Bénite, France.
- University Claude Bernard Lyon 1, 69100 Villeurbanne, France.
| | - Hélène Labussière-Wallet
- Department of Hematology, Lyon-Sud Hospital, Hospices Civils de Lyon, 69495 Pierre Bénite, France.
| | | | - Mauricette Michallet
- Department of Hematology, Lyon-Sud Hospital, Hospices Civils de Lyon, 69495 Pierre Bénite, France.
| | - Sandrine Hayette
- Laboratory of Molecular Biology, Lyon-Sud Hospital, Hospices Civils de Lyon, 69495 Pierre Bénite, France.
| | - Pierre Sujobert
- Laboratory of Molecular Biology, Lyon-Sud Hospital, Hospices Civils de Lyon, 69495 Pierre Bénite, France.
| | - Adriana Plesa
- Laboratory of Cytology and Immunology, Lyon-Sud Hospital, Hospices Civils de Lyon, 69495 Pierre Bénite, France.
| | - Marie Balsat
- Department of Hematology, Lyon-Sud Hospital, Hospices Civils de Lyon, 69495 Pierre Bénite, France.
| | - Etienne Paubelle
- Department of Hematology, Lyon-Sud Hospital, Hospices Civils de Lyon, 69495 Pierre Bénite, France.
| | - Fiorenza Barraco
- Department of Hematology, Lyon-Sud Hospital, Hospices Civils de Lyon, 69495 Pierre Bénite, France.
| | - Isabelle Tigaud
- Laboratory of Cytogenetics, Lyon-Sud Hospital, Hospices Civils de Lyon, 69495 Pierre Bénite, France.
| | - Sophie Ducastelle
- Department of Hematology, Lyon-Sud Hospital, Hospices Civils de Lyon, 69495 Pierre Bénite, France.
| | - Eric Wattel
- Department of Hematology, Lyon-Sud Hospital, Hospices Civils de Lyon, 69495 Pierre Bénite, France.
| | - Gilles Salles
- Department of Hematology, Lyon-Sud Hospital, Hospices Civils de Lyon, 69495 Pierre Bénite, France.
| | - Xavier Thomas
- Department of Hematology, Lyon-Sud Hospital, Hospices Civils de Lyon, 69495 Pierre Bénite, France.
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Elderly Patients (Age 70 Years or Older) With Secondary Acute Myeloid Leukemia or Acute Myeloid Leukemia Developed Concurrently to Another Malignant Disease. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2018; 18:e211-e218. [DOI: 10.1016/j.clml.2018.02.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 02/26/2018] [Indexed: 11/22/2022]
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Abstract
INTRODUCTION Treatment of elderly patients with acute leukemia is challenging. Older age is associated with increased risk of treatment-related toxicity. Currently, no consensus exists regarding optimal therapy in this patient population. Areas covered: The following review is a comprehensive summary of various therapeutic options reported over the past few years in elderly patients with acute leukemia. Expert commentary: While evidences can guide identification of frail older patients, sensitive assessment strategies are required to identify fit and vulnerable patients regardless of chronologic age. Individualized treatments may take into account not only an increase in survival, but also the maintenance or improvement in terms of quality of life, the management of symptoms, and a maximization of time outside of hospital care. In this setting, comprehensive geriatric assessments have been shown to improve routine assessment. Molecular abnormalities provide the genomic footprint for the development of targeted therapies. The addition of new monoclonal antibodies to conventional treatments also demonstrated promising primary results. Ongoing clinical trials testing the activity of these new agents may reshape treatment strategies in the elderly patient population.
