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Wiśniewski K, Pruszczyk-Matusiak K, Puła B, Lech-Marańda E, Góra-Tybor J. Real-World Outcome and Prognostic Factors in MDS Patients Treated with Azacitidine-A Retrospective Analysis. Cancers (Basel) 2024; 16:1333. [PMID: 38611011 PMCID: PMC11011162 DOI: 10.3390/cancers16071333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 03/24/2024] [Accepted: 03/27/2024] [Indexed: 04/14/2024] Open
Abstract
Azacitidine (AZA) is recognized as a vital drug used in the therapy of myelodysplastic syndromes (MDS) due to its beneficial effect on survival and quality of life. Nevertheless, many patients fail to respond to AZA treatment, as prognostic factors still are not identified. The present retrospective analysis included 79 patients with MDS treated with AZA as first-line therapy in a real-life setting. The percentage of patients with good, intermediate, and poor cytogenetics was 46.8%, 11.4%, and 34.2%, respectively. The overall response rate (complete remission [CR], partial remission [PR], and hematological improvement [HI]) was 24%. The CR, PR, and HI rates were 13.9%, 2.5%, and 7.6%, respectively. Stable disease (SD) was documented in 40.5% of patients. The median overall survival (OS) and progression-free survival (PFS) were 17.6 and 14.96 months, respectively. Patients with ORR and SD had a significantly longer median OS (23.8 vs. 5.7 months, p = 0.0005) and PFS (19.8 vs. 3.5 months, p < 0.001) compared to patients who did not respond to AZA. In univariate analysis, only an unfavorable cytogenetic group was a prognostic factor of a lower response rate (p = 0.03). In a multivariate model, older age (p = 0.047), higher IPSS (International Prognostic Scoring System) risk (p = 0.014), and higher IPSS-R cytogenetic risk (p = 0.004) were independent factors of shorter OS. Independent prognostic factors for shorter PFS were age (p = 0.001), IPSS risk (p = 0.02), IPSS cytogenetic risk (p = 0.002), and serum ferritin level (p = 0.008). The safety profile of AZA was predictable and consistent with previous studies. In conclusion, our study confirms the efficacy and safety of AZA in a real-world population and identifies potential biomarkers for response and survival.
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Affiliation(s)
- Kamil Wiśniewski
- Department of Hematology, Institute of Hematology and Transfusion Medicine, 02-776 Warsaw, Poland (E.L.-M.)
| | | | - Bartosz Puła
- Department of Hematology, Institute of Hematology and Transfusion Medicine, 02-776 Warsaw, Poland (E.L.-M.)
| | - Ewa Lech-Marańda
- Department of Hematology, Institute of Hematology and Transfusion Medicine, 02-776 Warsaw, Poland (E.L.-M.)
| | - Joanna Góra-Tybor
- Department of Hematology, Medical University of Lodz, 93-513 Lodz, Poland
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Majid H, Masoom M, Bansal N, Ahmad W, Khan MF, Farooqui S, Bhurani D, Khan MA. Spectrum of infections in different regimens of post-induction chemotherapy in acute myeloid leukemia ( de-novo): A comparative retrospective study. Heliyon 2024; 10:e24561. [PMID: 38317981 PMCID: PMC10839883 DOI: 10.1016/j.heliyon.2024.e24561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 01/10/2024] [Accepted: 01/10/2024] [Indexed: 02/07/2024] Open
Abstract
Background Patients diagnosed with acute myeloid leukemia (AML) face a heightened susceptibility to infections, which significantly elevates their risk of mortality and disability. The intensity of the chemotherapy treatment and its specific focus on inhibiting myeloid cell divisions render patients especially vulnerable, particularly during the early stages of chemotherapy. This vulnerability is compounded by the occurrence of repeated episodes of prolonged neutropenia, leaving patients highly susceptible to infections. The compromised immune systems of these individuals make them more susceptible to infections, which adversely affect their physical health and overall well-being. Consequently, our study aimed to investigate the range of infections experienced by patients with newly diagnosed AML undergoing different induction chemotherapy. Methods This was a comparative retrospective study, conducted at a tertiary hospital providing comprehensive cancer care in North India. All newly diagnosed patients with AML, who received induction chemotherapy from January 1, 2012 to November 1, 2022, were identified from the hospital database and included in this study. Results Four hundred and twenty AML patients treated with either high-intensity or low-intensity induction chemotherapy was observed in this study. It was found that patients who received high-intensity treatment had a higher rate of clinically and microbiologically documented infections, fever without a known cause, and more cases of febrile neutropenia than those who got low-intensity treatment. These differences between the two groups were particularly evident on day 14 (p = 0.0002) and persisted through day 28 (p = 0.005). Conclusions These findings underscore the effectiveness and downside of high-intensity induction chemotherapy regimens, as evidenced by the higher incidence of infections observed. Further investigation through prospective clinical studies is warranted to better evaluate and validate the efficacy of this approach.
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Affiliation(s)
- Haya Majid
- Department of Translational & Clinical Research, School of Chemical and Life Sciences, Jamia Hamdard, New Delhi, 110062, India
| | - Md Masoom
- Department of Translational & Clinical Research, School of Chemical and Life Sciences, Jamia Hamdard, New Delhi, 110062, India
| | - Nitin Bansal
- Department of Haemato-Oncology & Bone Marrow Transplantation, Rajiv Gandhi Cancer Institute & Research Centre, Rohini, New Delhi, 110085, India
| | - Wasim Ahmad
- Department of Pharmacy, Mohammed Al-Mana College for Medical Sciences, Safaa, Dammam 34222, Saudi Arabia
| | - Mohd Faiyaz Khan
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia
| | - Sadaf Farooqui
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia
| | - Dinesh Bhurani
- Department of Haemato-Oncology & Bone Marrow Transplantation, Rajiv Gandhi Cancer Institute & Research Centre, Rohini, New Delhi, 110085, India
| | - Mohd Ashif Khan
- Department of Translational & Clinical Research, School of Chemical and Life Sciences, Jamia Hamdard, New Delhi, 110062, India
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Pleyer L, Vaisband M, Drost M, Pfeilstöcker M, Stauder R, Heibl S, Sill H, Girschikofsky M, Stampfl-Mattersberger M, Pichler A, Hartmann B, Petzer A, Schreder M, Schmitt CA, Vallet S, Melchardt T, Zebisch A, Pichler P, Zaborsky N, Machherndl-Spandl S, Wolf D, Keil F, Hasenauer J, Larcher-Senn J, Greil R. Cox proportional hazards deep neural network identifies peripheral blood complete remission to be at least equivalent to morphologic complete remission in predicting outcomes of patients treated with azacitidine-A prospective cohort study by the AGMT. Am J Hematol 2023; 98:1685-1698. [PMID: 37548390 DOI: 10.1002/ajh.27046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 07/07/2023] [Accepted: 07/16/2023] [Indexed: 08/08/2023]
Abstract
The current gold standard of response assessment in patients with myelodysplastic syndromes (MDS), chronic myelomonocytic leukemia (CMML), and acute myeloid leukemia (AML) is morphologic complete remission (CR) and CR with incomplete count recovery (CRi), both of which require an invasive BM evaluation. Outside of clinical trials, BM evaluations are only performed in ~50% of patients during follow-up, pinpointing a clinical need for response endpoints that do not necessitate BM assessments. We define and validate a new response type termed "peripheral blood complete remission" (PB-CR) that can be determined from the differential blood count and clinical parameters without necessitating a BM assessment. We compared the predictive value of PB-CR with morphologic CR/CRi in 1441 non-selected, consecutive patients diagnosed with MDS (n = 522; 36.2%), CMML (n = 132; 9.2%), or AML (n = 787; 54.6%), included within the Austrian Myeloid Registry (aMYELOIDr; NCT04438889). Time-to-event analyses were adjusted for 17 covariates remaining in the final Cox proportional hazards (CPH) model. DeepSurv, a CPH neural network model, and permutation-based feature importance were used to validate results. 1441 patients were included. Adjusted median overall survival for patients achieving PB-CR was 22.8 months (95%CI 18.9-26.2) versus 10.4 months (95%CI 9.7-11.2) for those who did not; HR = 0.366 (95%CI 0.303-0.441; p < .0001). Among patients achieving CR, those additionally achieving PB-CR had a median adjusted OS of 32.6 months (95%CI 26.2-49.2) versus 21.7 months (95%CI 16.9-27.7; HR = 0.400 [95%CI 0.190-0.844; p = .0161]) for those who did not. Our deep neural network analysis-based findings from a large, prospective cohort study indicate that BM evaluations solely for the purpose of identifying CR/CRi can be omitted.
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Affiliation(s)
- Lisa Pleyer
- Austrian Group of Medical Tumor Therapy (AGMT) Study Group, Vienna, Austria
- Salzburg Cancer Research Institute (SCRI) Center for Clinical Cancer and Immunology Trials (CCCIT), Salzburg, Austria
- Cancer Cluster Salzburg (CCS), Salzburg, Austria
- 3rd Medical Department with Hematology, Medical Oncology, Hemostaseology, Rheumatology and Infectiology, Oncologic Center, Paracelsus Medical University, Salzburg, Austria
| | - Marc Vaisband
- Salzburg Cancer Research Institute (SCRI) Center for Clinical Cancer and Immunology Trials (CCCIT), Salzburg, Austria
- Cancer Cluster Salzburg (CCS), Salzburg, Austria
- 3rd Medical Department with Hematology, Medical Oncology, Hemostaseology, Rheumatology and Infectiology, Oncologic Center, Paracelsus Medical University, Salzburg, Austria
- Life & Medical Sciences Institute, University of Bonn, Bonn, Germany
| | - Manuel Drost
- Assign Data Management and Biostatistics GmbH, Innsbruck, Austria
| | - Michael Pfeilstöcker
- Austrian Group of Medical Tumor Therapy (AGMT) Study Group, Vienna, Austria
- 3rd Medical Department for Hematology and Oncology, Hanusch Hospital, Vienna, Austria
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University Vienna, Vienna, Austria
| | - Reinhard Stauder
- Austrian Group of Medical Tumor Therapy (AGMT) Study Group, Vienna, Austria
- Department of Hematology and Oncology, Comprehensive Cancer Center Innsbruck (CCCI), Medical University of Innsbruck (MUI), Innsbruck, Austria
| | - Sonja Heibl
- Austrian Group of Medical Tumor Therapy (AGMT) Study Group, Vienna, Austria
- 4th Medical Department of Internal Medicine, Hematology, Internistic Oncology and Palliative Medicine, Klinikum Wels-Grieskirchen GmbH, Wels, Austria
| | - Heinz Sill
- Austrian Group of Medical Tumor Therapy (AGMT) Study Group, Vienna, Austria
- Division of Hematology, Medical University of Graz, Graz, Austria
| | - Michael Girschikofsky
- Austrian Group of Medical Tumor Therapy (AGMT) Study Group, Vienna, Austria
- 1st Medical Department, Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Ordensklinikum Linz GmbH Elisabethinen, Linz, Austria
| | - Margarete Stampfl-Mattersberger
- Austrian Group of Medical Tumor Therapy (AGMT) Study Group, Vienna, Austria
- Department of Internal Medicine 2, Wiener Gesundheitsverbund, Klinik Donaustadt, Vienna, Austria
| | - Angelika Pichler
- Austrian Group of Medical Tumor Therapy (AGMT) Study Group, Vienna, Austria
- Department of Internal Medicine, Hematology and Internal Oncology, LKH Hochsteiermark, Leoben, Austria
| | - Bernd Hartmann
- Austrian Group of Medical Tumor Therapy (AGMT) Study Group, Vienna, Austria
- Department of Internal Medicine 2, Landeskrankenhaus Feldkirch, Feldkirch, Austria
| | - Andreas Petzer
- Austrian Group of Medical Tumor Therapy (AGMT) Study Group, Vienna, Austria
- Internal Medicine I: Medical Oncology and Hematology, Ordensklinikum Linz GmbH, Barmherzige Schwestern, Linz, Austria
| | - Martin Schreder
- Austrian Group of Medical Tumor Therapy (AGMT) Study Group, Vienna, Austria
- 1st Department of Internal Medicine, Center for Oncology and Hematology, Wiener Gesundheitsverbund, Klinik Ottakring, Vienna, Austria
| | - Clemens A Schmitt
- Austrian Group of Medical Tumor Therapy (AGMT) Study Group, Vienna, Austria
- Department of Hematology and Internal Oncology, Kepler University Hospital, Johannes Kepler University, Linz, Austria
- Charité-University Medical Center, Molecular Cancer Research Center, Berlin, Germany
| | - Sonia Vallet
- Austrian Group of Medical Tumor Therapy (AGMT) Study Group, Vienna, Austria
- University Hospital Krems, Department of Internal Medicine 2, Karl Landsteiner Private University of Health Sciences, Krems, Austria
| | - Thomas Melchardt
- Austrian Group of Medical Tumor Therapy (AGMT) Study Group, Vienna, Austria
- Salzburg Cancer Research Institute (SCRI) Center for Clinical Cancer and Immunology Trials (CCCIT), Salzburg, Austria
- Cancer Cluster Salzburg (CCS), Salzburg, Austria
- 3rd Medical Department with Hematology, Medical Oncology, Hemostaseology, Rheumatology and Infectiology, Oncologic Center, Paracelsus Medical University, Salzburg, Austria
| | - Armin Zebisch
- Austrian Group of Medical Tumor Therapy (AGMT) Study Group, Vienna, Austria
- Division of Hematology, Medical University of Graz, Graz, Austria
- Otto Loewi Research Center for Vascular Biology, Immunology and Inflammation, Division of Pharmacology, Medical University of Graz, Graz, Austria
| | - Petra Pichler
- Austrian Group of Medical Tumor Therapy (AGMT) Study Group, Vienna, Austria
- Clinical Department for Internal Medicine, University Hospital St Poelten, Karl Landsteiner University of Health Sciences, St Poelten, Austria
| | - Nadja Zaborsky
- Salzburg Cancer Research Institute (SCRI) Center for Clinical Cancer and Immunology Trials (CCCIT), Salzburg, Austria
- Cancer Cluster Salzburg (CCS), Salzburg, Austria
- 3rd Medical Department with Hematology, Medical Oncology, Hemostaseology, Rheumatology and Infectiology, Oncologic Center, Paracelsus Medical University, Salzburg, Austria
- Laboratory of Immunological and Molecular Cancer Research (LIMCR), Salzburg, Austria
| | - Sigrid Machherndl-Spandl
- Austrian Group of Medical Tumor Therapy (AGMT) Study Group, Vienna, Austria
- 1st Medical Department, Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Ordensklinikum Linz GmbH Elisabethinen, Linz, Austria
| | - Dominik Wolf
- Austrian Group of Medical Tumor Therapy (AGMT) Study Group, Vienna, Austria
- Department of Hematology and Oncology, Comprehensive Cancer Center Innsbruck (CCCI), Medical University of Innsbruck (MUI), Innsbruck, Austria
| | - Felix Keil
- Austrian Group of Medical Tumor Therapy (AGMT) Study Group, Vienna, Austria
- 3rd Medical Department for Hematology and Oncology, Hanusch Hospital, Vienna, Austria
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University Vienna, Vienna, Austria
| | - Jan Hasenauer
- Life & Medical Sciences Institute, University of Bonn, Bonn, Germany
| | | | - Richard Greil
- Austrian Group of Medical Tumor Therapy (AGMT) Study Group, Vienna, Austria
- Salzburg Cancer Research Institute (SCRI) Center for Clinical Cancer and Immunology Trials (CCCIT), Salzburg, Austria
- Cancer Cluster Salzburg (CCS), Salzburg, Austria
- 3rd Medical Department with Hematology, Medical Oncology, Hemostaseology, Rheumatology and Infectiology, Oncologic Center, Paracelsus Medical University, Salzburg, Austria
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Yamaoka K, Fujiwara M, Uchida M, Uesawa Y, Muroi N, Shimizu T. Adverse Event Profile of Azacitidine: Analysis by Route of Administration Using Japanese Pharmacovigilance Database. Oncology 2023; 101:664-674. [PMID: 37279701 DOI: 10.1159/000531390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 05/17/2023] [Indexed: 06/08/2023]
Abstract
INTRODUCTION Azacitidine is a useful drug for myelodysplastic syndromes and acute myeloid leukemia. In clinical trials, hematologic toxicity and infection have been observed as adverse events (AEs) of this drug. However, information on the time to onset of high risk AEs and subsequent outcomes, as well as differences in the frequency of AEs due to the route of administration is lacking. In this study, we investigated azacitidine-induced AEs comprehensively using the Japanese Adverse Event Reporting Database (JADER) published by the Pharmaceuticals and Medical Devices Agency, with disproportionate analysis of AE incidence trends, time to onset, and subsequent outcomes. In addition, we analyzed the differences in AEs by route of administration and the number of days until the occurrence of AEs and generated hypotheses. METHODS The study used JADER data reported from April 2004 to June 2022. Risk estimation was conducted using reported odds ratio. A signal was detected when the lower limit of the 95% confidence interval of the calculated ROR was ≥1. RESULTS A total of 34 signals were detected as AEs due to azacitidine. Among them, 15 were hematologic toxicities and 10 were infections, which demonstrated a particularly high rate of death. Signals of AEs such as tumor lysis syndrome (TLS) and cardiac failure, which have been described in case reports, were also detected, and the rate of death after onset was high. In addition, more AEs generally occurred within the first month of treatment. CONCLUSION The results of this study suggest that more attention should be paid to cardiac failure, hematologic toxicity, infection, and TLS. Because many patients in clinical trials have discontinued treatment due to serious AEs before the therapeutic effect became apparent, appropriate supportive care, dose reduction, and drug withdrawal are important for the continuation of treatment.
