1
|
Lin RJ, Dahi PB, Korc-Grodzicki B, Shahrokni A, Jakubowski AA, Giralt SA. Transplantation and Cellular Therapy for Older Adults-The MSK Approach. Curr Hematol Malig Rep 2024; 19:82-91. [PMID: 38332462 DOI: 10.1007/s11899-024-00725-y] [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] [Accepted: 01/30/2024] [Indexed: 02/10/2024]
Abstract
PURPOSE OF REVIEW Hematologic malignances more commonly affect older individuals and often present with advanced, higher risk disease than younger patients. Allogeneic and autologous hematopoietic cell transplantation is well-established treatment modalities with curative potential following either frontline treatments for these diseases or salvage therapy in the relapsed or refractory setting. More recently, novel cellular immunotherapy such as chimeric antigen receptor T-cell therapy has been shown to lead to high response rate and durable remission in many patients with advanced blood cancers. RECENT FINDINGS Given unique characteristics of older patients, how best to deliver these higher-intensity and time sensitive treatment modalities for them remains challenging. Moreover, their short-term and potential long-term impact on their functional status, cognitive status, and quality of life may be significant considerations for many older patients. All these issues contributed to the lack of access and significant underutilization of these potential curative treatment strategies. In this review, we present up to date evidence to support potential benefits of transplantation and cellular therapy for older adults, their steady improving outcomes, and most importantly, highlight the use of geriatric assessment to help select appropriate older patients and optimize them prior to and following transplantation and cellular therapy. We specifically describe our approach at Memorial Sloan Kettering Cancer Center and encouraging early results from its implementation.
Collapse
Affiliation(s)
- Richard J Lin
- Adult Blood and Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA.
- David H. Koch Center for Cancer Care, Memorial Sloan Kettering Cancer Center, 530 E 74th Street, Room 21-142, New York, NY, 10022, USA.
| | - Parastoo B Dahi
- Adult Blood and Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Beatriz Korc-Grodzicki
- Geriatrics Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Armin Shahrokni
- Geriatrics Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Ann A Jakubowski
- Adult Blood and Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Sergio A Giralt
- Adult Blood and Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| |
Collapse
|
2
|
Juul-Dam KL, Shukla NN, Cooper TM, Cuglievan B, Heidenreich O, Kolb EA, Rasouli M, Hasle H, Zwaan CM. Therapeutic targeting in pediatric acute myeloid leukemia with aberrant HOX/MEIS1 expression. Eur J Med Genet 2023; 66:104869. [PMID: 38174649 DOI: 10.1016/j.ejmg.2023.104869] [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: 08/31/2022] [Revised: 05/21/2023] [Accepted: 10/22/2023] [Indexed: 01/05/2024]
Abstract
Despite advances in the clinical management of childhood acute myeloid leukemia (AML) during the last decades, outcome remains fatal in approximately one third of patients. Primary chemoresistance, relapse and acute and long-term toxicities to conventional myelosuppressive therapies still constitute significant challenges and emphasize the unmet need for effective targeted therapies. Years of scientific efforts have translated into extensive insights on the heterogeneous spectrum of genetics and oncogenic signaling pathways of AML and identified a subset of patients characterized by upregulation of HOXA and HOXB homeobox genes and myeloid ecotropic virus insertion site 1 (MEIS1). Aberrant HOXA/MEIS1 expression is associated with genotypes such as rearrangements in Histone-lysine N-methyltransferase 2A (KMT2A-r), nucleoporin 98 (NUP98-r) and mutated nucleophosmin (NPM1c) that are found in approximately one third of children with AML. AML with upregulated HOXA/MEIS1 shares a number of molecular vulnerabilities amenable to recently developed molecules targeting the assembly of protein complexes or transcriptional regulators. The interaction between the nuclear scaffold protein menin and KMT2A has gained particular interest and constitutes a molecular dependency for maintenance of the HOXA/MEIS1 transcription program. Menin inhibitors disrupt the menin-KMT2A complex in preclinical models of KMT2A-r, NUP98-r and NPM1c acute leukemias and its occupancy at target genes leading to leukemic cell differentiation and apoptosis. Early-phase clinical trials are either ongoing or in development and preliminary data suggests tolerable toxicities and encouraging efficacy of menin inhibitors in adults with relapsed or refractory KMT2A-r and NPM1c AML. The Pediatric Acute Leukemia/European Pediatric Acute Leukemia (PedAL/EUPAL) project is focused to advance and coordinate informative clinical trials with new agents and constitute an ideal framework for testing of menin inhibitors in pediatric study populations. Menin inhibitors in combination with standard chemotherapy or other targeting agents may enhance anti-leukemic effects and constitute rational treatment strategies for select genotypes of childhood AML, and provide enhanced safety to avoid differentiation syndrome. In this review, we discuss the pathophysiological mechanisms in KMT2A-r, NUP98-r and NPM1c AML, emerging molecules targeting the HOXA/MEIS1 transcription program with menin inhibitors as the most prominent examples and future therapeutic implications of these agents in childhood AML.