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Affiliation(s)
- Xavier Thomas
- a Hospices Civils de Lyon, Hematology Department , Lyon-Sud Hospital , Pierre Bénite , France
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Heiblig M, Elhamri M, Le Jeune C, Laude MC, Deloire A, Wattel E, Salles G, Thomas X. Acute myeloid leukemia in the elderly (age 70 yr or older): long-term survivors. Eur J Haematol 2016; 98:134-141. [DOI: 10.1111/ejh.12811] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Maël Heiblig
- Clinical Hematology; Hospices Civils de Lyon; Lyon-Sud Hospital; Pierre-Bénite France
| | | | - Caroline Le Jeune
- Clinical Hematology; Hospices Civils de Lyon; Lyon-Sud Hospital; Pierre-Bénite France
| | - Marie-Charlotte Laude
- Clinical Hematology; Hospices Civils de Lyon; Lyon-Sud Hospital; Pierre-Bénite France
| | | | - Eric Wattel
- Clinical Hematology; Hospices Civils de Lyon; Lyon-Sud Hospital; Pierre-Bénite France
| | - Gilles Salles
- Clinical Hematology; Hospices Civils de Lyon; Lyon-Sud Hospital; Pierre-Bénite France
| | - Xavier Thomas
- Clinical Hematology; Hospices Civils de Lyon; Lyon-Sud Hospital; Pierre-Bénite France
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Heiblig M, Le Jeune C, Elhamri M, Balsat M, Tigaud I, Plesa A, Barraco F, Labussière H, Ducastelle S, Nicolini F, Wattel E, Salles G, Thomas X. Treatment patterns and comparative effectiveness in elderly acute myeloid leukemia patients (age 70 years or older): the Lyon-university hospital experience. Leuk Lymphoma 2016; 58:110-117. [PMID: 27184036 DOI: 10.1080/10428194.2016.1180688] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The treatment of very elderly patients (≥70 years) with acute myeloid leukemia remains controversial. We present here 302 patients seen over a 14-year period in order to understand the real-world treatment patterns and outcomes in this patient population. Less than 25% of patients achieved a complete remission. The median overall survival was 12.4, 11.5 and 2.6 months, with a 3-year rates of 27%, 17% and 6%, for non-acute promyelocytic leukemia patients receiving intensive chemotherapy, lower-intensity therapy or best supportive care (BSC), respectively. In all ages, results were not significantly different among patients receiving low-intensity therapy and intensive chemotherapy, but significantly worse in those treated with BSC only. Similarly, intensive chemotherapy and low-intensity therapy gave better survival rates than BSC in patients with favorable- or intermediate-risk cytogenetics and in those with unfavorable cytogenetics (p < 0.0001 and p = 0.04, respectively).
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Affiliation(s)
- Maël Heiblig
- a Department of Hematology , Lyon-Sud Hospital, Hospices Civils de Lyon , Pierre Bénite , France
| | - Caroline Le Jeune
- a Department of Hematology , Lyon-Sud Hospital, Hospices Civils de Lyon , Pierre Bénite , France
| | - Mohamed Elhamri
- a Department of Hematology , Lyon-Sud Hospital, Hospices Civils de Lyon , Pierre Bénite , France
| | - Marie Balsat
- a Department of Hematology , Lyon-Sud Hospital, Hospices Civils de Lyon , Pierre Bénite , France
| | - Isabelle Tigaud
- b Laboratory of Cytogenetics , Lyon-Sud Hospital, Hospices Civils de Lyon , Pierre Bénite , France
| | - Adriana Plesa
- c Laboratory of Cytology and Immunology , Lyon-Sud Hospital, Hospices Civils de Lyon , Pierre Bénite , France
| | - Fiorenza Barraco
- a Department of Hematology , Lyon-Sud Hospital, Hospices Civils de Lyon , Pierre Bénite , France
| | - Hélène Labussière
- a Department of Hematology , Lyon-Sud Hospital, Hospices Civils de Lyon , Pierre Bénite , France
| | - Sophie Ducastelle
- a Department of Hematology , Lyon-Sud Hospital, Hospices Civils de Lyon , Pierre Bénite , France
| | - Franck Nicolini
- a Department of Hematology , Lyon-Sud Hospital, Hospices Civils de Lyon , Pierre Bénite , France
| | - Eric Wattel
- a Department of Hematology , Lyon-Sud Hospital, Hospices Civils de Lyon , Pierre Bénite , France
| | - Gilles Salles
- a Department of Hematology , Lyon-Sud Hospital, Hospices Civils de Lyon , Pierre Bénite , France
| | - Xavier Thomas
- a Department of Hematology , Lyon-Sud Hospital, Hospices Civils de Lyon , Pierre Bénite , France
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Fattoum J, Cannas G, Elhamri M, Tigaud I, Plesa A, Heiblig M, Plesa C, Wattel E, Thomas X. Effect of Age on Treatment Decision-Making in Elderly Patients With Acute Myeloid Leukemia. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2015; 15:477-83. [PMID: 25843415 DOI: 10.1016/j.clml.2015.02.022] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 02/19/2015] [Accepted: 02/26/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Patients aged ≥ 70 years with acute myeloid leukemia (AML) have a poorer prognosis than those aged 60 to 69 years. PATIENTS AND METHODS We retrospectively analyzed the cases of 183 patients aged ≥ 70 years with a performance status of ≤ 2 treated at our institution from 2000 to 2014. Treatment consisted of anthracycline- and cytarabine-based chemotherapy for 93 patients and lower intensity therapy with low-dose cytarabine or hypomethylating agent cycles for 90 patients. RESULTS A total of 57 patients (61%) achieved complete remission in the intensive chemotherapy group versus only 11 (12%) in the lower intensity treatment group (P < .0001). The median overall survival (OS) was 14.5 months and 11.7 months with a 3-year OS rate of 34% and 18% (P = .005) for the intensive and lower intensity groups, respectively. The difference remained significant when considering patients aged ≤ 75 years, but not for patients aged > 75 years. Similarly, a significant difference was only observed when considering favorable and intermediate cytogenetic factors (P = .007) but not unfavorable karyotypes. On multivariate analysis, age did not appear as an independent prognostic factor. CONCLUSION With intensive chemotherapy, the median OS significantly increased after the introduction of an improved supportive care policy compared with historical controls (14 vs. 5.4 months, with a 3-year OS rate of 33% vs. 8%). After 2006, a more "personalized" therapeutic approach tended to erase the difference in terms of OS, especially in patients aged > 75 years.