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Affiliation(s)
- Kenta Yamaoka
- Department of Pharmacy, Kobe City Medical Center General Hospital, Kobe, Japan
- School of Pharmacy, Hyogo Medical University, Kobe, Japan
| | - Masaki Fujiwara
- Department of Pharmacy, Kobe City Medical Center General Hospital, Kobe, Japan
- School of Pharmacy, Hyogo Medical University, Kobe, Japan
| | - Mayako Uchida
- Department of Education and Research Center for Pharmacy Practice, Faculty of Pharmaceutical Sciences, Doshisha Women's College of Liberal Arts, Kyotanabe, Japan
| | - Yoshihiro Uesawa
- Department of Medical Molecular Informatics, Meiji Pharmaceutical University, Tokyo, Japan
| | - Nobuyuki Muroi
- Department of Pharmacy, Kobe City Medical Center General Hospital, Kobe, Japan
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Neuendorff NR, Gagelmann N, Singhal S, Meckstroth S, Thibaud V, Zhao Y, Mir N, Shih YY, Amaro DMC, Roy M, Lombardo J, Gjærde LK, Loh KP. Hypomethylating agent-based therapies in older adults with acute myeloid leukemia - A joint review by the Young International Society of Geriatric Oncology and European Society for Blood and Marrow Transplantation Trainee Committee. J Geriatr Oncol 2023; 14:101406. [PMID: 36435726 PMCID: PMC10106360 DOI: 10.1016/j.jgo.2022.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 10/23/2022] [Accepted: 11/17/2022] [Indexed: 11/25/2022]
Abstract
Acute myeloid leukemia (AML) is associated with poor outcomes in older adults. A major goal of treatment is to balance quality of life and functional independence with disease control. With the approval of new, more tolerable regimens, more older adults are able to receive AML-directed therapy. Among these options are hypomethylating agents (HMAs), specifically azacitidine and decitabine. HMAs have become an integral part of AML therapy over the last two decades. These agents are used either as monotherapy or nowadays more commonly in combination with other agents such as the Bcl-2 inhibitor venetoclax. Biological AML characteristics, such as molecular and cytogenetic risk factors, play crucial roles in guiding treatment decisions. In patients with high-risk AML, HMAs are increasingly used rather than intensive chemotherapy, although further trials based on a risk-adapted approach using patient- and disease-related factors are needed. Here, we review trials and evidence for the use of HMA monotherapy and combination therapy in the management of older adults with AML. Furthermore, we discuss the use of HMAs and HMA combination therapies in AML, mechanisms of action, their incorporation into hematopoietic stem cell transplantation strategies, and their use in patients with comorbidities and reduced organ function.
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Affiliation(s)
- Nina Rosa Neuendorff
- Clinic for Hematology and Stem-Cell Transplantation, University Hospital Essen, Hufelandstrasse 55, D-45147 Essen, Germany.
| | - Nico Gagelmann
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Surbhi Singhal
- Division of Hematology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Shelby Meckstroth
- Louisiana State University Health Sciences Center, School of Medicine, New Orleans, LA, USA
| | - Vincent Thibaud
- Department of Hematology, Hôpital Saint-Vincent, Université Catholique de Lille, 59000 Lille, France
| | - Yue Zhao
- Department of General, Visceral, Cancer and Transplantation Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Nabiel Mir
- Section of Geriatrics and Palliative Medicine, The University of Chicago Medical Center, Chicago, USA
| | - Yung-Yu Shih
- Department of Hematology and Oncology, Clinic Favoriten Vienna, Austria
| | - Danielle M C Amaro
- Department of Oncology and Hematology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Mukul Roy
- Department of Radiation Oncology, Jaslok Hospital, Mumbai, India
| | - Joseph Lombardo
- Department of Radiation Oncology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Lars Klingen Gjærde
- Department of Hematology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Kah Poh Loh
- Division of Hematology/Oncology, Department of Medicine, James P. Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, USA
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Moreno Vanegas Y, Badar T. Clinical Utility of Azacitidine in the Management of Acute Myeloid Leukemia: Update on Patient Selection and Reported Outcomes. Cancer Manag Res 2022; 14:3527-3538. [PMID: 36583031 PMCID: PMC9793740 DOI: 10.2147/cmar.s271442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 11/23/2022] [Indexed: 12/25/2022] Open
Abstract
Acute myeloid leukemia (AML) is predominantly a disease of the elderly, and a significant proportion of these patients are not candidates for intensive, curative-intent therapies. Epigenetic dysregulation resulting in abnormal DNA hypermethylation is one of the hallmarks of AML pathogenesis. For the past two decades, hypomethylating agents including azacitidine (AZA) have been the mainstay of treatment for AML patients who are ineligible to receive intensive chemotherapies. As our understanding of AML disease biology has improved, several novel treatment combinations have been developed to improve the outcome of AML patients, with remarkable success. A considerable proportion of these novel combinations have utilized AZA as the backbone of their treatment scheme. In this review, we have highlighted the evolution of AML treatment, focusing on novel AZA-based treatment combinations and their clinical efficacy.
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Affiliation(s)
- Yenny Moreno Vanegas
- Division of Hematology-Oncology and Blood and Marrow Transplantation and Cellular Therapy Program, Mayo Clinic, Jacksonville, FL, USA
| | - Talha Badar
- Division of Hematology-Oncology and Blood and Marrow Transplantation and Cellular Therapy Program, Mayo Clinic, Jacksonville, FL, USA,Correspondence: Talha Badar, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA, Email
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7
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Leisch M, Pfeilstöcker M, Stauder R, Heibl S, Sill H, Girschikofsky M, Stampfl-Mattersberger M, Tinchon C, Hartmann B, Petzer A, Schreder M, Kiesl D, Vallet S, Egle A, Melchardt T, Piringer G, Zebisch A, Machherndl-Spandl S, Wolf D, Keil F, Drost M, Greil R, Pleyer L. Adverse Events in 1406 Patients Receiving 13,780 Cycles of Azacitidine within the Austrian Registry of Hypomethylating Agents-A Prospective Cohort Study of the AGMT Study-Group. Cancers (Basel) 2022; 14:cancers14102459. [PMID: 35626063 PMCID: PMC9140081 DOI: 10.3390/cancers14102459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 04/27/2022] [Accepted: 05/05/2022] [Indexed: 11/16/2022] Open
Abstract
Simple Summary Azacitidine is thus far the only drug shown to prolong overall survival and is, therefore, the recommended (backbone) treatment in patients diagnosed with myelodysplastic syndromes, chronic myelomonocytic leukemia and acute myeloid leukemia who are not eligible for intensive chemotherapy. Detailed reports on adverse events are often lacking. We performed a thorough analysis of the adverse events that occur during treatment with azacitidine in the largest cohort of patients treated with this drug published so far. We also compared the frequency of adverse events documented in our cohort to published data from randomized clinical trials with an azacitidine monotherapy arm. Adverse event documentation in the Austrian Registry was high. Hematologic adverse events occurred at a similar rate compared to published trials, whereas gastrointestinal toxicities were significantly less commonly reported. Our data complement results from clinical trials with real-world evidence and form a reference for future combination strategies with azacitidine. Abstract Background: Azacitidine is the treatment backbone for patients with acute myeloid leukemia, myelodysplastic syndromes and chronic myelomonocytic leukemia who are considered unfit for intensive chemotherapy. Detailed reports on adverse events in a real-world setting are lacking. Aims: To analyze the frequency of adverse events in the Austrian Registry of Hypomethylating agents. To compare real-world data with that of published randomized clinical trials. Results: A total of 1406 patients uniformly treated with a total of 13,780 cycles of azacitidine were analyzed. Hematologic adverse events were the most common adverse events (grade 3–4 anemia 43.4%, grade 3–4 thrombopenia 36.8%, grade 3–4 neutropenia 36.1%). Grade 3–4 anemia was significantly more common in the Registry compared to published trials. Febrile neutropenia occurred in 33.4% of patients and was also more common in the Registry than in published reports. Other commonly reported adverse events included fatigue (33.4%), pain (29.2%), pyrexia (23.5%), and injection site reactions (23.2%). Treatment termination due to an adverse event was rare (5.1%). Conclusion: The safety profile of azacitidine in clinical trials is reproducible in a real-world setting. With the use of prophylactic and concomitant medications, adverse events can be mitigated and azacitidine can be safely administered to almost all patients with few treatment discontinuations.
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Affiliation(s)
- Michael Leisch
- 3rd Medical Department with Hematology, Medical Oncology, Rheumatology and Infectiology, Paracelsus Medical University, 5020 Salzburg, Austria; (M.L.); (A.E.); (T.M.); (R.G.)
- Salzburg Cancer Research Institute (SCRI) Center for Clinical Cancer and Immunology Trials (CCCIT), Cancer Cluster Salzburg (CCS), 5020 Salzburg, Austria
- Austrian Group of Medical Tumor Therapy (AGMT) Study Group, 1140 Vienna, Austria; (M.P.); (R.S.); (S.H.); (H.S.); (M.G.); (M.S.-M.); (C.T.); (B.H.); (A.P.); (M.S.); (D.K.); (S.V.); (G.P.); (A.Z.); (S.M.-S.); (D.W.); (F.K.)
| | - Michael Pfeilstöcker
- Austrian Group of Medical Tumor Therapy (AGMT) Study Group, 1140 Vienna, Austria; (M.P.); (R.S.); (S.H.); (H.S.); (M.G.); (M.S.-M.); (C.T.); (B.H.); (A.P.); (M.S.); (D.K.); (S.V.); (G.P.); (A.Z.); (S.M.-S.); (D.W.); (F.K.)
- 3rd Medical Department for Haematology and Oncology, Hanusch Hospital, 1140 Vienna, Austria
| | - Reinhard Stauder
- Austrian Group of Medical Tumor Therapy (AGMT) Study Group, 1140 Vienna, Austria; (M.P.); (R.S.); (S.H.); (H.S.); (M.G.); (M.S.-M.); (C.T.); (B.H.); (A.P.); (M.S.); (D.K.); (S.V.); (G.P.); (A.Z.); (S.M.-S.); (D.W.); (F.K.)
- Department of Internal Medicine V, Innsbruck Medical University, 6020 Innsbruck, Austria
| | - Sonja Heibl
- Austrian Group of Medical Tumor Therapy (AGMT) Study Group, 1140 Vienna, Austria; (M.P.); (R.S.); (S.H.); (H.S.); (M.G.); (M.S.-M.); (C.T.); (B.H.); (A.P.); (M.S.); (D.K.); (S.V.); (G.P.); (A.Z.); (S.M.-S.); (D.W.); (F.K.)
- 4th Medical Department of Internal Medicine, Hematology, Internistic Oncology and Palliative Medicine, Klinikum Wels-Grieskirchen GmbH, 4600 Wels, Austria
| | - Heinz Sill
- Austrian Group of Medical Tumor Therapy (AGMT) Study Group, 1140 Vienna, Austria; (M.P.); (R.S.); (S.H.); (H.S.); (M.G.); (M.S.-M.); (C.T.); (B.H.); (A.P.); (M.S.); (D.K.); (S.V.); (G.P.); (A.Z.); (S.M.-S.); (D.W.); (F.K.)
- Division of Hematology, Medical University of Graz, 8036 Graz, Austria
| | - Michael Girschikofsky
- Austrian Group of Medical Tumor Therapy (AGMT) Study Group, 1140 Vienna, Austria; (M.P.); (R.S.); (S.H.); (H.S.); (M.G.); (M.S.-M.); (C.T.); (B.H.); (A.P.); (M.S.); (D.K.); (S.V.); (G.P.); (A.Z.); (S.M.-S.); (D.W.); (F.K.)
- 1st Medical Department, Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Ordensklinikum Linz GmbH Elisabethinen, 4020 Linz, Austria
| | - Margarete Stampfl-Mattersberger
- Austrian Group of Medical Tumor Therapy (AGMT) Study Group, 1140 Vienna, Austria; (M.P.); (R.S.); (S.H.); (H.S.); (M.G.); (M.S.-M.); (C.T.); (B.H.); (A.P.); (M.S.); (D.K.); (S.V.); (G.P.); (A.Z.); (S.M.-S.); (D.W.); (F.K.)
- Department of Internal Medicine 2, Klinik Donaustadt, 1220 Vienna, Austria
| | - Christoph Tinchon
- Austrian Group of Medical Tumor Therapy (AGMT) Study Group, 1140 Vienna, Austria; (M.P.); (R.S.); (S.H.); (H.S.); (M.G.); (M.S.-M.); (C.T.); (B.H.); (A.P.); (M.S.); (D.K.); (S.V.); (G.P.); (A.Z.); (S.M.-S.); (D.W.); (F.K.)
- Department for Hemato-Oncology, LKH Hochsteiermark, 8700 Leoben, Austria
| | - Bernd Hartmann
- Austrian Group of Medical Tumor Therapy (AGMT) Study Group, 1140 Vienna, Austria; (M.P.); (R.S.); (S.H.); (H.S.); (M.G.); (M.S.-M.); (C.T.); (B.H.); (A.P.); (M.S.); (D.K.); (S.V.); (G.P.); (A.Z.); (S.M.-S.); (D.W.); (F.K.)
- Department of Internal Medicine, Landeskrankenhaus Feldkirch, 6800 Feldkirch, Austria
| | - Andreas Petzer
- Austrian Group of Medical Tumor Therapy (AGMT) Study Group, 1140 Vienna, Austria; (M.P.); (R.S.); (S.H.); (H.S.); (M.G.); (M.S.-M.); (C.T.); (B.H.); (A.P.); (M.S.); (D.K.); (S.V.); (G.P.); (A.Z.); (S.M.-S.); (D.W.); (F.K.)
- Medical Oncology and Hematology, Internal Medicine I, Ordensklinikum Linz GmbH Barmherzige Schwestern, 4020 Linz, Austria
| | - Martin Schreder
- Austrian Group of Medical Tumor Therapy (AGMT) Study Group, 1140 Vienna, Austria; (M.P.); (R.S.); (S.H.); (H.S.); (M.G.); (M.S.-M.); (C.T.); (B.H.); (A.P.); (M.S.); (D.K.); (S.V.); (G.P.); (A.Z.); (S.M.-S.); (D.W.); (F.K.)
- 1st Department of Internal Medicine, Center for Oncology and Hematology, Klinik Ottakring, 1160 Vienna, Austria
| | - David Kiesl
- Austrian Group of Medical Tumor Therapy (AGMT) Study Group, 1140 Vienna, Austria; (M.P.); (R.S.); (S.H.); (H.S.); (M.G.); (M.S.-M.); (C.T.); (B.H.); (A.P.); (M.S.); (D.K.); (S.V.); (G.P.); (A.Z.); (S.M.-S.); (D.W.); (F.K.)
- Department of Hematology and Medical Oncology, Kepleruniversitätsklinikum, 4020 Linz, Austria
| | - Sonia Vallet
- Austrian Group of Medical Tumor Therapy (AGMT) Study Group, 1140 Vienna, Austria; (M.P.); (R.S.); (S.H.); (H.S.); (M.G.); (M.S.-M.); (C.T.); (B.H.); (A.P.); (M.S.); (D.K.); (S.V.); (G.P.); (A.Z.); (S.M.-S.); (D.W.); (F.K.)
- Department of Internal Medicine 2, University Hospital Krems, Karl Landsteiner Private University of Health Sciences, 3500 Krems, Austria
| | - Alexander Egle
- 3rd Medical Department with Hematology, Medical Oncology, Rheumatology and Infectiology, Paracelsus Medical University, 5020 Salzburg, Austria; (M.L.); (A.E.); (T.M.); (R.G.)
- Salzburg Cancer Research Institute (SCRI) Center for Clinical Cancer and Immunology Trials (CCCIT), Cancer Cluster Salzburg (CCS), 5020 Salzburg, Austria
- Austrian Group of Medical Tumor Therapy (AGMT) Study Group, 1140 Vienna, Austria; (M.P.); (R.S.); (S.H.); (H.S.); (M.G.); (M.S.-M.); (C.T.); (B.H.); (A.P.); (M.S.); (D.K.); (S.V.); (G.P.); (A.Z.); (S.M.-S.); (D.W.); (F.K.)
| | - Thomas Melchardt
- 3rd Medical Department with Hematology, Medical Oncology, Rheumatology and Infectiology, Paracelsus Medical University, 5020 Salzburg, Austria; (M.L.); (A.E.); (T.M.); (R.G.)
- Salzburg Cancer Research Institute (SCRI) Center for Clinical Cancer and Immunology Trials (CCCIT), Cancer Cluster Salzburg (CCS), 5020 Salzburg, Austria
- Austrian Group of Medical Tumor Therapy (AGMT) Study Group, 1140 Vienna, Austria; (M.P.); (R.S.); (S.H.); (H.S.); (M.G.); (M.S.-M.); (C.T.); (B.H.); (A.P.); (M.S.); (D.K.); (S.V.); (G.P.); (A.Z.); (S.M.-S.); (D.W.); (F.K.)
| | - Gudrun Piringer
- Austrian Group of Medical Tumor Therapy (AGMT) Study Group, 1140 Vienna, Austria; (M.P.); (R.S.); (S.H.); (H.S.); (M.G.); (M.S.-M.); (C.T.); (B.H.); (A.P.); (M.S.); (D.K.); (S.V.); (G.P.); (A.Z.); (S.M.-S.); (D.W.); (F.K.)