Collapse
Affiliation(s)
- Kristian L Juul-Dam
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark.
| | - Neerav N Shukla
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Todd M Cooper
- Division of Hematology/Oncology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Branko Cuglievan
- Division of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Olaf Heidenreich
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands; Wolfson Childhood Cancer Research Centre, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - E Anders Kolb
- Division of Oncology, Nemours/Alfred I. Dupont Hospital for Children, Wilmington, DE, USA
| | - Milad Rasouli
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands; Department of Pediatric Oncology, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Henrik Hasle
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - C Michel Zwaan
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands; Department of Pediatric Oncology, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| |
Collapse
|
3
|
Saini L, Griffin JD, Pandya BJ, Shah MV, Zhou M, Yang H, Song Y, Marshall DA. Patient and Physician Preferences for Acute Myeloid Leukemia Maintenance Treatments Following Hematopoietic Stem Cell Transplantation. Patient Prefer Adherence 2023; 17:2805-2819. [PMID: 37953977 PMCID: PMC10637189 DOI: 10.2147/ppa.s421871] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 10/14/2023] [Indexed: 11/14/2023] Open
Abstract
Purpose This study assessed and compared preferences for treatment attributes of maintenance therapies post-hematopoietic stem cell transplantation (HSCT) in patients with acute myeloid leukemia (AML) and in physicians who treat these patients. Patients and Methods Patients with AML post HSCT and physicians from the United States, United Kingdom, Canada, and Australia (physicians only) completed a web-based discrete choice experiment (DCE). The DCE used inputs identified via a targeted literature review and qualitative interviews to ascertain relevant treatment attributes and associated levels. Six treatment attributes were selected (chance of 2-year relapse-free survival, quality of life [QoL], risk of serious infections, risk of nausea, chance of achieving transfusion independence, and duration of hospitalization annually), each with three or four levels. The experimental design included 36 choice tasks that presented a pair of hypothetical treatment profiles with varying attribute levels; participants chose a preferred treatment for each choice task. Choice tasks were divided into three blocks of 12 tasks each in the patient survey and 4 blocks of 9 tasks each in the physician survey; survey participants were randomly assigned to one of the blocks. Random parameter logit regression models were used to assess the impact of stated attributes on preferences for maintenance treatment post HSCT. Results Surveys from 84 patients and 149 physicians were assessed. For patients, QoL was the most important attribute, followed by duration of hospitalization and chance of 2-year relapse-free survival. For physicians, chance of 2-year relapse-free survival was the most important attribute, followed by QoL and risk of serious infections. Conclusion Differences in how patients and physicians valued post-HSCT maintenance treatment attributes were identified. These differences suggest that patient-centered decision-making may help physicians choose maintenance treatments for patients with AML post HSCT that better meet their treatment needs and improve their treatment satisfaction.