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Affiliation(s)
- Jihane Fattoum
- Department of Hematology, Lyon-Sud Hospital, Hospices Civils de Lyon, Pierre Bénite, France
| | - Giovanna Cannas
- Department of Hematology, Lyon-Sud Hospital, Hospices Civils de Lyon, Pierre Bénite, France
| | - Mohamed Elhamri
- Department of Hematology, Lyon-Sud Hospital, Hospices Civils de Lyon, Pierre Bénite, France
| | - Isabelle Tigaud
- Laboratory of Cytogenetics, Lyon-Sud Hospital, Hospices Civils de Lyon, Pierre Bénite, France
| | - Adriana Plesa
- Laboratory of Cytology and Immunology, Lyon-Sud Hospital, Hospices Civils de Lyon, Pierre Bénite, France
| | - Maël Heiblig
- Department of Hematology, Lyon-Sud Hospital, Hospices Civils de Lyon, Pierre Bénite, France
| | | | - Eric Wattel
- Department of Hematology, Lyon-Sud Hospital, Hospices Civils de Lyon, Pierre Bénite, France
| | - Xavier Thomas
- Department of Hematology, Lyon-Sud Hospital, Hospices Civils de Lyon, Pierre Bénite, France.
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Abstract
SUMMARY Acute myeloid leukemia in older patients is of poor outcome, characterized by a specific biology of acute myeloid leukemia and factors related to the patient’s physical condition. Aggressive therapy results in improved survival and quality of life when compared with palliative care. However, not all patients are candidates for such therapy. Disease often demonstrates resistance related to poor-risk cytogenetics, and patients are often unable to tolerate intensive chemotherapy. For those patients, novel agents are being investigated. Understanding of the disease biology, as well as the prognostic factors associated with the host, allows the better estimation of which patients are likely to benefit from standard therapy and which require alternative approaches.
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Affiliation(s)
- Xavier Thomas
- Hospices Civils de Lyon, Lyon-Sud Hospital, Hematology Department, Pavillon Marcel Bérard, Bat.1G, 69495 Pierre-Bénite, France
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Thomas X. DNA methyltransferase inhibitors in acute myeloid leukemia: discovery, design and first therapeutic experiences. Expert Opin Drug Discov 2012; 7:1039-51. [PMID: 22950862 DOI: 10.1517/17460441.2012.722618] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION DNA methylation is an epigenetic change mediated by DNA methyltranferases (DNMTs), which are promising epigenetic targets for the treatment of acute myeloid leukemia (AML). This is evidenced by the two DNMT inhibitors (azacitidine and decitabine) approved by the Food and Drug Administration of the United States for the treatment of high-risk myelodysplastic syndromes and the first clinical data available in AML. AREAS COVERED This paper reviews data from the international literature regarding the design, sites of impact and pharmacodynamic characteristics of DNMT inhibitors, and their first clinical experiences in AML. EXPERT OPINION The strongest advances in epigenetic therapy have been in the treatment of AML. There are now an increasing number of DNMT inhibitors. These agents may be potentially administered at different times of leukemia therapy: before or instead of chemotherapy, as maintenance therapy, prior to allogeneic stem cell transplant (SCT) or after relapse following SCT.
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Affiliation(s)
- Xavier Thomas
- Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Service d'Hématologie Clinique, Pierre Bénite, France.
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Leukocytosis and Circulating Blasts in Older Adults With Newly Diagnosed Acute Myeloid Leukemia: Are They Valuable Factors for Therapeutic Decision-Making? CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2011; 11:342-9. [DOI: 10.1016/j.clml.2011.06.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2010] [Revised: 12/06/2010] [Accepted: 01/20/2011] [Indexed: 11/23/2022]
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