- 4th Medical Department of Internal Medicine, Hematology, Internistic Oncology and Palliative Medicine, Klinikum Wels-Grieskirchen GmbH, 4600 Wels, Austria
| | - Armin Zebisch
- Austrian Group of Medical Tumor Therapy (AGMT) Study Group, 1140 Vienna, Austria; (M.P.); (R.S.); (S.H.); (H.S.); (M.G.); (M.S.-M.); (C.T.); (B.H.); (A.P.); (M.S.); (D.K.); (S.V.); (G.P.); (A.Z.); (S.M.-S.); (D.W.); (F.K.)
- Division of Hematology, Medical University of Graz, 8036 Graz, Austria
- Otto Loewi Research Center for Vascular Biology, Immunology and Inflammation, Division of Pharmacology, Medical University of Graz, 8036 Graz, Austria
| | - Sigrid Machherndl-Spandl
- Austrian Group of Medical Tumor Therapy (AGMT) Study Group, 1140 Vienna, Austria; (M.P.); (R.S.); (S.H.); (H.S.); (M.G.); (M.S.-M.); (C.T.); (B.H.); (A.P.); (M.S.); (D.K.); (S.V.); (G.P.); (A.Z.); (S.M.-S.); (D.W.); (F.K.)
- 1st Medical Department, Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Ordensklinikum Linz GmbH Elisabethinen, 4020 Linz, Austria
| | - Dominik Wolf
- Austrian Group of Medical Tumor Therapy (AGMT) Study Group, 1140 Vienna, Austria; (M.P.); (R.S.); (S.H.); (H.S.); (M.G.); (M.S.-M.); (C.T.); (B.H.); (A.P.); (M.S.); (D.K.); (S.V.); (G.P.); (A.Z.); (S.M.-S.); (D.W.); (F.K.)
- Department of Internal Medicine V, Innsbruck Medical University, 6020 Innsbruck, Austria
| | - Felix Keil
- Austrian Group of Medical Tumor Therapy (AGMT) Study Group, 1140 Vienna, Austria; (M.P.); (R.S.); (S.H.); (H.S.); (M.G.); (M.S.-M.); (C.T.); (B.H.); (A.P.); (M.S.); (D.K.); (S.V.); (G.P.); (A.Z.); (S.M.-S.); (D.W.); (F.K.)
- 3rd Medical Department for Haematology and Oncology, Hanusch Hospital, 1140 Vienna, Austria
| | - Manuel Drost
- Assign Data Management and Biostatistics GmbH, 6020 Innsbruck, Austria;
| | - Richard Greil
- 3rd Medical Department with Hematology, Medical Oncology, Rheumatology and Infectiology, Paracelsus Medical University, 5020 Salzburg, Austria; (M.L.); (A.E.); (T.M.); (R.G.)
- Salzburg Cancer Research Institute (SCRI) Center for Clinical Cancer and Immunology Trials (CCCIT), Cancer Cluster Salzburg (CCS), 5020 Salzburg, Austria
- Austrian Group of Medical Tumor Therapy (AGMT) Study Group, 1140 Vienna, Austria; (M.P.); (R.S.); (S.H.); (H.S.); (M.G.); (M.S.-M.); (C.T.); (B.H.); (A.P.); (M.S.); (D.K.); (S.V.); (G.P.); (A.Z.); (S.M.-S.); (D.W.); (F.K.)
| | - Lisa Pleyer
- 3rd Medical Department with Hematology, Medical Oncology, Rheumatology and Infectiology, Paracelsus Medical University, 5020 Salzburg, Austria; (M.L.); (A.E.); (T.M.); (R.G.)
- Salzburg Cancer Research Institute (SCRI) Center for Clinical Cancer and Immunology Trials (CCCIT), Cancer Cluster Salzburg (CCS), 5020 Salzburg, Austria
- Austrian Group of Medical Tumor Therapy (AGMT) Study Group, 1140 Vienna, Austria; (M.P.); (R.S.); (S.H.); (H.S.); (M.G.); (M.S.-M.); (C.T.); (B.H.); (A.P.); (M.S.); (D.K.); (S.V.); (G.P.); (A.Z.); (S.M.-S.); (D.W.); (F.K.)
- Correspondence:
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Mądry K, Lis K, Tukiendorf A, Szwedyk P, Kapelko-Słowik K, Subocz E, Gołos A, Makowska W, Masternak A, Kopińska A, Czemerska M, Zawadzka-Leska S, Rusicka P, Drozd-Sokołowska J, Wiater E, Hołojda J, Pogłódek B, Centkowski P, Waszczuk-Gajda A, Machowicz R, Hałka J, Czerw T, Basak G, Dwilewicz-Trojaczek J. Low serum albumin level deteriorates prognosis in azacitidine-treated myelodysplastic syndromes patients - results of the PALG study 'PolAZA'. ACTA ACUST UNITED AC 2021; 26:556-564. [PMID: 34384334 DOI: 10.1080/16078454.2021.1956182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Azacitidine (AZA) is the standard of care for higher-risk myelodysplastic syndrome (HR-MDS) patients ineligible for intensive therapy. Clinical outcome discrepancies reported in clinical trials and real-life settings stimulate the search for new prognostic factors. METHODS We retrospectively evaluated 315 MDS, 20-30% blast acute myeloid leukemia (AML) and chronic myelomonocytic leukemia (CMML) patients treated with azacitidine in 12 centers cooperating within the Polish Adult Leukemia Group (PALG). RESULTS The median number of AZA cycles was 7 (1-69) and 24% patients received fewer than 4 cycles (early failure, EF). Serum albumin level was an independent predictor of EF occurrence. Complete remission (CR) was obtained in 20% and partial remission (PR) in 12% of patients. Hematologic improvement - erythroid (HI-E), neutrophil (HI-N), or platelet (HI-P) was achieved in 51%, 36%, and 48% of patients, respectively. No factors significantly predicted CR or PR in the multivariate analysis. For HI-E and HI-P, lower LDH level predicted response. Median survival was 15 (13-19) months. Lower serum albumin level, serious infection and receiving <4 AZA cycles independently predicted a worse overall survival (OS) (p < 0.05). CONCLUSION Serum albumin assessment before azacitidine treatment can help to identify patients with higher risk of early failure and worse clinical outcome.
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Affiliation(s)
- Krzysztof Mądry
- Department of Hematology, Oncology and Internal Diseases, Medical University, Warsaw, Poland
| | - Karol Lis
- Department of Hematology, Oncology and Internal Diseases, Medical University, Warsaw, Poland
| | - Andrzej Tukiendorf
- Department of Public Health, Wrocław Medical University, Wrocław, Poland
| | - Paweł Szwedyk
- Department of Hematology, Voivodal Specialist Hospital, Kraków, Poland
| | - Katarzyna Kapelko-Słowik
- Department of Hematology, Blood Neoplasms and Bone Marrow Transplantation, University Hospital, Wrocław, Poland
| | - Edyta Subocz
- Department of Hematology, Warmian-Masurian Cancer Center of the Ministry of the Interior and Administration's Hospital, Olsztyn, Poland
| | - Aleksandra Gołos
- Department of Hematology, Institute of Hematology and Blood Transfusion, Warsaw, Poland
| | - Wioletta Makowska
- Department of Hematology, Institute of Hematology and Blood Transfusion, Warsaw, Poland
| | - Anna Masternak
- Department of Hematology and Hematooncology, District Specialist Hospital, Opole, Poland
| | - Anna Kopińska
- Department of Hematology and Bone Marrow Transplantation, Medical University of Silesia, Katowice, Poland
| | | | - Sara Zawadzka-Leska
- Department of Hematology, Oncology and Internal Diseases, Medical University, Warsaw, Poland
| | - Patrycja Rusicka
- Department of Hematology, Oncology and Internal Diseases, Medical University, Warsaw, Poland
| | - Joanna Drozd-Sokołowska
- Department of Hematology, Oncology and Internal Diseases, Medical University, Warsaw, Poland
| | - Elżbieta Wiater
- Department of Hematology, District Hospital in Toruń, Toruń, Poland
| | - Jadwiga Hołojda
- Department of Hematology, District Specialist Hospital in Legnica, Legnica, Poland
| | | | - Piotr Centkowski
- Department of Hematology, District Specialist Hospital in Biała Podlaska, Biała Podlaska, Poland
| | - Anna Waszczuk-Gajda
- Department of Hematology, Oncology and Internal Diseases, Medical University, Warsaw, Poland
| | - Rafał Machowicz
- Department of Hematology, Oncology and Internal Diseases, Medical University, Warsaw, Poland
| | - Janusz Hałka
- Department of Hematology, Warmian-Masurian Cancer Center of the Ministry of the Interior and Administration's Hospital, Olsztyn, Poland
| | - Tomasz Czerw
- Department of Bone Marrow Transplantation and Oncohematology, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Warszawa, Poland
| | - Grzegorz Basak
- Department of Hematology, Oncology and Internal Diseases, Medical University, Warsaw, Poland
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10
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Abstract
Despite the success of the combination of venetoclax with the hypomethylating agents (HMA) decitabine or azacitidine in inducing remission in older, previously untreated patients with acute myeloid leukemia (AML), resistance - primary or secondary - still constitutes a significant roadblock in the quest to prolong the duration of response. Here we review the proposed and proven mechanisms of resistance to venetoclax monotherapy, HMA monotherapy, and the doublet of venetoclax and HMA for the treatment of AML. We approach the mechanisms of resistance to HMAs and venetoclax in the light of the agents' mechanisms of action. We briefly describe potential therapeutic strategies to circumvent resistance to this promising combination, including alternative scheduling or the addition of other agents to the HMA and venetoclax backbone. Understanding the mechanisms of action and evolving resistance in AML remains a priority in order to maximize the benefit from novel drugs and combinations, identify new therapeutic targets, define potential prognostic markers, and avoid treatment failure.
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Affiliation(s)
- Antoine N Saliba
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - August J John
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN 55905, USA
| | - Scott H Kaufmann
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA.,Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN 55905, USA.,Division of Oncology Research, Department of Oncology, Mayo Clinic, Rochester, MN 55905, USA
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11
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Pepe S, Scalzulli E, Colafigli G, Di Prima A, Diverio D, Mancini M, Latagliata R, Martelli M, Foà R, Breccia M. Predictive factors for response and survival in elderly acute myeloid leukemia patients treated with hypomethylating agents: a real-life experience. Ann Hematol 2020; 99:2405-2416. [PMID: 32813071 DOI: 10.1007/s00277-020-04217-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 08/10/2020] [Indexed: 11/25/2022]
Abstract
Predictive factors of response to hypomethylating agents (HMA) in elderly acute myeloid leukemia (AML) patients remain unclear in the real-life setting and no direct comparison between azacitidine (AZA) and decitabine (DEC) has been carried out. We retrospectively evaluated 110 AML patients treated with HMA (78 AZA, 32 DEC) as first-line therapy outside of clinical trials. Median age was 75 years (range 58-87). The median overall survival (OS) of the entire cohort was 8.0 months (95% CI 6.1-10), without significant differences among the subgroups: AZA 8.8 months vs DEC 6.3 months (p = 0.291). HMA treatment yielded an overall response rate (ORR) of 40% (AZA 37% vs DEC 47%, p = 0.237). A stable disease (SD) after 4 HMA cycles was not associated with a worse survival outcome compared with an early optimal response. Factors independently associated with a better OS were transfusion independence during treatment (p = 0.049), achievement of an optimal response to treatment (p < 0.001), and a baseline hemoglobin level ≥ 9.25 (p = 0.018). A bone marrow (BM) blast count ≥ 30% (p < 0.001) and a therapy-related AML (p = 0.008) remain poor survival predictors. Of the available biologic features, an adverse risk category according to the ELN classification was significantly associated with a shorter survival over the intermediate risk category (p = 0.034). Disease progression remains the primary cause of death. Infectious complications were more severe (p = 0.036) and occurred earlier (p = 0.006) in the DEC group compared with that of the AZA group. In conclusion, clinical prognostic factors associated to response and survival have been identified without significant associations concerning overall outcomes between the two HMAs.
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Affiliation(s)
- Sara Pepe
- Hematology, Department of Translational and Precision Medicine, Azienda Ospedaliera Policlinico Umberto I, Sapienza University, Via Benevento 6, 00161, Rome, Italy
| | - Emilia Scalzulli
- Hematology, Department of Translational and Precision Medicine, Azienda Ospedaliera Policlinico Umberto I, Sapienza University, Via Benevento 6, 00161, Rome, Italy
| | - Gioia Colafigli
- Hematology, Department of Translational and Precision Medicine, Azienda Ospedaliera Policlinico Umberto I, Sapienza University, Via Benevento 6, 00161, Rome, Italy
| | - Alessio Di Prima
- Hematology, Department of Translational and Precision Medicine, Azienda Ospedaliera Policlinico Umberto I, Sapienza University, Via Benevento 6, 00161, Rome, Italy
| | - Daniela Diverio
- Hematology, Department of Translational and Precision Medicine, Azienda Ospedaliera Policlinico Umberto I, Sapienza University, Via Benevento 6, 00161, Rome, Italy
| | - Marco Mancini
- Hematology, Department of Translational and Precision Medicine, Azienda Ospedaliera Policlinico Umberto I, Sapienza University, Via Benevento 6, 00161, Rome, Italy
| | - Roberto Latagliata
- Hematology, Department of Translational and Precision Medicine, Azienda Ospedaliera Policlinico Umberto I, Sapienza University, Via Benevento 6, 00161, Rome, Italy
| | - Maurizio Martelli
- Hematology, Department of Translational and Precision Medicine, Azienda Ospedaliera Policlinico Umberto I, Sapienza University, Via Benevento 6, 00161, Rome, Italy
| | - Robin Foà
- Hematology, Department of Translational and Precision Medicine, Azienda Ospedaliera Policlinico Umberto I, Sapienza University, Via Benevento 6, 00161, Rome, Italy
| | - Massimo Breccia
- Hematology, Department of Translational and Precision Medicine, Azienda Ospedaliera Policlinico Umberto I, Sapienza University, Via Benevento 6, 00161, Rome, Italy.
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12
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Papadopoulos V, Diamantopoulos PT, Papageorgiou SG, Papoutselis M, Vrachiolias G, Pappa V, Galanopoulos AG, Vassilakopoulos TP, Hatzimichael E, Zikos P, Papadaki HA, Bouchla A, Panayiotidis P, Megalakaki A, Papaioannou M, Liapis K, Dryllis G, Tsokanas D, Kourakli A, Symeonidis A, Viniou NA, Kotsianidis I. Estimated glomerular filtration rate independently predicts outcome of azacitidine therapy in higher-risk Myelodysplastic syndromes. Results from 536 patients of the Hellenic National Registry of Myelodysplastic and Hypoplastic syndromes. Hematol Oncol 2020; 38:541-553. [PMID: 32495951 DOI: 10.1002/hon.2756] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 05/27/2020] [Accepted: 05/28/2020] [Indexed: 12/23/2022]
Abstract
Higher-risk Myelodysplastic syndromes (MDS) patients undergoing treatment with 5-azacytidine (AZA) are typically elderly with several comorbidities. However, the effect of comorbidities on the effectiveness and safety of AZA in real-world settings remains unclear. We analyzed data from 536 AZA-treated patients with higher-risk MDS, Myelodysplastic/Myeloproliferative neoplasms and low blast count Acute Myeloid Leukemia enrolled to the Hellenic National Registry of Myelodysplastic and Hypoplastic Syndromes. Multivariate analysis adjusted also for the International Prognostic Scoring System (IPSS), its revised version (IPSS-R) and the French Prognostic Scoring System (FPSS), demonstrated independent associations of overall and leukemia-free survival with estimated glomerular filtration rate (eGFR) <45 mL min-1 /1.73 m2 (P = .039, P = .023, respectively), ECOG performance status <2 (P = .015, P = .006), and presence of peripheral blood blasts (P = .008, P = .034), while secondary MDS also correlated with significantly shorter leukemia-free survival (P = .039). Addition of eGFR <45 mL min-1 /1.73 m2 , in IPSS-R and FPSS increased the predictive power of both models. Only FPSS ≤2 and eGFR <45 mL min-1 /1.73 m2 predicted worse response to AZA in multivariate analysis, whereas eGFR <45 mL min-1 /1.73 m2 correlated significantly with death from hemorrhage (P = .003) and cardiovascular complications (P = .006). In conclusion, in the second largest real-world series of AZA-treated MDS patients, we show that an eGFR <45 mL min-1 /1.73 m2 is an independent predictor of worse response and survival. This higher cut-off, instead of the commonly used serum creatinine >2 mg/dL, can be utilized as a more precise indicator of renal comorbidity during AZA therapy. Incorporation of eGFR in the prognostic assessment of AZA-treated MDS patients may prove useful not only in routine practice, but also for the appropriate patient stratification in clinical trials with AZA combinations.