Collapse
Affiliation(s)
- Lalit Saini
- London Health Sciences Centre, London, Ontario, Canada
| | | | | | | | - Mo Zhou
- Analysis Group, Boston, MA, USA
| | | | | | - Deborah A Marshall
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
4
|
Kent A, Schwartz M, McMahon C, Amaya M, Smith CA, Tobin J, Marciano K, Rezac R, Bosma G, Pollyea DA, Gutman JA. Venetoclax is safe and tolerable as post-transplant maintenance therapy for AML patients at high risk for relapse. Bone Marrow Transplant 2023; 58:849-854. [PMID: 37185614 DOI: 10.1038/s41409-023-01987-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 04/05/2023] [Accepted: 04/11/2023] [Indexed: 05/17/2023]
Abstract
Relapse is the most common cause of mortality in acute myeloid leukemia (AML) patients after allogeneic stem cell transplant (SCT). Post-SCT maintenance strategies that prevent relapse are desirable but must be well tolerated and convenient to administer. We hypothesized single agent venetoclax (ven) may be an effective maintenance therapy among high relapse risk patients. Between February 2019 and December 2021, we administered post-SCT ven maintenance to 49 AML patients at high-risk for relapse as a prospectively defined off-label practice at our institution. Ven was planned to be administered until 1-year post-SCT. While temporary interruptions were common (67.3% of all patients), of those with >1 year follow up, 22/25 (88%) completed the full year of planned therapy. Cytopenias (40.8%) and gastrointestinal adverse events (34.7%) were the most common toxicities. At 1-year post-SCT, overall survival (OS) and relapse-free survival (RFS) were 70% and 67% respectively. Our experience demonstrates single agent ven is a safe, tolerable, and feasible maintenance therapy that may improve RFS and OS in high relapse risk post-SCT patients.
Collapse
Affiliation(s)
- Andrew Kent
- The University of Colorado School of Medicine, Division of Hematology, Aurora, CO, USA
| | - Marc Schwartz
- The University of Colorado School of Medicine, Division of Hematology, Aurora, CO, USA
| | - Christine McMahon
- The University of Colorado School of Medicine, Division of Hematology, Aurora, CO, USA
| | - Maria Amaya
- The University of Colorado School of Medicine, Division of Hematology, Aurora, CO, USA
| | - Clayton A Smith
- The University of Colorado School of Medicine, Division of Hematology, Aurora, CO, USA
| | - Jennifer Tobin
- The University of Colorado School of Medicine, Division of Hematology, Aurora, CO, USA
| | - Kelsey Marciano
- The University of Colorado School of Medicine, Division of Hematology, Aurora, CO, USA
| | - Rebecca Rezac
- The University of Colorado School of Medicine, Division of Hematology, Aurora, CO, USA
| | - Grace Bosma
- The University of Colorado School of Medicine, Division of Hematology, Aurora, CO, USA
| | - Daniel A Pollyea
- The University of Colorado School of Medicine, Division of Hematology, Aurora, CO, USA
| | - Jonathan A Gutman
- The University of Colorado School of Medicine, Division of Hematology, Aurora, CO, USA.
| |
Collapse
|
5
|
Molica M, Perrone S, Rossi M. Gilteritinib: The Story of a Proceeding Success into Hard-to-Treat FLT3-Mutated AML Patients. J Clin Med 2023; 12:jcm12113647. [PMID: 37297842 DOI: 10.3390/jcm12113647] [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: 04/26/2023] [Revised: 05/18/2023] [Accepted: 05/22/2023] [Indexed: 06/12/2023] Open
Abstract
The traditionally dismal outcome of acute myeloid leukemia (AML) patients carrying the FMS-related tyrosine kinase 3 (FLT3) mutations has been mitigated by the recent introduction of tyrosine kinase inhibitors (TKI) into clinics, such as midostaurin and gilteritinib. The present work summarizes the clinical data that led to the use of gilteritinib in clinical practice. Gilteritinib is a second-generation TKI with deeper single-agent activity than first-generation drugs against both FLT3-ITD and TKD mutations in human studies. Moreover, the phase I/II dose-escalation, dose-expansion Chrysalis trial showed an acceptable safety profile of gilteritinib (diarrhea, elevated aspartate aminotransferase, febrile neutropenia, anemia, thrombocytopenia, sepsis, and pneumonia) and a 49% overall response rate (ORR) in 191 FLT3-mutated relapsed/refractory (R/R) AML patients. In 2019, the pivotal ADMIRAL trial showed that the median overall survival was significantly longer in patients treated with gilteritinib than among those receiving chemotherapy (9.3 vs. 5.6 months, respectively) and the ORR to gilteritinib was 67.6%, outperforming the 25.8% for chemotherapy arm and leading to the license for its clinical use by the US Food and Drug Administration. Since then, several real-world experiences have confirmed the positive results in the R/R AML setting. Finally, gilteritinib-based combinations currently under investigation, with several compounds (venetoclax, azacitidine, conventional chemotherapy, etc.) and some practical tips (maintenance after allogeneic transplantation, interaction with antifungal drugs, extramedullary disease, and onset of resistance), will be analyzed in detail in this review.