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Affiliation(s)
- Vasileios Papadopoulos
- Department of Hematology, Democritus University of Thrace Medical School, Alexandroupolis, Greece
| | | | - Sotirios G Papageorgiou
- Second Department of Internal Medicine, Hematology Unit, Attikon University General Hospital, Athens, Greece
| | - Menelaos Papoutselis
- Department of Hematology, Democritus University of Thrace Medical School, Alexandroupolis, Greece
| | - George Vrachiolias
- Department of Hematology, Democritus University of Thrace Medical School, Alexandroupolis, Greece
| | - Vassiliki Pappa
- Second Department of Internal Medicine, Hematology Unit, Attikon University General Hospital, Athens, Greece
| | | | - Theodoros P Vassilakopoulos
- Department of Hematology, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Panagiotis Zikos
- Department of Hematology, General Hospital of Patras "Agios Andreas", Patras, Greece
| | - Helen A Papadaki
- Department of Hematology, University General Hospital of Heraklion, Heraklion, Greece
| | - Anthi Bouchla
- Second Department of Internal Medicine, Hematology Unit, Attikon University General Hospital, Athens, Greece
| | - Panayiotis Panayiotidis
- First Propaedeutic Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Maria Papaioannou
- Department of Hematology, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
| | - Konstantinos Liapis
- Department of Hematology, Democritus University of Thrace Medical School, Alexandroupolis, Greece
| | - George Dryllis
- First Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitris Tsokanas
- Department of Internal Medicine, University Hospital of Patras, Rio, Greece
| | - Alexandra Kourakli
- Department of Internal Medicine, University Hospital of Patras, Rio, Greece
| | - Argiris Symeonidis
- Department of Internal Medicine, University Hospital of Patras, Rio, Greece
| | - Nora-Athina Viniou
- First Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioannis Kotsianidis
- Department of Hematology, Democritus University of Thrace Medical School, Alexandroupolis, Greece
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13
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Vey N. Low-intensity regimens versus standard-intensity induction strategies in acute myeloid leukemia. Ther Adv Hematol 2020; 11:2040620720913010. [PMID: 32215195 PMCID: PMC7081460 DOI: 10.1177/2040620720913010] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 02/12/2020] [Indexed: 12/11/2022] Open
Abstract
Treatment options for elderly patients with acute myeloid leukemia (AML) remain limited. In this age group, AML is frequently associated with poor-risk features, while patients’ present comorbidities and reduced functional reserves. As such, intensive chemotherapy (ICT) is frequently too toxic or ineffective in elderly patients and is restricted to a select minority, though it is standard therapy for the youngest and fittest patients or for those belonging to either the favorable or intermediate-risk groups. The use of hypomethylating agents represent an effective alternative for patients who are unfit for ICT, yet the results remain unsatisfactory. In recent years, prognostic scores were developed that include geriatric assessment tools and improved risk-stratification. In addition, several effective new drugs have emerged. The combination of these drugs with hypomethylating agents or low-dose cytarabine has produced encouraging preliminary results that may change standard practices and offer an alternative to the dilemma of ICT versus low-intensity therapies.
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Affiliation(s)
- Norbert Vey
- Institut Paoli-Calmettes, 232 Boulevard de Sainte Marguerite, Marseille, 13009, France
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14
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Garcia-Manero G, Abaza Y, Takahashi K, Medeiros BC, Arellano M, Khaled SK, Patnaik M, Odenike O, Sayar H, Tummala M, Patel P, Maness-Harris L, Stuart R, Traer E, Karamlou K, Yacoub A, Ghalie R, Giorgino R, Atallah E. Pracinostat plus azacitidine in older patients with newly diagnosed acute myeloid leukemia: results of a phase 2 study. Blood Adv 2019; 3:508-18. [PMID: 30760466 DOI: 10.1182/bloodadvances.2018027409] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 01/05/2019] [Indexed: 12/27/2022] Open
Abstract
Pracinostat, a potent oral pan-histone deacetylase inhibitor with modest single-agent activity in acute myeloid leukemia (AML), has shown synergistic antitumor activity when combined with azacitidine. This single-group, multicenter phase 2 study assessed the safety and efficacy of pracinostat combined with azacitidine in patients who were at least 65 years old with newly diagnosed AML and who were ineligible for standard induction chemotherapy. Patients received pracinostat 60 mg/d, 3 d/wk, for 3 consecutive weeks, plus azacitidine 75 mg/m2 daily for 7 days in a 28-day cycle. Primary endpoints were complete remission (CR), CR with incomplete count recovery (CRi), and morphologic leukemia-free state (MLFS) rates of the combination. Secondary endpoints included safety, progression-free survival (PFS), and overall survival (OS) of the regimen. Fifty patients (33 de novo, 12 secondary, and 5 therapy-related AML) were enrolled. Twenty-six patients (52%) achieved the primary endpoint of CR (42%), CRi (4%), and MLFS (6%). Median OS and PFS were 19.1 months (95% confidence interval [CI], 10-26.5 months) and 12.6 months (95% CI, 10-17.7 months), respectively, with a 1-year OS rate of 62%. Forty-three patients (86%) experienced at least 1 grade 3 or worse treatment-emergent adverse event with the combination, with infections (52%), thrombocytopenia (46%), and febrile neutropenia (44%) reported as the most common toxicities. The 30- and 60-day all-cause mortality rates were 2% and 10%, respectively. DNA sequencing revealed somatic mutations at baseline, and clearance rates correlated with response to treatment. Pracinostat plus azacitidine is a well-tolerated and active regimen in the frontline treatment of older patients with AML unfit for intensive therapy. A larger controlled trial is ongoing. This trial was registered at www.clinicaltrials.gov as #NCT01912274.
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15
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Bodepudi SK, Devdas SK, Maka VV, Rasmi P, Hiregoudar SS, Kilara N. Hypomethylating Agents Use in Acute Myeloid Leukemia: A Single-Center Experience. Indian J Med Paediatr Oncol 2020. [DOI: 10.4103/ijmpo.ijmpo_155_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Abstract
Context: Acute myeloid leukemia (AML) is a heterogeneous disease. Approximately 80% of older AML patients will die of their disease or its treatment with currently available antileukemic therapy because of the adverse prognostic risk factors. In elderly patients who are not candidates for induction chemotherapy (IC) or who declines IC, the preferred induction regimen is with hypomethylating agents (HMAs). In India, data regarding therapy with HMA, response to therapy and overall survival (OS) is seldom reported. Aims: This study aims to study the response rate and survival of patients treated with HMAs in whom IC was not feasible. Settings and Design: This is retrospective and descriptive single-center study. Subjects and Methods: Data of newly diagnosed AML patients who were unfit for IC and treated with HMA in our institution was collected retrospectively and analyzed. Results: Twenty-three patients received HMAs as a treatment for AML. Eight (34.7%) of 23 patients had initial response to therapy (two [25%] had complete remission [CR], four [50%] had CR with incomplete hematologic recovery, one [12.5%] had partial remission) and one (12.5%) had stable disease. The median progression-free survival and OS observed are 6.06 ± 0.65 months and 7 ± 1.32 months, respectively. Conclusions: HMAs provide an important additional treatment option in newly diagnosed AML patients who are older, with poor performance status, higher comorbidity indices, and who refuse IC.
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Affiliation(s)
- Sravan Kumar Bodepudi
- Department of Medical Oncology, Ramaiah Medical College, Bengaluru, Karnataka, India
| | - Santhosh Kumar Devdas
- Department of Medical Oncology, Ramaiah Medical College, Bengaluru, Karnataka, India
| | - Vinayak V Maka
- Department of Medical Oncology, Ramaiah Medical College, Bengaluru, Karnataka, India
| | - Palassery Rasmi
- Department of Medical Oncology, Ramaiah Medical College, Bengaluru, Karnataka, India
| | - Sumathi S Hiregoudar
- Transfusion Medicine and Blood Centre, Ramaiah Medical College, Bengaluru, Karnataka, India
| | - Nalini Kilara
- Department of Medical Oncology, Ramaiah Medical College, Bengaluru, Karnataka, India
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16
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Griffiths EA, Carraway HE, Chandhok NS, Prebet T. Advances in non-intensive chemotherapy treatment options for adults diagnosed with acute myeloid leukemia. Leuk Res 2020; 91:106339. [PMID: 32146154 DOI: 10.1016/j.leukres.2020.106339] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 01/28/2020] [Accepted: 02/25/2020] [Indexed: 12/23/2022]
Abstract
Acute myeloid leukemia (AML) is primarily a disease of older adults. Many older patients with AML are not candidates for intensive chemotherapy regimens aimed at inducing remission before transplantation. The prognosis for this patient population remains poor, with 5-year overall survival (OS) rates of less than 10 %. At present, there is no standard of care, and clinical trials should be considered. Hypomethylating agents often are the mainstay of treatment in this setting; however, improved genetic profiling and risk stratification based on molecular, biological, and clinical characteristics of AML enhance the ability to identify an individual patient's risk and can refine therapeutic options. Over the past 2 years, several novel agents have been approved for AML patients in either the frontline or relapsed settings. Additional agents have also shown promising activity. It is becoming a challenge for physicians to navigate these different options and select the optimal therapy or combination of therapies. The aim of this review is to summarize the available information to assist with treatment decisions for leukemia patients who are not suitable for intensive chemotherapy.
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Affiliation(s)
- Elizabeth A Griffiths
- Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Buffalo, NY, USA.
| | - Hetty E Carraway
- Taussig Cancer Institute, Cleveland Clinic, 10900 Euclid Ave, Cleveland, OH, USA.
| | | | - Thomas Prebet
- Smilow Cancer Center at Yale New Haven Hospital, 35 Park Street, New Haven, CT, USA.
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17
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Stein EM, DiNardo CD, Pollyea DA, Schuh AC. Response Kinetics and Clinical Benefits of Nonintensive AML Therapies in the Absence of Morphologic Response. Clinical Lymphoma Myeloma and Leukemia 2020; 20:e66-e75. [DOI: 10.1016/j.clml.2019.11.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 11/05/2019] [Accepted: 11/19/2019] [Indexed: 02/06/2023]
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18
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Schlenk RF, Weber D, Herr W, Wulf G, Salih HR, Derigs HG, Kuendgen A, Ringhoffer M, Hertenstein B, Martens UM, Grießhammer M, Bernhard H, Krauter J, Girschikofsky M, Wolf D, Lange E, Westermann J, Koller E, Kremers S, Wattad M, Heuser M, Thol F, Göhring G, Haase D, Teleanu V, Gaidzik V, Benner A, Döhner K, Ganser A, Paschka P, Döhner H. Randomized phase-II trial evaluating induction therapy with idarubicin and etoposide plus sequential or concurrent azacitidine and maintenance therapy with azacitidine. Leukemia 2019; 33:1923-1933. [PMID: 30728457 PMCID: PMC6756041 DOI: 10.1038/s41375-019-0395-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 01/04/2019] [Accepted: 01/11/2019] [Indexed: 01/17/2023]
Abstract
The aim of this randomized phase-II study was to evaluate the effect of substituting cytarabine by azacitidine in intensive induction therapy of patients with acute myeloid leukemia (AML). Patients were randomized to four induction schedules for two cycles: STANDARD (idarubicin, cytarabine, etoposide); and azacitidine given prior (PRIOR), concurrently (CONCURRENT), or after (AFTER) therapy with idarubicin and etoposide. Consolidation therapy consisted of allogeneic hematopoietic-cell transplantation or three courses of high-dose cytarabine followed by 2-year maintenance therapy with azacitidine in the azacitidine-arms. AML with CBFB-MYH11, RUNX1-RUNX1T1, mutated NPM1, and FLT3-ITD were excluded and accrued to genotype-specific trials. The primary end point was response to induction therapy. The statistical design was based on an optimal two-stage design applied for each arm separately. During the first stage, 104 patients (median age 62.6, range 18-82 years) were randomized; the study arms PRIOR and CONCURRENT were terminated early due to inefficacy. After randomization of 268 patients, all azacitidine-containing arms showed inferior response rates compared to STANDARD. Event-free and overall survival were significantly inferior in the azacitidine-containing arms compared to the standard arm (p < 0.001 and p = 0.03, respectively). The data from this trial do not support the substitution of cytarabine by azacitidine in intensive induction therapy.
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Affiliation(s)
- R F Schlenk
- Department of Internal Medicine III, University Hospital of Ulm, Ulm, Germany.
- NCT-Trial Center, National Center of Tumor Diseases, Heidelberg University Hospital and German Cancer Research Center, Heidelberg, Germany.
- Department of Internal Medicine V, Heidelberg University Hospital, Heidelberg, Germany.
| | - D Weber
- Department of Internal Medicine III, University Hospital of Ulm, Ulm, Germany
| | - W Herr
- Department of Hematology, Medical Oncology and Pneumology, University Medical Center Mainz, Mainz, Germany
| | - G Wulf
- Department of Hematology and Oncology, University Hospital of Göttingen, Göttingen, Germany
| | - H R Salih
- Department of Hematology and Oncology, Eberhard-Karls University, Tübingen, Germany
| | - H G Derigs
- Department of Internal Medicine III, Hospital Frankfurt-Hoechst, Frankfurt, Germany
| | - A Kuendgen
- Department of Hematology, Oncology and Clinical Immunology, University of Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | - M Ringhoffer
- Department of Hematology and Oncology, Städtisches Klinikum Karlsruhe, Karlsruhe, Germany
| | - B Hertenstein
- Department of Hematology and Oncology, Klinikum Bremen Mitte, Bremen, Germany
- Department of Hematology and Oncology, Klinikum am Gesundbrunnen, Heilbronn, Germany
| | - U M Martens
- Department of Hematology and Oncology, University Hospital of Minden, Minden, Germany
| | - M Grießhammer
- Department of Hematology and Oncology, University Hospital of Minden, Minden, Germany
| | - H Bernhard
- Department of Hematology and Oncology, Darmstadt, Municipal Hospital, Darmstadt, Germany
| | - J Krauter
- Department Hematology and Oncology, Braunschweig Municipal Hospital, Braunschweig, Germany
| | - M Girschikofsky
- Department of Hematology and Oncology, Hospital Elisabethinen Linz, Linz, Austria
| | - D Wolf
- Internal Medicine III, University Hospital of Bonn, Bonn, Germany
- Department of Internal Medicine V, Medical University Innsbruck, Innsbruck, Austria
| | - E Lange
- Department of Hematology and Oncology, Evangelisches Krankenhaus Hamm, Hamm, Germany
| | - J Westermann
- Department of Hematology, Oncology and Tumor Immunology, Charité - Campus Virchow Clinic, Berlin, Germany
| | - E Koller
- Department of Internal Medicine III, Hanuschkrankenhaus Wien, Wien, Austria
| | - S Kremers
- Department of Internal Medicine, Caritas-Krankenhaus Lebach, Lebach, Germany
| | - M Wattad
- Department of Hematology and Oncology, Hospital Essen-Werden, Essen, Germany
| | - M Heuser
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - F Thol
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - G Göhring
- Institute of Human Genetics, Hannover Medical School, Hannover, Germany
| | - D Haase
- Department of Hematology and Oncology, University Hospital of Göttingen, Göttingen, Germany
| | - V Teleanu
- Department of Internal Medicine III, University Hospital of Ulm, Ulm, Germany
| | - V Gaidzik
- Department of Internal Medicine III, University Hospital of Ulm, Ulm, Germany
| | - A Benner
- Division of Biostatistics, German Cancer Research Center Heidelberg, Heidelberg, Germany
| | - K Döhner
- Department of Internal Medicine III, University Hospital of Ulm, Ulm, Germany
| | - A Ganser
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - P Paschka
- Department of Internal Medicine III, University Hospital of Ulm, Ulm, Germany
| | - H Döhner
- Department of Internal Medicine III, University Hospital of Ulm, Ulm, Germany
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19
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Santini V, Ossenkoppele GJ. Hypomethylating agents in the treatment of acute myeloid leukemia: A guide to optimal use. Crit Rev Oncol Hematol 2019; 140:1-7. [PMID: 31153036 DOI: 10.1016/j.critrevonc.2019.05.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 05/13/2019] [Accepted: 05/14/2019] [Indexed: 12/21/2022] Open
Abstract
The hypomethylating agents (HMAs), decitabine and azacitidine, are valuable treatment options in acute myeloid leukemia patients who are not eligible for intensive chemotherapy. Both agents are generally well tolerated, and complications most commonly relate to myelosuppression. Antibiotic / antifungal use, regular monitoring, and proactive patient education are important to minimize these events, and reduce the need for dose delay. Responses to HMAs are often not evident for up to 6 cycles, and there is currently no validated clinical marker for predicting response. Hence, treatment should be continued for at least 4-6 cycles to ensure that patients have sufficient opportunity to respond. Delivery of insufficient numbers of cycles is a key reason for HMA failure, and premature discontinuation must be avoided. Genetic factors offer potential for better predicting responders to HMAs in future, but require further study.
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Abstract
In April 2018, an updated version of the previously published guidelines on acute myeloid leukemia (AML) from 2010 and 2017 was released. A revision was necessary because of two positive aspects: First, new data and insights on risk stratification and monitoring, and second, the clinical development and approval of new agents. The modified genetic risk classification allows a more precise distinction of different diagnostic groups and consequently a better matched post-remission treatment. The availability of new targeted drugs such as inhibitors turns genetic analyses from a mere prognostic tool into an instrument for treatment decisions. Several recently approved agents expand the treatment options for AML and raise hope for an improved prognosis and cure in the future.
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21
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Leisch M, Jansko B, Zaborsky N, Greil R, Pleyer L. Next Generation Sequencing in AML-On the Way to Becoming a New Standard for Treatment Initiation and/or Modulation? Cancers (Basel) 2019; 11:E252. [PMID: 30795628 DOI: 10.3390/cancers11020252] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 02/08/2019] [Accepted: 02/12/2019] [Indexed: 12/19/2022] Open
Abstract
Acute myeloid leukemia (AML) is a clonal disease caused by genetic abberations occurring predominantly in the elderly. Next generation sequencing (NGS) analysis has led to a deeper genetic understanding of the pathogenesis and the role of recently discovered genetic precursor lesions (clonal hematopoiesis of indeterminate/oncogenic potential (CHIP/CHOP)) in the evolution of AML. These advances are reflected by the inclusion of certain mutations in the updated World Health Organization (WHO) 2016 classification and current treatment guidelines by the European Leukemia Net (ELN) and National Comprehensive Cancer Network (NCCN) and results of mutational testing are already influencing the choice and timing of (targeted) treatment. Genetic profiling and stratification of patients into molecularly defined subgroups are expected to gain ever more weight in daily clinical practice. Our aim is to provide a concise summary of current evidence regarding the relevance of NGS for the diagnosis, risk stratification, treatment planning and response assessment in AML, including minimal residual disease (MRD) guided approaches. We also summarize recently approved drugs targeting genetically defined patient populations with risk adapted- and individualized treatment strategies.
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22
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Mądry K, Lis K, Biecek P, Młynarczyk M, Rytel J, Górka M, Kacprzyk P, Dutka M, Rodzaj M, Bołkun Ł, Krochmalczyk D, Łątka E, Drozd-Sokołowska J, Waszczuk-Gajda A, Knopińska-Posłuszny W, Kopińska A, Subocz E, Masternak A, Guzicka-Kazimierczak R, Gil L, Machowicz R, Biliński J, Giebel S, Czerw T, Dwilewicz-Trojaczek J. Predictive Model for Infection Risk in Myelodysplastic Syndromes, Acute Myeloid Leukemia, and Chronic Myelomonocytic Leukemia Patients Treated With Azacitidine; Azacitidine Infection Risk Model: The Polish Adult Leukemia Group Study. Clin Lymphoma Myeloma Leuk 2019; 19:264-274.e4. [PMID: 30898482 DOI: 10.1016/j.clml.2019.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 01/04/2019] [Accepted: 01/10/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Myelodysplastic syndromes (MDS), chronic myelomonocytic leukemia (CMML), and acute myeloid leukemia (AML) patients, including those treated with azacitidine, are at increased risk for serious infections. The aim of our study was to identify patients with higher infectious risk at the beginning of azacitidine treatment. PATIENTS AND METHODS We performed a retrospective evaluation of 298 MDS/CMML/AML patients and included in the analysis 232 patients who completed the first 3 cycles of azacitidine therapy or developed Grade III/IV infection before completing the third cycle. RESULTS Overall, 143 patients (62%) experienced serious infection, and in 94 patients (41%) infection occurred within the first 3 cycles. The following variables were found to have the most significant effect on the infectious risk in multivariate analysis: red blood cell transfusion dependency (odds ratio [OR], 2.38; 97.5% confidence interval [CI], 1.21-4.79), neutropenia <0.8 × 109/L (OR, 3.03; 97.5% CI, 1.66-5.55), platelet count <50 × 109/L (OR, 2.63; 97.5% CI, 1.42-4.76), albumin level <35 g/dL (OR, 2.04; 97.5% CI, 1.01-4.16), and Eastern Cooperative Oncology Group performance status ≥2 (OR, 2.19; 97.5% CI, 1.40-3.54). Each of these variables is assigned 1 point, and the combined score represents the proposed Azacitidine Infection Risk Model. The infection rate in the first 3 cycles of therapy in lower-risk (0-2 score) and higher-risk (3-5 score) patients was 25% and 73%, respectively. The overall survival was significantly reduced in higher-risk patients compared with the lower-risk cohort (8 vs. 29 months). CONCLUSION We selected a subset with high early risk for serious infection and worse clinical outcome among patients treated with azacitidine.
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Affiliation(s)
- Krzysztof Mądry
- Department of Hematology, Oncology and Internal Diseases, Medical University, Warsaw, Poland
| | - Karol Lis
- Department of Hematology, Oncology and Internal Diseases, Medical University, Warsaw, Poland.
| | - Przemysław Biecek
- Faculty of Mathematics and Information Science, Warsaw University of Technology, Warsaw, Poland
| | - Magda Młynarczyk
- Faculty of Mathematics and Information Science, Warsaw University of Technology, Warsaw, Poland
| | - Jagoda Rytel
- Department of Hematology, Oncology and Internal Diseases, Medical University, Warsaw, Poland
| | - Michał Górka
- Department of Hematology, Oncology and Internal Diseases, Medical University, Warsaw, Poland
| | - Piotr Kacprzyk
- Department of Hematology, Oncology and Internal Diseases, Medical University, Warsaw, Poland
| | - Magdalena Dutka
- Department of Hematology and Bone Marrow Transplantation, Medical University, Gdańsk, Poland
| | - Marek Rodzaj
- Department of Hematology, Voivodal Specialistic Hospital, Kraków, Poland
| | - Łukasz Bołkun
- Department of Hematology, Medical University, Białystok, Poland
| | | | - Ewa Łątka
- Department of Hematology, Jagiellonian University, Kraków, Poland
| | - Joanna Drozd-Sokołowska
- Department of Hematology, Oncology and Internal Diseases, Medical University, Warsaw, Poland
| | - Anna Waszczuk-Gajda
- Department of Hematology, Oncology and Internal Diseases, Medical University, Warsaw, Poland
| | | | - Anna Kopińska
- Department of Hematology and Bone Marrow Transplantation, Medical University of Silesia, Katowice, Poland
| | - Edyta Subocz
- Department of Hematology and Internal Diseases, Military Institute of Medicine, Warsaw, Poland
| | - Anna Masternak
- Department of Hematology, Specialist Hospital, Opole, Poland
| | | | - Lidia Gil
- Department of Hematology, Medical University, Poznań, Poland
| | - Rafał Machowicz
- Department of Hematology, Oncology and Internal Diseases, Medical University, Warsaw, Poland
| | - Jarosław Biliński
- Department of Hematology, Oncology and Internal Diseases, Medical University, Warsaw, Poland
| | - Sebastian Giebel
- Department of Bone Marrow Transplantation and Hematology-Oncology, Cancer Center and Institute of Oncology, Gliwice, Poland
| | - Tomasz Czerw
- Department of Bone Marrow Transplantation and Hematology-Oncology, Cancer Center and Institute of Oncology, Gliwice, Poland
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Savona MR, Kolibaba K, Conkling P, Kingsley EC, Becerra C, Morris JC, Rifkin RM, Laille E, Kellerman A, Ukrainskyj SM, Dong Q, Skikne BS. Extended dosing with CC-486 (oral azacitidine) in patients with myeloid malignancies. Am J Hematol 2018; 93:1199-1206. [PMID: 30016552 PMCID: PMC6221082 DOI: 10.1002/ajh.25216] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 07/10/2018] [Indexed: 12/17/2022]
Abstract
CC‐486 (oral azacitidine) is an epigenetic modifier in clinical development for treatment of hematological cancers. This study of extended CC‐486 dosing included patients with myelodysplastic syndromes (MDSs), chronic myelomonocytic leukemia (CMML), or acute myeloid leukemia (AML). After a pharmacokinetic assessment period, 31 patients (MDS n = 18, CMML n = 4, and AML n = 9) entered a clinical phase in which they received CC‐486 300 mg once‐daily for 21 days of repeated 28‐day cycles. Median age was 71 years (range: 53‐93); 42% of patients were aged ≥75 years. A total of 5 patients with AML (63%) had prior MDS. Median number of CC‐486 treatment cycles was 4 (range: 1‐32). The most common treatment‐emergent adverse events (TEAEs) were gastrointestinal (84% of patients) and hematologic (81%). Most common grade 3‐4 TEAEs were neutropenia (n = 13, 42%) and anemia (n = 9, 29%). Ten patients experienced grade 4 neutropenia. Infrequently, CC‐486 dose was interrupted or reduced due to gastrointestinal (n = 5, 16%) or hematologic (n = 6, 19%) TEAEs. Overall response rate (complete remission [CR], CR with incomplete hematological recovery [CRi], partial remission [PR], marrow CR) in the MDS/CMML subgroups was 32% and in the AML subgroup (CR/CRi/PR) was 22%. Red blood cell transfusion independence rates in the MDS/CMML and AML subgroups were 33% and 25%, respectively, and 2 MDS/CMML patients attained hematologic improvement as a best response on‐study. No baseline gene mutation was predictive of response/nonresponse. CC‐486 allows flexible dosing and schedules to improve tolerability or response. Neutropenia in early treatment cycles deserves scrutiny and may warrant initiation of prophylactic antibiotics. KEY POINTS The safety profile of oral CC‐486 was comparable to that of injectable azacitidine; most adverse events were hematological and gastrointestinal. Extended (21‐day/cycle) CC‐486 dosing induced responses in patients with hematological malignancies, many of whom had prior DNMTi failure.
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Affiliation(s)
| | - Kathryn Kolibaba
- US Oncology Research; Woodlands Texas
- Northwest Cancer Specialists; Vancouver Western Australia
| | - Paul Conkling
- US Oncology Research; Woodlands Texas
- Virginia Oncology Associates; Norfolk Virginia
| | - Edwin C. Kingsley
- US Oncology Research; Woodlands Texas
- Comprehensive Cancer Centers of Nevada; Las Vegas Nevada
| | - Carlos Becerra
- US Oncology Research; Woodlands Texas
- Texas Oncology, PA (North), Sammons Cancer Center; Dallas Texas
| | - John C. Morris
- University of Cincinnati Cancer Institute; Cincinnati Ohio
| | - Robert M. Rifkin
- US Oncology Research; Woodlands Texas
- Rocky Mountain Cancer Centers; Denver Colorado
| | | | | | | | - Qian Dong
- Celgene Corporation; Summit New Jersey
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24
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Tampe B, Zeisberg M. Chromatin dynamics at the core of kidney fibrosis. Matrix Biol 2018; 68-69:194-229. [DOI: 10.1016/j.matbio.2018.02.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Revised: 02/16/2018] [Accepted: 02/17/2018] [Indexed: 02/06/2023]
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25
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Maurillo L, Buccisano F, Spagnoli A, Voso MT, Fianchi L, Papayannidis C, Gaidano GL, Breccia M, Musto P, De Bellis E, Del Principe MI, Lunghi M, Lessi F, Martinelli G, Venditti A. Comparative analysis of azacitidine and intensive chemotherapy as front-line treatment of elderly patients with acute myeloid leukemia. Ann Hematol 2018; 97:1767-74. [DOI: 10.1007/s00277-018-3374-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 05/18/2018] [Indexed: 01/31/2023]
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26
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Arellano M, Carlisle JW. How I treat older patients with acute myeloid leukemia. Cancer 2018; 124:2472-2483. [DOI: 10.1002/cncr.31347] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 11/30/2017] [Accepted: 01/04/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Martha Arellano
- Department of Hematology and Medical Oncology, Winship Cancer Institute; Emory University; Atlanta Georgia
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Abstract
DNA methyltransferase inhibitors, so-called hypomethylating agents (HMAs), are the only drugs approved for the treatment of higher-risk myelodysplastic syndromes and are widely used in this context. However, it is still unclear why some patients respond to HMAs, whereas others do not. Recent sequencing efforts have identified molecular disease entities that may be specifically sensitive to these drugs, and many attempts are being made to clarify how HMAs affect the malignant clone during treatment. Here, we review the most recent data on the clinical effects of HMAs in myeloid malignancies.
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Bloomfield CD, Estey E, Pleyer L, Schuh AC, Stein EM, Tallman MS, Wei A. Time to repeal and replace response criteria for acute myeloid leukemia? Blood Rev 2018; 32:416-425. [PMID: 29706486 DOI: 10.1016/j.blre.2018.03.006] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 02/14/2018] [Accepted: 03/22/2018] [Indexed: 01/08/2023]
Abstract
The International Working Group (IWG) response criteria for acute myeloid leukemia, published in 2003, have remained the standard by which the efficacy of new drugs is measured in clinical trials. Over the last decade, concepts related to treatment response have been challenged by several factors; for example, the dissociation between early clinical response and survival outcome in older patients, the recognition that epigenetic and newer differentiating-agent therapies may produce delayed responses and also hematologic improvement/transfusion independence without a morphologic response, and evidence that remissions without minimal (or measurable) residual disease (MRD) may result in outcomes superior to those of morphologic remissions with persistent MRD. The evolving role of MRD status as a potential surrogate for predicting long-term survival has enhanced the clinical need to standardize and incorporate emerging technologies that enable deeper responses beyond those recognized by the IWG, and to pre-emptively identify patients at risk of early relapse. The potential for therapeutic interventions to erase MRD and alter the natural history represents an important and open research question. Reviewed here are some of the implications and challenges associated with establishing and incorporating new treatment response criteria, initially into clinical research, and eventually into real-world practice.
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Affiliation(s)
| | - Elihu Estey
- Fred Hutchinson Cancer Research Center, Seattle, United States
| | - Lisa Pleyer
- Paracelsus Medical University, Salzburg, Austria; Salzburg Cancer Research Institute, Center for Clinical Cancer and Immunology Trials, Salzburg, Austria; Cancer Cluster Salzburg, Salzburg, Austria
| | | | - Eytan M Stein
- Memorial Sloan-Kettering Cancer Center, New York, United States; Weill Cornell Medical College, New York, United States
| | - Martin S Tallman
- Memorial Sloan-Kettering Cancer Center, New York, United States; Weill Cornell Medical College, New York, United States
| | - Andrew Wei
- The Alfred Hospital and Monash University, Melbourne, Australia.
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Komrokji R, Swern AS, Grinblatt D, Lyons RM, Tobiasson M, Silverman LR, Sayar H, Vij R, Fliss A, Tu N, Sugrue MM. Azacitidine in Lower-Risk Myelodysplastic Syndromes: A Meta-Analysis of Data from Prospective Studies. Oncologist 2018; 23:159-170. [PMID: 29118268 PMCID: PMC5813747 DOI: 10.1634/theoncologist.2017-0215] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 09/06/2017] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND After erythropoiesis-stimulating agent (ESA) failure, lenalidomide and hypomethylating agents are the only remaining treatment options for most patients with lower-risk myelodysplastic syndromes (LR-MDS). Optimal choice of these agents as front-line therapy in non-del(5q) LR-MDS is unclear. Because azacitidine clinical data mainly describe experience in higher-risk MDS, we performed a meta-analysis of patient-level data to evaluate azacitidine in patients with red blood cell (RBC) transfusion-dependent LR-MDS. MATERIALS AND METHODS We searched English-language articles for prospective phase II and III azacitidine clinical trials and patient registries published between 2000 and 2015, and Embase abstracts from 2015 conferences. Patient-level data from identified relevant studies were provided by investigators. Meta-analyses followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Efficacy endpoints were RBC transfusion independence (TI) and Clinical Benefit (RBC-TI, erythroid response, and complete or partial remission, per International Working Group 2006 criteria for MDS). RESULTS Data for 233 patients from 6 clinical studies and 1 registry study met criteria for inclusion in analyses. Overall, 90.3% of patients had non-del(5q) LR-MDS. Pooled estimates from random-effects models of RBC-TI and Clinical Benefit were 38.9% and 81.1%, respectively; for the ESA-refractory subgroup, they were 40.5% and 77.3%; and for patients with isolated anemia, they were 41.9% and 82.5%. In multivariate analyses, planned use of ≥6 azacitidine treatment cycles was significantly predictive of response. CONCLUSION Azacitidine effects in these patients, most with non-del(5q) LR-MDS, were promising and generally similar to those reported for lenalidomide in similar patients. The choice of initial therapy is important because most patients eventually stop responding to front-line therapy and alternatives are limited. IMPLICATIONS FOR PRACTICE Lower-risk myelodysplastic syndromes (LR-MDS) are primarily characterized by anemia. After erythropoiesis-stimulating agent (ESA) failure, lenalidomide and hypomethylating agents are the only remaining treatment options for most patients. This meta-analysis of 233 azacitidine-treated red blood cell (RBC) transfusion-dependent patients with LR-MDS (92.3% non-del[5q]) from 7 studies showed 38.9% became RBC transfusion-independent. There is no clear guidance regarding the optimal choice of lenalidomide or hypomethylating agents for patients with non-del(5q) LR-MDS following ESA failure. Clinical presentation (e.g., number of cytopenias) and potential outcomes after hypomethylating agent failure are factors to consider when making initial treatment decisions for LR-MDS patients.