Collapse
Affiliation(s)
- Matteo Molica
- Department of Hematology-Oncology, Azienda Ospedaliera Pugliese-Ciaccio, 88100 Catanzaro, Italy
| | - Salvatore Perrone
- Department of Hematology, Polo Universitario Pontino, S.M. Goretti Hospital, 04100 Latina, Italy
| | - Marco Rossi
- Department of Hematology-Oncology, Azienda Ospedaliera Pugliese-Ciaccio, 88100 Catanzaro, Italy
| |
Collapse
|
6
|
Najima Y. Overcoming relapse: prophylactic or pre-emptive use of azacitidine or FLT3 inhibitors after allogeneic transplantation for AML or MDS. Int J Hematol 2023:10.1007/s12185-023-03596-w. [PMID: 37036626 DOI: 10.1007/s12185-023-03596-w] [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] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 03/24/2023] [Accepted: 03/28/2023] [Indexed: 04/11/2023]
Abstract
Relapse remains the most critical obstacle in treatment by allogeneic hematopoietic stem cell transplantation (HSCT). Non-relapse mortality has improved annually, but relapse mortality remains high. Post-transplant maintenance treatment, such as hypomethylating agents and FMS-like tyrosine kinase 3 (FLT3) inhibitors, has been investigated for decades as a means of preventing disease relapse after HSCT. Other factors besides the relapse tendency of the primary disease that can affect the transition of estimated disease burden in patients undergoing HSCT are disease status at HSCT (non-remission, remission with minimal/measurable residual disease (MRD), and remission without MRD) and conditioning regimen intensity. Optimal selection of patients at high risk for relapse who can tolerate a long duration of therapy is pivotal for successful post-transplant maintenance therapy. In this review, we provide an overview of current progress in research on post-transplant maintenance treatment using azacitidine or FLT3 inhibitors for preventing disease relapse after HSCT for AML or MDS, and discuss the future outlook in this area.
Collapse
Affiliation(s)
- Yuho Najima
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-8-22 Honkomagome, Bunkyo-Ku, Tokyo, 113-8677, Japan.
| |
Collapse
|
7
|
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.
Collapse
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
| |
Collapse
|
8
|
Zavras PD, Sinanidis I, Tsakiroglou P, Karantanos T. Understanding the Continuum between High-Risk Myelodysplastic Syndrome and Acute Myeloid Leukemia. Int J Mol Sci 2023; 24:ijms24055018. [PMID: 36902450 PMCID: PMC10002503 DOI: 10.3390/ijms24055018] [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: 01/31/2023] [Revised: 03/01/2023] [Accepted: 03/03/2023] [Indexed: 03/08/2023] Open
Abstract
Myelodysplastic syndrome (MDS) is a clonal hematopoietic neoplasm characterized by bone marrow dysplasia, failure of hematopoiesis and variable risk of progression to acute myeloid leukemia (AML). Recent large-scale studies have demonstrated that distinct molecular abnormalities detected at earlier stages of MDS alter disease biology and predict progression to AML. Consistently, various studies analyzing these diseases at the single-cell level have identified specific patterns of progression strongly associated with genomic alterations. These pre-clinical results have solidified the conclusion that high-risk MDS and AML arising from MDS or AML with MDS-related changes (AML-MRC) represent a continuum of the same disease. AML-MRC is distinguished from de novo AML by the presence of certain chromosomal abnormalities, such as deletion of 5q, 7/7q, 20q and complex karyotype and somatic mutations, which are also present in MDS and carry crucial prognostic implications. Recent changes in the classification and prognostication of MDS and AML by the International Consensus Classification (ICC) and the World Health Organization (WHO) reflect these advances. Finally, a better understanding of the biology of high-risk MDS and the mechanisms of disease progression have led to the introduction of novel therapeutic approaches, such as the addition of venetoclax to hypomethylating agents and, more recently, triplet therapies and agents targeting specific mutations, including FLT3 and IDH1/2. In this review, we analyze the pre-clinical data supporting that high-risk MDS and AML-MRC share the same genetic abnormalities and represent a continuum, describe the recent changes in the classification of these neoplasms and summarize the advances in the management of patients with these neoplasms.