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Affiliation(s)
- Rami Komrokji
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Arlene S Swern
- Biostatistics, Celgene Corporation, Summit, New Jersey, USA
| | - David Grinblatt
- Hematology, Northshore University Health System, Evanston, Illinois, USA
| | - Roger M Lyons
- Department of Hematology, US Oncology-Texas Oncology, San Antonio, Texas, USA
| | - Magnus Tobiasson
- Division of Hematology, Karolinska University Hospital, Stockholm, Sweden
| | - Lewis R Silverman
- Division of Hematology/Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Hamid Sayar
- Simon Cancer Center, Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Ravi Vij
- Department of Internal Medicine, Division of Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Albert Fliss
- Medical Affairs, Celgene Corporation, Summit, New Jersey, USA
| | - Nora Tu
- Biostatistics, Celgene Corporation, Summit, New Jersey, USA
| | - Mary M Sugrue
- Medical Affairs, Celgene Corporation, Summit, New Jersey, USA
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Swords RT, Coutre S, Maris MB, Zeidner JF, Foran JM, Cruz J, Erba HP, Berdeja JG, Tam W, Vardhanabhuti S, Pawlikowska-Dobler I, Faessel HM, Dash AB, Sedarati F, Dezube BJ, Faller DV, Savona MR. Pevonedistat, a first-in-class NEDD8-activating enzyme inhibitor, combined with azacitidine in patients with AML. Blood 2018; 131:1415-24. [PMID: 29348128 DOI: 10.1182/blood-2017-09-805895] [Citation(s) in RCA: 131] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 01/03/2018] [Indexed: 12/25/2022] Open
Abstract
Pevonedistat (TAK-924/MLN4924) is a novel inhibitor of NEDD8-activating enzyme (NAE) with single-agent activity in relapsed/refractory acute myeloid leukemia (AML). We performed a phase 1b study of pevonedistat (PEV) with azacitidine (AZA) based on synergistic activity seen preclinically. Primary objectives included safety and tolerability, and secondary objectives included pharmacokinetics (PK) and disease response. Patients ≥60 years with treatment-naive AML (unfit for standard induction therapy) received PEV 20 or 30 mg/m2 IV on days 1, 3, and 5 combined with fixed-dose AZA (75 mg/m2 IV/subcutaneously) on days 1 to 5, 8, and 9, every 28 days. The most common treatment-emergent adverse events were constipation (48%), nausea (42%), fatigue (42%), and anemia (39%). In total, 11 deaths were observed and considered unrelated to study therapy by the investigators. Transient elevations in aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were dose limiting. The recommended phase 2 dose (RP2D) of PEV in this combination is 20 mg/m2 PEV PK was not altered by the addition of AZA. Overall response rate (ORR) based on an intent-to-treat analysis was 50% (20 complete remissions [CRs], 5 complete remission with incomplete peripheral count recovery, 7 partial remissions [PRs]), with an 8.3-month median duration of remission. In patients receiving ≥6 cycles of therapy (n = 23, 44%), ORR was 83%. In patients with TP53 mutations, the composite CR/PR rate was 80% (4/5). Two of these patients stayed on study for >10 cycles. Baseline bone marrow blast percentage or cytogenetic/molecular risk did not influence ORR. This study was registered at www.clinicaltrials.gov as #NCT01814826.
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31
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Livio P, Alessandro B, Anna C, Marianna C, Matteo GDP, Luana F, Federica L, Francesco M, Maria TV. Risk of infection in elderly patients with AML and MDS treated with hypomethylating agents. Acta Biomed 2018; 89. [PMCID: PMC6502134 DOI: 10.23750/abm.v89i11-s.7988] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/06/2022]
Abstract
The aim of this small volume is to raise awareness among Italian hematologists using hypomethylating drugs about risk - and even more important about “risk management” - and the treatment of the infectious events that may arise during therapy with these drugs. Since we wanted this review to be an extremely practical tool, we have included the most recent clinical case studies, the indications provided by the guidelines and expert opinions. Infectious complications are among the most common adverse events that can arise during treatment with hypomethylating drugs. For this reason, a large portion of the chapters of this small volume has been dedicated to a detailed description (on the basis of an attentive review of the literature) of what the hematologist can expect to encounter in terms of risk of infection, in patients treated with azacitidine or decitabine, and to the preventive investigations to carry out and the active prophylaxis measures recommended before commencing treatment with these drugs. What led us to write this book was the conviction that the critical sharing of the studies published in literature and of our personal experiences could contribute to prompting reflection on how we operate and that this, in turn, would lead to the best possible management of these treatments, both in patients with myelodysplasia and in patients with acute myeloid leukemia, preventing - and efficiently managing - infectious events - during therapy. We should not be misled by the fact that the treatments are prevalently administered on an outpatient basis; these patients due to their disease and, in particular, to their age, are extremely frail, and infectious and hemorrhagic complications are the main causes of their admissions to hospital. But expert knowledge and management of the risks of infection can guarantee better management of their needs on an outpatient basis, with undeniable advantages for the clinic but, first and foremost, for the patients. (www.actabiomedica.it)
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Affiliation(s)
- Pagano Livio
- Associate Professor of Hematology, Director UOSA “Geriatric Hematology and Rare Blood Disorders” - Department of Radiological, Radiotherapeutic and Hematological Sciences - Foundation Polyclinic University A. Gemelli - IRCCS - Catholic University of the Sacred Heart - Rome,Correspondence: Prof. Livio Pagano Department of Radiological, Radiotherapeutic and Hematological Sciences Foundation Polyclinic A. Gemelli - IRCCS Università Cattolica del Sacro Cuore, Roma E-mail:
| | - Busca Alessandro
- Department of Oncology, SSD Allogeneic Stem Cell Transplant Unit, AOU City of Health and Science University Hub, Turin
| | - Candoni Anna
- Clinical Hematology Unit, Health Authorities-University Hospital of Udine (ASUIUD)
| | - Criscuolo Marianna
- Department of Radiological Radiotherapeutic and Hematological Sciences, Foundation Polyclinic University A. Gemelli, IRCCS, Rome
| | | | - Fianchi Luana
- Department of Radiological, Radiotherapeutic and Hematological Sciences - Foundation Polyclinic University A. Gemelli, IRCCS, Rome
| | - Lessi Federica
- Division of Hematology and Clinical Immunology, Padua University Hospital
| | - Marchesi Francesco
- UOSD Hematology and Stem Cell Transplant Unit, IRCCS Regina Elena National Cancer Institute, Rome
| | - Teresa Voso Maria
- Associate Professor of Hematology, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome
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32
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Abstract
Remission induction with chemotherapy has long been the frontline treatment of acute myeloid leukemia (AML). However, intensive therapy is limited in frail patients by its associated toxicity and higher rates of failure or relapse in patients with chemoresistant disease, such as secondary AML or poor-risk cytogenetics. Frailty and chemoresistance are more frequent in older adults with AML. In recent years, epigenetic therapies with the hypomethylating agents decitabine and azacitidine have been thoroughly explored in AML. The results of two pivotal studies carried out with these agents in older adults with newly diagnosed AML have challenged the role of intensive chemotherapy as the frontline treatment option in this high-risk population. Here, we review the results of treatment with intensive chemotherapy and hypomethylating agents in older patients with AML; discuss the patient- and disease-specific criteria to integrate into treatment decision making; and also, highlight the methodological limitations of cross-study comparison in this population.
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Affiliation(s)
- Hervé Dombret
- Hôpital Saint-Louis, Institut Universitaire d'Hématologie, Université Paris Diderot, Paris, France
| | - Raphael Itzykson
- Hôpital Saint-Louis, Institut Universitaire d'Hématologie, Université Paris Diderot, Paris, France
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33
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Craddock CF, Houlton AE, Quek LS, Ferguson P, Gbandi E, Roberts C, Metzner M, Garcia-Martin N, Kennedy A, Hamblin A, Raghavan M, Nagra S, Dudley L, Wheatley K, McMullin MF, Pillai SP, Kelly RJ, Siddique S, Dennis M, Cavenagh JD, Vyas P. Outcome of Azacitidine Therapy in Acute Myeloid Leukemia Is not Improved by Concurrent Vorinostat Therapy but Is Predicted by a Diagnostic Molecular Signature. Clin Cancer Res 2017; 23:6430-6440. [PMID: 28765326 DOI: 10.1158/1078-0432.ccr-17-1423] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 06/30/2017] [Accepted: 07/26/2017] [Indexed: 11/16/2022]
Abstract
Purpose: Azacitidine (AZA) is a novel therapeutic option in older patients with acute myeloid leukemia (AML), but its rational utilization is compromised by the fact that neither the determinants of clinical response nor its mechanism of action are defined. Co-administration of histone deacetylase inhibitors, such as vorinostat (VOR), is reported to improve the clinical activity of AZA, but this has not been prospectively studied in patients with AML.Experimental Design: We compared outcomes in 259 adults with AML (n = 217) and MDS (n = 42) randomized to receive either AZA monotherapy (75 mg/m2 × 7 days every 28 days) or AZA combined with VOR 300 mg twice a day on days 3 to 9 orally. Next-generation sequencing was performed in 250 patients on 41 genes commonly mutated in AML. Serial immunophenotyping of progenitor cells was performed in 47 patients.Results: Co-administration of VOR did not increase the overall response rate (P = 0.84) or overall survival (OS; P = 0.32). Specifically, no benefit was identified in either de novo or relapsed AML. Mutations in the genes CDKN2A (P = 0.0001), IDH1 (P = 0.004), and TP53 (P = 0.003) were associated with reduced OS. Lymphoid multipotential progenitor populations were greatly expanded at diagnosis and although reduced in size in responding patients remained detectable throughout treatment.Conclusions: This study demonstrates no benefit of concurrent administration of VOR with AZA but identifies a mutational signature predictive of outcome after AZA-based therapy. The correlation between heterozygous loss of function CDKN2A mutations and decreased OS implicates induction of cell-cycle arrest as a mechanism by which AZA exerts its clinical activity. Clin Cancer Res; 23(21); 6430-40. ©2017 AACR.
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Affiliation(s)
- Charles F Craddock
- Centre for Clinical Haematology, Queen Elizabeth Hospital, Birmingham, United Kingdom.
| | - Aimee E Houlton
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Lynn Swun Quek
- MRC Molecular Haematology Unit and Centre for Haematology, Weatherall Institute of Molecular Medicine, University of Oxford and Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - Paul Ferguson
- Centre for Clinical Haematology, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Emma Gbandi
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Corran Roberts
- Centre for Statistics in Medicine, Oxford, United Kingdom
| | - Marlen Metzner
- MRC Molecular Haematology Unit and Centre for Haematology, Weatherall Institute of Molecular Medicine, University of Oxford and Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - Natalia Garcia-Martin
- MRC Molecular Haematology Unit and Centre for Haematology, Weatherall Institute of Molecular Medicine, University of Oxford and Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - Alison Kennedy
- MRC Molecular Haematology Unit and Centre for Haematology, Weatherall Institute of Molecular Medicine, University of Oxford and Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - Angela Hamblin
- MRC Molecular Haematology Unit and Centre for Haematology, Weatherall Institute of Molecular Medicine, University of Oxford and Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - Manoj Raghavan
- Centre for Clinical Haematology, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Sandeep Nagra
- Centre for Clinical Haematology, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Louise Dudley
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Keith Wheatley
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | | | - Srinivas P Pillai
- University Hospitals of North Midlands, Stoke on Trent, United Kingdom
| | | | - Shamyla Siddique
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Michael Dennis
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Jamie D Cavenagh
- Department of Haemato-Oncology, St Bartholomew's Hospital, Bart's Health NHS Trust, London, United Kingdom
| | - Paresh Vyas
- MRC Molecular Haematology Unit and Centre for Haematology, Weatherall Institute of Molecular Medicine, University of Oxford and Oxford University Hospitals NHS Trust, Oxford, United Kingdom.
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Abstract
Acute myeloid leukemia (AML) is predominantly a disease of older adults associated with poor long-term outcomes with available therapies. Used as single agents, hypomethylating agents (HMAs) induce only 15 to 25% complete remissions, but current data suggest that median OS observed after HMAs is comparable to that observed after more intensive therapies. Whether long-term cure may be obtained in some patients treated with HMAs is unknown. Combinations of HMAs to novel agents are now extensively investigated and attractive response rates have been reported when combining HMAs to different drug classes. The absence of reliable predictive biomarkers of efficacy of HMAs in AML and the uncertainties regarding their most relevant mechanisms of action hinder the rational design of the combinations to be tested in priority, usually in untreated older AML patients.
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35
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Abstract
Acute myeloid leukemia (AML) is a heterogenous disease associated with distinct genetic and molecular abnormalities. Somatic mutations result in dysregulation of intracellular signaling pathways, epigenetics, and apoptosis of the leukemia cells. Understanding the basis for the dysregulated processes provides the platform for the design of novel targeted therapy for AML patients. The effort to devise new targeted therapy has been helped by recent advances in methods for high-throughput genomic screening and the availability of computer-assisted techniques for the design of novel agents that are predicted to specifically inhibit the mutant molecules involved in these intracellular events. In this review, we will provide the scientific basis for targeting the dysregulated molecular mechanisms and discuss the agents currently being investigated, alone or in combination with chemotherapy, for treating patients with AML. Successes in molecular targeting will ultimately change the treatment paradigm for the disease.
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Affiliation(s)
- Seah H. Lim
- Division of Hematology and Oncology, Brown University Warren Alpert Medical School, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903 USA
| | - Patrycja M. Dubielecka
- Division of Hematology and Oncology, Brown University Warren Alpert Medical School, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903 USA
| | - Vikram M. Raghunathan
- Division of Hematology and Oncology, Brown University Warren Alpert Medical School, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903 USA
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36
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Boddu P, Kantarjian H, Garcia-Manero G, Ravandi F, Jabbour E, Borthakur G, Daver N, Pemmaraju N, Pierce S, Cortes J, Kadia TM. Time to response and survival in hypomethylating agent-treated acute myeloid leukemia. Leuk Lymphoma 2017; 59:1012-1015. [DOI: 10.1080/10428194.2017.1365857] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Prajwal Boddu
- Department of Leukemia, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Guillermo Garcia-Manero
- Department of Leukemia, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Elias Jabbour
- Department of Leukemia, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Gautam Borthakur
- Department of Leukemia, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Naval Daver
- Department of Leukemia, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Naveen Pemmaraju
- Department of Leukemia, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Sherry Pierce
- Department of Leukemia, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Jorge Cortes
- Department of Leukemia, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Tapan M. Kadia
- Department of Leukemia, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
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Falantes J, Pleyer L, Thépot S, Almeida AM, Maurillo L, Martínez-Robles V, Stauder R, Itzykson R, Pinto R, Venditti A, Bargay J, Burgstaller S, Martínez MP, Seegers V, Cortesão E, Foncillas MÁ, Gardin C, Montesinos P, Musto P, Fenaux P, Greil R, Sanz MA, Ramos F. Real life experience with frontline azacitidine in a large series of older adults with acute myeloid leukemia stratified by MRC/LRF score: results from the expanded international E-ALMA series (E-ALMA+). Leuk Lymphoma 2017; 59:1113-1120. [PMID: 28838276 DOI: 10.1080/10428194.2017.1365854] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Azacitidine (AZA) prolonged overall survival (OS) in the AZA-AML-001 trial. However, few subjects were randomized to AZA or intensive chemotherapy (IC). The Medical Research Council (MRC) and the Leukemia Research Foundation (LRF) developed a score for older AML patients receiving IC or non-intensive regimens, whereas the E-ALMA study validated a score for survival and response in elderly patients receiving AZA in daily practice. Both identified three groups with different risk estimates. This analysis evaluates the efficacy of frontline AZA in older AML patients (N = 710) unfit for IC from different national registries (E-ALMA + series) stratified by the MRC/LRF risk score. Median OS of patients categorized as good, standard and poor-risk groups by the MRC/LRF score was 13.4 (95% CI, 10.8-16), 12.4 (95% CI, 9.9-14.8), and 8.1 months (95% CI, 7-9.1), respectively (p = .0001). In conclusion, this is the largest retrospective cohort of older AML patients treated with AZA.
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Affiliation(s)
- José Falantes
- a Department of Hematology , University Hospital Virgen del Rocío , Seville , Spain
| | - Lisa Pleyer
- b 3rd Medical Department with Hematology and Medical Oncology, Hemostaseology, Rheumatology and Infectious Diseases, Laboratory for Immunological and Molecular Cancer Research , Oncologic Center, Paracelsus Medical University Hospital Salzburg , Salzburg , Austria.,c Salzburg Cancer Research Institute - Center for Clinical Cancer and Immunology Trials , Salzburg , Austria.,d Cancer Cluster Salzburg , Salzburg , Austria
| | - Sylvain Thépot
- e Department of Blood Diseases/Hematology , CHU Angers , Angers , France
| | - António M Almeida
- f Department of Hematology , Instituto Português de Oncologia Francisco Gentil , Lisbon , Portugal
| | - Luca Maurillo
- g Department of Hematology , Tor Vergata Foundation Polyclinic, University of Rome , Rome , Italy
| | | | - Reinhard Stauder
- i Department of Internal Medicine V (Hematology and Oncology) , Innsbruck Medical University , Innsbruck , Austria
| | - Raphael Itzykson
- j Department of Hematology , Saint Louis Hospital, Paris VII University (APHP) , Paris , France
| | - Ricardo Pinto
- k Department of Hematology , Hospital São João , Porto , Portugal
| | - Adriano Venditti
- g Department of Hematology , Tor Vergata Foundation Polyclinic, University of Rome , Rome , Italy
| | - Joan Bargay
- l Department of Hematology , Son Llatzer Hospital , Palma de Mallorca , Spain
| | - Sonja Burgstaller
- m Department of Internal Medicine IV , Wels-Grieskirchen Hospital , Wels , Austria
| | - María Pilar Martínez
- n Department of Hematology , Doce de Octubre University Hospital , Madrid , Spain
| | - Valerie Seegers
- o Department of Hematology , Avicenne Hospital, Paris XIII University (APHP) , Bobigny , France
| | - Emilia Cortesão
- p Department of Hematology , Centro Hospitalar Universitário de Coimbra , Coimbra , Portugal
| | | | - Claude Gardin
- o Department of Hematology , Avicenne Hospital, Paris XIII University (APHP) , Bobigny , France
| | - Pau Montesinos
- r Department of Hematology , La Fe University Hospital , Valencia , Spain
| | - Pellegrino Musto
- s Scientific Direction, IRCCS-CROB Referral Cancer Center of Basilicata , Rionero in Vulture , Italy
| | - Pierre Fenaux
- j Department of Hematology , Saint Louis Hospital, Paris VII University (APHP) , Paris , France
| | - Richard Greil
- b 3rd Medical Department with Hematology and Medical Oncology, Hemostaseology, Rheumatology and Infectious Diseases, Laboratory for Immunological and Molecular Cancer Research , Oncologic Center, Paracelsus Medical University Hospital Salzburg , Salzburg , Austria.,c Salzburg Cancer Research Institute - Center for Clinical Cancer and Immunology Trials , Salzburg , Austria.,d Cancer Cluster Salzburg , Salzburg , Austria
| | - Miguel Angel Sanz
- r Department of Hematology , La Fe University Hospital , Valencia , Spain
| | - Fernando Ramos
- h Department of Hematology , University Hospital , León , Spain.,t Institute of Biomedicine , University of León , León , Spain
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Oh S, Park S, Chung J, Lee W, Lee H, Cho S, Choi Y, Lim S, Shin H; on behalf of the Hematology Association of South-East Korea (HASEK) study group. Therapeutic decision-making in elderly patients with acute myeloid leukemia: conventional intensive chemotherapy versus hypomethylating agent therapy. Ann Hematol 2017; 96:1801-9. [DOI: 10.1007/s00277-017-3104-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 08/10/2017] [Indexed: 01/23/2023]
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De Bellis E, Fianchi L, Buccisano F, Criscuolo M, Maurillo L, Cicconi L, Brescini M, Del Principe MI, Di Veroli A, Venditti A, Amadori S, Arcese W, Lo-Coco F, Voso MT. Treatment of Low-Blast Count AML using Hypomethylating Agents. Mediterr J Hematol Infect Dis 2017; 9:e2017045. [PMID: 28698788 DOI: 10.4084/MJHID.2017.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Accepted: 06/10/2017] [Indexed: 11/08/2022] Open
Abstract
In 2002, the WHO classification reduced the proportion of blasts in the bone marrow (BM) necessary for the diagnosis of acute myeloid leukemia (AML) from 30% to 20%, eliminating the RAEB-t subtype of myelodysplastic syndromes (MDS). However, this AML subtype, defined as low-blast count AML (LBC-AML, with 20-30% BM-blasts) is characterized by peculiar features, as increased frequency in elderly individuals and after cytotoxic treatment for a different primary disease (therapy-related), poor-risk cytogenetics, lower white blood cell counts, and less frequent mutations of NPM1 and FLT3 genes. The clinical course of this entity is often similar to MDS with 10-19% BM-blasts. The hypomethylating agents azacitidine and decitabine have been shown to induce responses and prolong survival both in MDS and LBC-AML. The role of these agents has also been demonstrated in AML with >30% BM-blasts, particularly in patients with poor-risk cytogenetics and in AML with myelodysplasia-related changes. Most recent studies are evaluating strategies to improve outcome, including combinations of hypomethylating agents with immune-response checkpoint inhibitors, which have a role in cancer immune surveillance. Efforts are also ongoing to identify mutations which may predict response and survival in these patients.
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40
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Schuh AC, Döhner H, Pleyer L, Seymour JF, Fenaux P, Dombret H. Azacitidine in adult patients with acute myeloid leukemia. Crit Rev Oncol Hematol 2017; 116:159-177. [PMID: 28693797 DOI: 10.1016/j.critrevonc.2017.05.010] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 05/23/2017] [Accepted: 05/28/2017] [Indexed: 01/13/2023] Open
Abstract
Azacitidine is recommended front-line treatment for older patients with acute myeloid leukemia (AML) who are not candidates for intensive treatment regimens, and was recently granted approval in the European Union for treatment of adult AML. Reviewed here is azacitidine experience in AML, including: mechanistic and pharmacokinetic data; safety and efficacy in controlled trials; treatment effects in AML subpopulations defined by disease characteristics; experience in unselected patients treated in the community setting; clinical outcomes relative to other approved AML therapies; and experience with azacitidine-based combination treatment regimens. Collectively, these data suggest that (a) azacitidine may prolong overall survival to a similar or greater extent than do other approved AML treatments, but with less toxicity, (b) azacitidine may be the preferred treatment option for older patients with unfavorable cytogenetics, and (c) experience and outcomes with azacitidine in the clinic are similar to those seen in clinical trials. Continued investigation of combination regimens on an azacitidine backbone is warranted.
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Affiliation(s)
- Andre C Schuh
- Princess Margaret Cancer Centre, Toronto, Ontario, Canada.
| | | | - Lisa Pleyer
- 3rd Medical Department with Hematology and Medical Oncology, Hemostaseology, Rheumatology and Infectious Diseases, Laboratory for Immunological and Molecular Cancer Research, Oncologic Center, Paracelsus Medical University Salzburg, Austria; Salzburg Cancer Research Institute - Center for Clinical Cancer and Immunology Trials, Salzburg, Austria; Cancer Cluster Salzburg, Austria
| | - John F Seymour
- Peter MacCallum Cancer Centre, Melbourne, Australia; University of Melbourne, Parkville, Australia
| | - Pierre Fenaux
- Hôpital Saint Louis, Institut Universitaire d'Hématologie, Paris, France
| | - Hervé Dombret
- Hôpital Saint Louis, Institut Universitaire d'Hématologie, Paris, France
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41
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Agarwal SK, Mangal N, Menon RM, Freise KJ, Salem AH. Response Rates as Predictors of Overall Survival: A Meta-Analysis of Acute Myeloid Leukemia Trials. J Cancer 2017; 8:1562-1567. [PMID: 28775775 PMCID: PMC5535711 DOI: 10.7150/jca.18686] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 03/31/2017] [Indexed: 01/23/2023] Open
Abstract
Background: Response rates such as overall response rate (ORR), complete response (CR) and complete response with incomplete blood recovery (CRi) can be evaluated in a much shorter period of time than overall survival (OS), potentially accelerating decision making during drug development. The objective of this work was to evaluate the relationship between ORR, CR, CRi or better (CRi+CR) rates and median OS to determine whether response rates could be used as predictors of median OS in acute myeloid leukemia (AML). Methods: A review of published literature was conducted to identify relevant AML clinical trials. Weighted linear regression was performed with various linearizing transformations of response rates and median OS. Covariates of interest were evaluated using a forward inclusion, backward elimination covariate model building procedure at α=0.01 and α=0.005, respectively. Results: Twenty trials involving 26 cohorts were included in the meta-analysis. Azactidine treatment was a significant predictor with longer OS compared to decitabine or low dose cytarabine for a given response rate (P < 0.005). Linear regression analysis indicated that the correlation of both CRi or better rates and CR rates with median OS was higher than that of ORR with median OS. The final model showed a strong correlation between CRi or better rates and median OS (R2=0.66). Conclusion: Significant correlation between CRi or better rates and median OS in AML highlights the potential for CRi or better rate, in addition to CR rate, to serve as surrogate markers for median OS.
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Affiliation(s)
| | - Naveen Mangal
- Abbvie, Inc., North Chicago, IL, USA.,Center for Pharmacometrics and Systems Pharmacology, University of Florida, Orlando, FL, USA
| | | | | | - Ahmed Hamed Salem
- Abbvie, Inc., North Chicago, IL, USA.,Department of Clinical Pharmacy, Faculty of Pharmacy, Ain Shams University, Cairo, Egypt
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42
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Garcia-Manero G, Sekeres MA, Egyed M, Breccia M, Graux C, Cavenagh JD, Salman H, Illes A, Fenaux P, DeAngelo DJ, Stauder R, Yee K, Zhu N, Lee JH, Valcarcel D, MacWhannell A, Borbenyi Z, Gazi L, Acharyya S, Ide S, Marker M, Ottmann OG. A phase 1b/2b multicenter study of oral panobinostat plus azacitidine in adults with MDS, CMML or AML with ⩽30% blasts. Leukemia 2017; 31:2799-2806. [PMID: 28546581 PMCID: PMC5729337 DOI: 10.1038/leu.2017.159] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 02/13/2017] [Accepted: 02/23/2017] [Indexed: 12/15/2022]
Abstract
Treatment with azacitidine (AZA), a demethylating agent, prolonged overall survival (OS) vs conventional care in patients with higher-risk myelodysplastic syndromes (MDS). As median survival with monotherapy is <2 years, novel agents are needed to improve outcomes. This phase 1b/2b trial (n=113) was designed to determine the maximum tolerated dose (MTD) or recommended phase 2 dose (RP2D) of panobinostat (PAN)+AZA (phase 1b) and evaluate the early efficacy and safety of PAN+AZA vs AZA monotherapy (phase 2b) in patients with higher-risk MDS, chronic myelomonocytic leukemia or oligoblastic acute myeloid leukemia with <30% blasts. The MTD was not reached; the RP2D was PAN 30 mg plus AZA 75 mg/m2. More patients receiving PAN+AZA achieved a composite complete response ([CR)+morphologic CR with incomplete blood count+bone marrow CR (27.5% (95% CI, 14.6–43.9%)) vs AZA (14.3% (5.4–28.5%)). However, no significant difference was observed in the 1-year OS rate (PAN+AZA, 60% (50–80%); AZA, 70% (50–80%)) or time to progression (PAN+AZA, 70% (40–90%); AZA, 70% (40–80%)). More grade 3/4 adverse events (97.4 vs 81.0%) and on-treatment deaths (13.2 vs 4.8%) occurred with PAN+AZA. Further dose or schedule optimization may improve the risk/benefit profile of this regimen.
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Affiliation(s)
- G Garcia-Manero
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - M A Sekeres
- Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA
| | - M Egyed
- Kaposi Mor County Teaching Hospital, Kasposvár, Hungary
| | | | - C Graux
- Mont-Godinne University Hospital, Yvoir, Belgium
| | | | - H Salman
- Augusta University, Augusta, GA, USA
| | - A Illes
- University of Debrecen, Debrecen, Hungary
| | - P Fenaux
- Hôpital Saint-Louis, Université Paris Diderot, Paris, France
| | | | - R Stauder
- Innsbruck Medical University, Innsbruck, Austria
| | - K Yee
- Princess Margaret Cancer Centre, Toronto, Canada
| | - N Zhu
- University of Alberta Hospital, Edmonton, Canada
| | - J-H Lee
- Asan Medical Center, University of Ulsan, Seoul, South Korea
| | | | - A MacWhannell
- The Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | | | - L Gazi
- Novartis Pharma AG, Basel, Switzerland
| | - S Acharyya
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - S Ide
- Novartis Pharmaceuticals Corporation, Cambridge, MA, USA
| | - M Marker
- Novartis Pharma S.A.S., Rueil-Malmaison, France
| | - O G Ottmann
- Department of Haematology, School of Medicine, Cardiff University, Cardiff, UK
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43
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Leisch M, Weiss L, Lindlbauer N, Jungbauer C, Egle A, Rohde E, Greil R, Grabmer C, Pleyer L. Red blood cell alloimmunization in 184 patients with myeloid neoplasms treated with azacitidine - A retrospective single center experience. Leuk Res 2017; 59:12-19. [PMID: 28535394 DOI: 10.1016/j.leukres.2017.05.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 04/26/2017] [Accepted: 05/06/2017] [Indexed: 12/28/2022]
Abstract
Alloimmunization to Red Blood Cell (RBC) antigens frequently occurs in patients with myeloid neoplasms (AML, MDS and CMML) and potentially poses the patient at risk for delayed hemolytic transfusion reactions and limited supply of compatible RBC-units. However, there is comparatively little data on transfusion associated characteristics in this patient cohort. We therefore retrospectively analyzed transfusion requirements and clinical outcomes of 184 patients with myloid neoplasms treated with azacitidine at the Paracelsus Medical University Salzburg, which were included in the Austrian Registry of Hypomethylating Agents. The mean blood component requirements for AML, MDS and CMML were 39.8, 67.4 and 31.4 RBC units and 31.7, 27.6 and 19.1 platelet (PLT) units respectively. In spite of an extended and stringent RBC unit matching policy (ABO, RhD, RhCcEe and K antigens), 20 (11%) patients formed at least one alloantibody ("allo-group"), whereas 164 patients (89%) did not ("non-allo-group"). The most frequent antibody specificity was anti-E, followed by anti-Wra -Lua, -D, -C and -Jka. Alloimmunization was associated with higher numbers of transfused RBC units (68 vs. 38; p=0.001), as well as with longer time under transfusion (16.7 vs. 9.4 months; p=0.014). Median overall survival (OS) did not differ significantly between the "allo"- and "non-allo-group".
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Affiliation(s)
- M Leisch
- 3rd Medical Department with Hematology and Medical Oncology, Hemostaseology, Rheumatology and Infectious Diseases, Laboratoy for Immunological and Molecular Cancer Research, Oncologic Center, Paracelsus Medical University, Salzburg, Austria; Center for Clinical Cancer and Immunology Trials as Salzburg Cancer Research Institute, Salzburg, Austria
| | - L Weiss
- 3rd Medical Department with Hematology and Medical Oncology, Hemostaseology, Rheumatology and Infectious Diseases, Laboratoy for Immunological and Molecular Cancer Research, Oncologic Center, Paracelsus Medical University, Salzburg, Austria; Center for Clinical Cancer and Immunology Trials as Salzburg Cancer Research Institute, Salzburg, Austria
| | - N Lindlbauer
- Department of Blood Group Serology and Transfusion Medicine, SALK - Paracelsus Medical University, Salzburg Austria
| | - C Jungbauer
- Austrian Red Cross, Blood Service for Vienna, Lower Austria and Burgenland, Vienna, Austria
| | - A Egle
- 3rd Medical Department with Hematology and Medical Oncology, Hemostaseology, Rheumatology and Infectious Diseases, Laboratoy for Immunological and Molecular Cancer Research, Oncologic Center, Paracelsus Medical University, Salzburg, Austria; Center for Clinical Cancer and Immunology Trials as Salzburg Cancer Research Institute, Salzburg, Austria
| | - E Rohde
- Department of Blood Group Serology and Transfusion Medicine, SALK - Paracelsus Medical University, Salzburg Austria
| | - R Greil
- 3rd Medical Department with Hematology and Medical Oncology, Hemostaseology, Rheumatology and Infectious Diseases, Laboratoy for Immunological and Molecular Cancer Research, Oncologic Center, Paracelsus Medical University, Salzburg, Austria; Center for Clinical Cancer and Immunology Trials as Salzburg Cancer Research Institute, Salzburg, Austria; Cancer Cluster, Salzburg, Austria
| | - C Grabmer
- Department of Blood Group Serology and Transfusion Medicine, SALK - Paracelsus Medical University, Salzburg Austria
| | - L Pleyer
- 3rd Medical Department with Hematology and Medical Oncology, Hemostaseology, Rheumatology and Infectious Diseases, Laboratoy for Immunological and Molecular Cancer Research, Oncologic Center, Paracelsus Medical University, Salzburg, Austria; Center for Clinical Cancer and Immunology Trials as Salzburg Cancer Research Institute, Salzburg, Austria; Cancer Cluster, Salzburg, Austria.
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44
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Almeida AM, Prebet T, Itzykson R, Ramos F, Al-Ali H, Shammo J, Pinto R, Maurillo L, Wetzel J, Musto P, Van De Loosdrecht AA, Costa MJ, Esteves S, Burgstaller S, Stauder R, Autzinger EM, Lang A, Krippl P, Geissler D, Falantes JF, Pedro C, Bargay J, Deben G, Garrido A, Bonanad S, Diez-Campelo M, Thepot S, Ades L, Sperr WR, Valent P, Fenaux P, Sekeres MA, Greil R, Pleyer L. Clinical Outcomes of 217 Patients with Acute Erythroleukemia According to Treatment Type and Line: A Retrospective Multinational Study. Int J Mol Sci 2017; 18:ijms18040837. [PMID: 28420120 PMCID: PMC5412421 DOI: 10.3390/ijms18040837] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 03/20/2017] [Accepted: 04/06/2017] [Indexed: 01/01/2023] Open
Abstract
Acute erythroleukemia (AEL) is a rare disease typically associated with a poor prognosis. The median survival ranges between 3-9 months from initial diagnosis. Hypomethylating agents (HMAs) have been shown to prolong survival in patients with myelodysplastic syndromes (MDS) and AML, but there is limited data of their efficacy in AEL. We collected data from 210 AEL patients treated at 28 international sites. Overall survival (OS) and PFS were estimated using the Kaplan-Meier method and the log-rank test was used for subgroup comparisons. Survival between treatment groups was compared using the Cox proportional hazards regression model. Eighty-eight patients were treated with HMAs, 44 front line, and 122 with intensive chemotherapy (ICT). ICT led to a higher overall response rate (complete or partial) compared to first-line HMA (72% vs. 46.2%, respectively; p ≤ 0.001), but similar progression-free survival (8.0 vs. 9.4 months; p = 0.342). Overall survival was similar for ICT vs. HMAs (10.5 vs. 13.7 months; p = 0.564), but patients with high-risk cytogenetics treated with HMA first-line lived longer (7.5 for ICT vs. 13.3 months; p = 0.039). Our results support the therapeutic value of HMA in AEL.