Collapse
|
9
|
Hassan MA, Moukalled N, El Cheikh J, Bazarbachi A, Abou Dalle I. Azacitidine in Combination with Venetoclax Maintenance Post-allogeneic Hematopoietic Stem Cell Transplantation in T Cell Acute Lymphoblastic Leukemia. Clin Hematol Int 2023. [PMID: 36595164 DOI: 10.1007/s44228-022-00019-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 09/09/2022] [Indexed: 01/04/2023] Open
|
10
|
Lin RJ. Allogeneic Transplantation for Older Patients with Acute Myeloid Leukemia: The Dawn of a New Era. Transplant Cell Ther 2022; 28:793-794. [PMID: 36470612 PMCID: PMC9827512 DOI: 10.1016/j.jtct.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
|
11
|
Gutman JA. How Can We Intervene to Mitigate Post-transplantation Relapse in AML? Strategies to Mitigate Post-transplantation Relapse in AML. Best Pract Res Clin Haematol 2022. [DOI: 10.1016/j.beha.2022.101411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
|
12
|
Najima Y, Tachibana T, Takeda Y, Koda Y, Aoyama Y, Toya T, Igarashi A, Tanaka M, Sakaida E, Abe R, Onizuka M, Kobayashi T, Doki N, Ohashi K, Kanamori H, Ishizaki T, Yokota A, Morita S, Okamoto S, Kanda Y. Dose-finding trial of azacitidine as post-transplant maintenance for high-risk MDS: a KSGCT prospective study. Ann Hematol 2022; 101:2719-2729. [PMID: 36149461 DOI: 10.1007/s00277-022-04981-x] [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: 10/28/2021] [Accepted: 09/15/2022] [Indexed: 11/28/2022]
Abstract
This 3+3 dose-escalation phase I multicenter study investigated the optimal dose of azacitidine (AZA) for post-hematopoietic stem cell transplantation (HSCT) maintenance, which remains unknown in Japan. Recipients of a first HSCT for high-risk myelodysplastic syndromes (MDS, n = 12) or acute myeloid leukemia (AML) with antecedent MDS (n = 3) received post-HSCT AZA maintenance in 2015-2019. The optimal AZA dose was defined as the dose at which 50-70% of patients can complete four cycles without dose-limiting toxicity (DLT). The initial dose level 1 was set as 30 mg/m2 for 5 days per 28-day cycle, and dose levels 0, 2, and 3 were set as 20, 40, and 50 mg/m2. DLT was defined as any grade 3 non-hematological or grade 4 hematological toxicity. The 15 evaluable patients were 55 (37-64) years old. The median observation of the post-HSCT survivors was 935 (493-1915) days. The median number of days post-HSCT to the start of AZA was 101 (59-176). In the first, second, and third cohorts, five of nine patients completed four cycles at dose level 1. In the final cohort, five of six additional patients completed at the same dose. In total, 10 (67%) patients tolerated AZA 30 mg/m2, which was determined as optimal. DLT occurred in five cases: grade 3 hepatotoxicity, pneumonia, enterocolitis, and grade 4 thrombocytopenia and neutropenia. The 2-year overall survival and disease-free survival rates post-HSCT were 77.0% and 73.3%. Post-HSCT AZA maintenance was well-tolerated and merits further evaluation for patients with MDS or AML with antecedent MDS. Trial registration: UMIN000018791.
Collapse
Affiliation(s)
- Yuho Najima
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, 113-8677, Japan.
| | | | - Yusuke Takeda
- Department of Hematology, Chiba University Hospital, Chiba, Japan
| | - Yuya Koda
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yasuhisa Aoyama
- Department of Hematology and Oncology, Tokai University School of Medicine, Isehara, Japan
| | - Takashi Toya
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, 113-8677, Japan
| | - Aiko Igarashi
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, 113-8677, Japan
| | - Masatsugu Tanaka
- Department of Hematology, Kanagawa Cancer Center, Yokohama, Japan
| | - Emiko Sakaida
- Department of Hematology, Chiba University Hospital, Chiba, Japan
| | - Ryohei Abe
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Makoto Onizuka
- Department of Hematology and Oncology, Tokai University School of Medicine, Isehara, Japan
| | - Takeshi Kobayashi
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, 113-8677, Japan
| | - Noriko Doki
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, 113-8677, Japan
| | - Kazuteru Ohashi
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, 113-8677, Japan
| | - Heiwa Kanamori
- Department of Hematology, Kanagawa Cancer Center, Yokohama, Japan
| | - Takuma Ishizaki
- Department of Hematology, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Akira Yokota
- Department of Hematology, Chiba Aoba Municipal Hospital, Chiba, Japan
| | - Satoshi Morita
- Department of Biomedical Statistics and Bioinformatics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Shinichiro Okamoto
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yoshinobu Kanda
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| |
Collapse
|
13
|
Abstract
Allogeneic hematopoietic cell transplant (allo-HCT) for eligible patients with acute myeloid leukemia (AML) in first complete remission is a central treatment paradigm to achieve durable remission. However, disease relapse after allo-HCT remains a significant concern and generally portends a poor prognosis. There is significant interest regarding the role for maintenance therapy after allo-HCT for patients with high risk of relapse, regardless of the presence of measurable residual disease. While there are currently no therapies approved for maintenance therapy for AML after allo-HCT, there are a number of ongoing investigations examining the role of maintenance therapies that include targeted agents against FLT3-ITD or IDH mutations, hypomethylating agents, immunomodulatory therapies and cellular therapies. In this review, we examine the current landscape and future strategies for maintenance therapy for AML after allo-HCT.
Collapse
Affiliation(s)
- Rahul K. Nayak
- Department of Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Yi-Bin Chen
- Hematopoietic Cell Transplant and Cell Therapy Program, Massachusetts General Hospital, Boston, MA, United States
| |
Collapse
|
14
|
Manobianco SA, Rakiewicz T, Wilde L, Palmisiano ND. Novel Mechanisms for Post-Transplant Maintenance Therapy in Acute Myeloid Leukemia. Front Oncol 2022; 12:892289. [PMID: 35912243 PMCID: PMC9336463 DOI: 10.3389/fonc.2022.892289] [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: 03/08/2022] [Accepted: 06/08/2022] [Indexed: 11/13/2022] Open
Abstract
Allogeneic stem cell transplantation has improved survival for patients with acute myeloid leukemia (AML), especially for patients with disease at high risk of relapse. However, relapse remains the most common cause of treatment failure and death in the post-transplant period. Maintenance therapy, an extended course of treatment after achieving remission to reduce the rate of relapse, is an important component of the treatment of various hematologic malignancies; however, its role in the treatment of AML is far less well-defined. Recently, there has been significant interest in the use of novel therapeutic agents as maintenance therapy after allogeneic stem cell transplant, utilizing new mechanisms of treatment and more favorable toxicity profiles. In this review, we will discuss the mechanistic and clinical data for post-transplant maintenance therapies in AML. Then, we will review several emergent and current clinical trials which aim to incorporate novel agents into maintenance therapy regimens.
Collapse
Affiliation(s)
- Steven A. Manobianco
- Thomas Jefferson University Hospital, Jefferson University Hospitals, Philadelphia, PA, United States
| | - Tara Rakiewicz
- Thomas Jefferson University Hospital, Jefferson University Hospitals, Philadelphia, PA, United States
| | - Lindsay Wilde
- Department of Medical Oncology, Division of Hematologic Malignancy and Stem Cell Transplantation, Philadelphia, PA, United States
| | - Neil D. Palmisiano
- Department of Medical Oncology, Division of Hematologic Malignancy and Stem Cell Transplantation, Philadelphia, PA, United States
| |
Collapse
|
15
|
Kungwankiattichai S, Ponvilawan B, Roy C, Tunsing P, Kuchenbauer F, Owattanapanich W. Maintenance With Hypomethylating Agents After Allogeneic Stem Cell Transplantation in Acute Myeloid Leukemia and Myelodysplastic Syndrome: A Systematic Review and Meta-Analysis. Front Med (Lausanne) 2022; 9:801632. [PMID: 35242779 PMCID: PMC8887643 DOI: 10.3389/fmed.2022.801632] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [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: 10/25/2021] [Accepted: 01/10/2022] [Indexed: 01/25/2023] Open
Abstract
Introduction Hypomethylating agents (HMAs) seem to have a range of properties favorable to post-allogeneic hematopoietic stem cell transplantation (allo-SCT) maintenance in acute myeloid leukemia (AML) patients. Materials and Methods The Embase, MEDLINE, and Cochrane Central Register of Controlled Trials databases were independently searched by two investigators to identify relevant studies published inception to 18 November 2021. These trials compared HMA maintenance to observation following allo-SCT for AML or myelodysplastic syndrome. Results The meta-analysis eligibility criteria were fulfilled by 14 studies. The overall survival and relapse-free survival of the HMA maintenance group were superior to the observation group, with a pooled risk ratio (RR) of 1.38 and 1.46, respectively. Moreover, the cumulative incidence of relapse was significantly lower in those who received HMAs. The HMA group also had lower non-relapse mortality compared with the observation group. Overall, the incidences of grades III–IV acute graft-vs.-host disease (GVHD) and chronic GVHD did not differ in both groups. However, when looking specifically at those receiving decitabine maintenance, the rate of chronic GVHD seemed to be lower compared with observation alone. Conclusions The current systematic review and meta-analysis illustrated that AML and MDS patients receiving HMA maintenance after allo-SCT had better outcomes in regards to OS, RFS, NRM, CIR as well as a reduced incidence of chronic GVHD.