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Affiliation(s)
- Antonio M Almeida
- Instituto Português de Oncologia de Lisboa (IPOL), 1200-795 Lisbon, Portugal.
| | - Thomas Prebet
- Institut Paoli Calmettes, Marseille, France and Yale New Haven Hospital, New Haven, CT 06512, USA.
| | - Raphael Itzykson
- Hopital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris Diderot University, 75010 Paris, France.
| | | | - Haifa Al-Ali
- University Hospital of Halle, 06120 Halle, Germany.
| | - Jamile Shammo
- Rush University Medical Center, Chicago, IN 60612, USA.
| | | | | | - Jaime Wetzel
- Cleveland Clinic Taussig Cancer Institute, Cleveland, OH 44195, USA.
| | - Pellegrino Musto
- RCCS-CROB, Referral Cancer Center of Basilicata, 85028 Rionero in Vulture (Pz), Italy.
| | | | - Maria Joao Costa
- Centro Hospitalar Lisboa Norte Hospital Santa Maria, 1649-035 Lisbon, Portugal.
| | - Susana Esteves
- Instituto Português de Oncologia de Lisboa (IPOL), 1200-795 Lisbon, Portugal.
| | - Sonja Burgstaller
- Department of Internal Medicine IV, Hospital Wels-Grieskirchen, 4600 Wels, Austria.
| | - Reinhard Stauder
- Department of Internal Medicine V (Haematology and Oncology), Innsbruck Medical University, 6020 Innsbruck, Austria.
| | - Eva M Autzinger
- 1st Department of Internal Medicine, Center for Oncology and Hematology, Wilhelminenspital, 1160 Vienna, Austria.
| | - Alois Lang
- Internal Medicine, Hospital Feldkirch,6800 Feldkirch, Austria.
| | - Peter Krippl
- Department of Internal Medicine, Hospital Fürstenfeld, 8280 Fürstenfeld, Austria.
| | - Dietmar Geissler
- Department for Internal Medicine, Klinikum Klagenfurt am Wörthersee, 9020 Pörtschach am Wörthersee, Austria.
| | | | | | - Joan Bargay
- Hospital Son Llatzer, 07198 Palma de Mallorca, Spain.
| | | | - Ana Garrido
- Hospital de la Santa Creu i Sant Pau, 08026 Barcelona, Spain.
| | | | | | | | - Lionel Ades
- Hopital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris Diderot University, 75010 Paris, France.
| | - Wolfgang R Sperr
- Department of Internal Medicine I, Division of Hematology & Hemostaseology and Ludwig Boltzmann Cluster Oncology, Medical University of Vienna, 1090 Vienna, Austria.
| | - Peter Valent
- Department of Internal Medicine I, Division of Hematology & Hemostaseology and Ludwig Boltzmann Cluster Oncology, Medical University of Vienna, 1090 Vienna, Austria.
| | - Pierre Fenaux
- Hopital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris Diderot University, 75010 Paris, France.
| | - Mikkael A Sekeres
- Cleveland Clinic Taussig Cancer Institute, Cleveland, OH 44195, USA.
| | - Richard Greil
- 3rd Med. Department, Paracelsus Medical University, 5020 Salzburg, Austria.
- Salzburg Cancer Research Institute, 5020 Salzburg, Austria.
- Cancer Cluster Salzburg, 5020 Salzburg, Austria.
- Arbeitsgemeinschaft Medikamentöse Tumortherapie (AGMT), 5020 Salzburg, Austria.
| | - Lisa Pleyer
- 3rd Med. Department, Paracelsus Medical University, 5020 Salzburg, Austria.
- Salzburg Cancer Research Institute, 5020 Salzburg, Austria.
- Cancer Cluster Salzburg, 5020 Salzburg, Austria.
- Arbeitsgemeinschaft Medikamentöse Tumortherapie (AGMT), 5020 Salzburg, Austria.
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45
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Wolff F, Leisch M, Greil R, Risch A, Pleyer L. The double-edged sword of (re)expression of genes by hypomethylating agents: from viral mimicry to exploitation as priming agents for targeted immune checkpoint modulation. Cell Commun Signal 2017; 15:13. [PMID: 28359286 PMCID: PMC5374693 DOI: 10.1186/s12964-017-0168-z] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 03/21/2017] [Indexed: 12/20/2022] Open
Abstract
Hypomethylating agents (HMAs) have been widely used over the last decade, approved for use in myelodysplastic syndrome (MDS), chronic myelomonocytic leukemia (CMML) and acute myeloid leukemia (AML). The proposed central mechanism of action of HMAs, is the reversal of aberrant methylation in tumor cells, thus reactivating CpG-island promoters and leading to (re)expression of tumor suppressor genes. Recent investigations into the mode of action of azacitidine (AZA) and decitabine (DAC) have revealed new molecular mechanisms that impinge on tumor immunity via induction of an interferon response, through activation of endogenous retroviral elements (ERVs) that are normally epigenetically silenced. Although the global demethylation of DNA by HMAs can induce anti-tumor effects, it can also upregulate the expression of inhibitory immune checkpoint receptors and their ligands, resulting in secondary resistance to HMAs. Recent studies have, however, suggested that this could be exploited to prime or (re)sensitize tumors to immune checkpoint inhibitor therapies. In recent years, immune checkpoints have been targeted by novel therapies, with the aim of (re)activating the host immune system to specifically eliminate malignant cells. Antibodies blocking checkpoint receptors have been FDA-approved for some solid tumors and a plethora of clinical trials testing these and other checkpoint inhibitors are under way. This review will discuss AZA and DAC novel mechanisms of action resulting from the re-expression of pathologically hypermethylated promoters of gene sets that are related to interferon signaling, antigen presentation and inflammation. We also review new insights into the molecular mechanisms of action of transient, low-dose HMAs on various tumor types and discuss the potential of new treatment options and combinations.
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Affiliation(s)
- Florian Wolff
- Department of Molecular Biology, University of Salzburg, Salzburg, Austria
| | - Michael Leisch
- 3rd Medical Department with Hematology and Medical Oncology, Hemostaseology, Rheumatology and Infectious Diseases, Laboratory for Immunological and Molecular Cancer Research, Oncologic Center, Paracelsus Medical University Salzburg, Müllner Hauptstraße 48, A-5020, Salzburg, Austria
| | - Richard Greil
- 3rd Medical Department with Hematology and Medical Oncology, Hemostaseology, Rheumatology and Infectious Diseases, Laboratory for Immunological and Molecular Cancer Research, Oncologic Center, Paracelsus Medical University Salzburg, Müllner Hauptstraße 48, A-5020, Salzburg, Austria.,Salzburg Cancer Research Institute - Center for Clinical Cancer and Immunology Trials, Salzburg, Austria.,Cancer Cluster Salzburg, Salzburg, Austria
| | - Angela Risch
- Department of Molecular Biology, University of Salzburg, Salzburg, Austria.,Cancer Cluster Salzburg, Salzburg, Austria
| | - Lisa Pleyer
- 3rd Medical Department with Hematology and Medical Oncology, Hemostaseology, Rheumatology and Infectious Diseases, Laboratory for Immunological and Molecular Cancer Research, Oncologic Center, Paracelsus Medical University Salzburg, Müllner Hauptstraße 48, A-5020, Salzburg, Austria. .,Salzburg Cancer Research Institute - Center for Clinical Cancer and Immunology Trials, Salzburg, Austria. .,Cancer Cluster Salzburg, Salzburg, Austria.
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46
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Abstract
DNA methylation aberrancies are hallmarks of human cancers and are characterized by global DNA hypomethylation of repetitive elements and non-CpG rich regions concomitant with locus-specific DNA hypermethylation. DNA methylation changes may result in altered gene expression profiles, most notably the silencing of tumor suppressors, microRNAs, endogenous retorviruses and tumor antigens due to promoter DNA hypermethylation, as well as oncogene upregulation due to gene-body DNA hypermethylation. Here, we review DNA methylation aberrancies in human cancers, their use in cancer surveillance and the interplay between DNA methylation and histone modifications in gene regulation. We also summarize DNA methylation inhibitors and their therapeutic effects in cancer treatment. In this context, we describe the integration of DNA methylation inhibitors with conventional chemotherapies, DNA repair inhibitors and immune-based therapies, to bring the epigenome closer to its normal state and increase sensitivity to other therapeutic agents to improve patient outcome and survival.
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Affiliation(s)
- Gangning Liang
- a Department of Urology , University of Southern California, USC Norris Comprehensive Cancer Center , Los Angeles , CA , USA
| | - Daniel J Weisenberger
- b Department of Biochemistry and Molecular Medicine , University of Southern California, USC Norris Comprehensive Cancer Center , Los Angeles , CA , USA
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47
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Cooper ML, Choi J, Karpova D, Vij K, Ritchey J, Schroeder MA, DiPersio JF. Azacitidine Mitigates Graft-versus-Host Disease via Differential Effects on the Proliferation of T Effectors and Natural Regulatory T Cells In Vivo. J Immunol 2017; 198:3746-3754. [PMID: 28330901 DOI: 10.4049/jimmunol.1502399] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 02/20/2017] [Indexed: 12/13/2022]
Abstract
Azacitidine (AzaC) mitigates graft-versus-host disease (GvHD) in both murine preclinical transplant models and in human clinical trials while maintaining a robust graft-versus-leukemia effect. Previous studies have failed to investigate the role of natural regulatory T cells (nTregs) on the mitigation of GvHD by AzaC, instead focusing on the generation of suppressive Tregs (CD4+CD25+FOXP3+) through the in vivo conversion of alloreactive donor T effectors (Teffs; CD4+CD25-FOXP3-) and the direct antiproliferative effects of AzaC on allogeneic T cells. Using B6.Foxp3DTR/GFP mice in which Tregs can be specifically ablated through administration of diphtheria toxin, we demonstrate that natural Tregs are required in the donor graft for AzaC to optimally protect against GvHD and that nTregs, unlike Teffs (CD3+FOXP3-), are resistant to the antiproliferative effects of AzaC. Gene expression analysis identified the potent cell cycle inhibitor, p21, was significantly upregulated in Teffs but not nTregs after treatment with AzaC. Furthermore, we demonstrate that Teffs deficient in p21 are less sensitive to the antiproliferative effects of AzaC. These results demonstrate that nTregs are essential for AzaC to fully protect against GvHD and have important clinical implications for future clinical trials testing AzaC as a novel method of GvHD prophylaxis in man.
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Affiliation(s)
- Matthew L Cooper
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110
| | - Jaebok Choi
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110
| | - Darja Karpova
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110
| | - Kiran Vij
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110
| | - Julie Ritchey
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110
| | - Mark A Schroeder
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110
| | - John F DiPersio
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110
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48
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Dumas PY, Bertoli S, Bérard E, Médiavilla C, Yon E, Tavitian S, Leguay T, Huguet F, Forcade E, Milpied N, Sarry A, Sauvezie M, Bories P, Pigneux A, Récher C. Azacitidine or intensive chemotherapy for older patients with secondary or therapy-related acute myeloid leukemia. Oncotarget 2017; 8:79126-36. [PMID: 29108292 DOI: 10.18632/oncotarget.15988] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 02/27/2017] [Indexed: 12/21/2022] Open
Abstract
The treatment of older patients with acute myeloid leukemia that is secondary to previous myelodysplastic syndrome, myeloproliferative neoplasm, or prior cytotoxic exposure remains unsatisfactory. We compared 92 and 107 patients treated, respectively, with intensive chemotherapy or azacitidine within two centres. Diagnoses were 37.5% post-myelodysplastic syndrome, 17.4% post-myeloproliferative neoplasia, and 45.1% therapy-related acute myeloid leukemia. Patients treated by chemotherapy had less adverse cytogenetics, higher white blood-cell counts, and were younger: the latter two being independent factors entered into the multivariate analyses. Median overall-survival times with chemotherapy and azacitidine were 9.6 (IQR: 3.6-22.8) and 10.8 months (IQR: 4.8-26.4), respectively (p = 0.899). Adjusted time-dependent analyses showed that, before 1.6 years post-treatment, there were no differences in survival times between chemotherapy and azacitidine treatments whereas, after this time-point, patients that received chemotherapy had a lower risk of death compared to those that received azacitidine (adjusted HR 0.61, 95%CI: 0.38-0.99 at 1.6 years). There were no interactions between treatment arms and secondary acute myeloid leukemia subtypes in all multivariate analyses, indicating that the treatments had similar effects in all three subtypes. Although a comparison between chemotherapy and azacitidine remains challenging, azacitidine represents a valuable alternative to chemotherapy in older patients that have secondary acute myeloid leukemia because it provides similar midterm outcomes with less toxicity.
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49
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Ding H, Hashem H, Cabral L, Rangarajan H, Abusin G, Lazarus HM, Abu-Arja R. Azacitidine as a bridge to allogeneic hematopoietic cell transplantation in a pediatric patient with Fanconi anemia and acute myeloid leukemia. Pediatr Transplant 2017; 21. [PMID: 27976488 DOI: 10.1111/petr.12870] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/10/2016] [Indexed: 11/28/2022]
Abstract
HCT is the definitive therapy for patients with FA and AML. Conventional cytotoxic agents cause potential DNA damage, and currently, there is no established regimen for these patients prior to HCT. A 13-year-old male with FA and refractory AML was given azacitidine, achieved morphologic remission and underwent HCT. At 95 days after HCT, he relapsed. Azacitidine along with DLI was used as first salvage therapy. Azacitidine was overall well tolerated with minimal side effects. In patients with AML and FA, azacitidine can be considered an alternative to conventional chemotherapy.
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Affiliation(s)
- Hilda Ding
- Pediatric Hematology-Oncology and Bone Marrow Transplantation, University Hospitals Rainbow Babies & Children's Hospital/Case Medical Center, Cleveland, OH, USA
| | - Hasan Hashem
- Pediatric Hematology-Oncology and Bone Marrow Transplantation, University Hospitals Rainbow Babies & Children's Hospital/Case Medical Center, Cleveland, OH, USA
| | - Linda Cabral
- Pediatric Hematology-Oncology and Bone Marrow Transplantation, University Hospitals Rainbow Babies & Children's Hospital/Case Medical Center, Cleveland, OH, USA
| | - Hemalatha Rangarajan
- Pediatric Hematology Oncology and Bone Marrow Transplant, Nationwide Children's Hospital, Columbus, OH, USA
| | - Ghada Abusin
- Pediatric Hematology/Oncology and Bone Marrow Transplant, University of Iowa Children's Hospital, Iowa City, IA, USA
| | - Hillard M Lazarus
- Department of Medicine-Hematology and Oncology, University Hospitals Case Medical Center, Cleveland, OH, USA
| | - Rolla Abu-Arja
- Pediatric Hematology Oncology and Bone Marrow Transplant, Nationwide Children's Hospital, Columbus, OH, USA
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50
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Pleyer L, Döhner H, Dombret H, Seymour JF, Schuh AC, Beach CL, Swern AS, Burgstaller S, Stauder R, Girschikofsky M, Sill H, Schlick K, Thaler J, Halter B, Machherndl Spandl S, Zebisch A, Pichler A, Pfeilstöcker M, Autzinger EM, Lang A, Geissler K, Voskova D, Sperr WR, Hojas S, Rogulj IM, Andel J, Greil R. Azacitidine for Front-Line Therapy of Patients with AML: Reproducible Efficacy Established by Direct Comparison of International Phase 3 Trial Data with Registry Data from the Austrian Azacitidine Registry of the AGMT Study Group. Int J Mol Sci 2017; 18:E415. [PMID: 28212292 DOI: 10.3390/ijms18020415] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 02/06/2017] [Accepted: 02/08/2017] [Indexed: 01/05/2023] Open
Abstract
We recently published a clinically-meaningful improvement in median overall survival (OS) for patients with acute myeloid leukaemia (AML), >30% bone marrow (BM) blasts and white blood cell (WBC) count ≤15 G/L, treated with front-line azacitidine versus conventional care regimens within a phase 3 clinical trial (AZA-AML-001; NCT01074047; registered: February 2010). As results obtained in clinical trials are facing increased pressure to be confirmed by real-world data, we aimed to test whether data obtained in the AZA-AML-001 trial accurately represent observations made in routine clinical practice by analysing additional AML patients treated with azacitidine front-line within the Austrian Azacitidine Registry (AAR; NCT01595295; registered: May 2012) and directly comparing patient-level data of both cohorts. We assessed the efficacy of front-line azacitidine in a total of 407 patients with newly-diagnosed AML. Firstly, we compared data from AML patients with WBC ≤ 15 G/L and >30% BM blasts included within the AZA-AML-001 trial treated with azacitidine ("AML-001" cohort; n = 214) with AAR patients meeting the same inclusion criteria ("AAR (001-like)" cohort; n = 95). The current analysis thus represents a new sub-analysis of the AML-001 trial, which is directly compared with a new sub-analysis of the AAR. Baseline characteristics, azacitidine application, response rates and OS were comparable between all patient cohorts within the trial or registry setting. Median OS was 9.9 versus 10.8 months (p = 0.616) for "AML-001" versus "AAR (001-like)" cohorts, respectively. Secondly, we pooled data from both cohorts (n = 309) and assessed the outcome. Median OS of the pooled cohorts was 10.3 (95% confidence interval: 8.7, 12.6) months, and the one-year survival rate was 45.8%. Thirdly, we compared data from AAR patients meeting AZA-AML-001 trial inclusion criteria (n = 95) versus all AAR patients with World Health Organization (WHO)-defined AML ("AAR (WHO-AML)" cohort; n = 193). Within the registry population, median OS for AAR patients meeting trial inclusion criteria versus all WHO-AML patients was 10.8 versus 11.8 months (p = 0.599), respectively. We thus tested and confirmed the efficacy of azacitidine as a front-line agent in patients with AML, >30% BM blasts and WBC ≤ 15 G/L in a routine clinical practice setting. We further show that the efficacy of azacitidine does not appear to be limited to AML patients who meet stringent clinical trial inclusion criteria, but instead appears efficacious as front-line treatment in all patients with WHO-AML.
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