Collapse
Affiliation(s)
- Smith Kungwankiattichai
- Division of Hematology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ben Ponvilawan
- Department of Pharmacology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Claudie Roy
- Vancouver General Hospital, L/BMT Program of British Columbia, Vancouver, BC, Canada
| | - Pattaraporn Tunsing
- Division of Hematology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Florian Kuchenbauer
- Vancouver General Hospital, L/BMT Program of British Columbia, Vancouver, BC, Canada.,British Columbia Research Centre, Terry Fox Laboratory, Vancouver, BC, Canada
| | - Weerapat Owattanapanich
- Division of Hematology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| |
Collapse
|
16
|
Abstract
PURPOSE OF REVIEW Disease relapse remains the most common cause of death among patients with acute myeloid leukemia (AML) following induction therapy and allogeneic hematopoietic cell transplant (allo-HCT). Prolonging the duration of remission with minimal nonrelapse mortality risk is an area of unmet need for AML patients. RECENT FINDINGS In QUAZAR AML-001 study, the oral azacitidine analogue CC-486 demonstrated an overall survival (OS) benefit when given as postremission therapy (PRT) for patients in CR1 that were ineligible to proceed to allo-HCT. Used as maintenance post allo-HCT, CC-486 has also shown safety with encouraging disease-free survival (DFS). Although a recent randomized trial of parenteral azacitidine vs. placebo post allo-HCT failed to show relapse reduction, a subsequent meta-analysis of maintenance studies posttransplant has shown good utility with this approach. Such conflicting results emphasize the need for robust study designs to identify subsets of patients that derive maximal benefits using latest tools to risk stratify relapse risk. SUMMARY PRT with hypomethylating agents is feasible and in select population, there is a survival advantage with CC-486. Better understanding of distinct epigenetic and immunomodulatory properties of azacitidine, holds significant promise to synergize pharmacologic and cellular drivers of disease control as PRT in future AML trials.
Collapse
Affiliation(s)
- Jan Philipp Bewersdorf
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Thomas Prebet
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Lohith Gowda
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, Yale University, New Haven, Connecticut, USA
| |
Collapse
|
17
|
Abstract
As in younger patients, allogeneic stem cell transplantation (alloHSCT) offers the best chance for durable remission in older patients (≥60 years) with acute myeloid leukemia (AML). However, defining the best treatment strategy (and in particular, whether or not to proceed to alloHSCT) for elderly patients with AML remains a difficult decision for the hematologist, since potential toxicity of conditioning regimens, risks of graft-versus-host disease, impaired immune reconstitution and the need for prolonged immunosuppression may be of major concern in these vulnerable patients with complex needs. Hopefully, significant progress has been made over the past decade in alloHSCT for elderly patients and current evidence suggests that chronological age per se (between 60 and 75) is not a reliable predictor of outcome after alloHSCT. Here, we review the current state of alloHSCT in elderly patients with AML and also discuss the different approaches currently being investigated to improve both accessibility to as well as success of alloHSCT in these patients.
Collapse
Affiliation(s)
- Sophie Servais
- Department of Clinical Hematology, CHU of Liège, Liège, Belgium
- Hematology Research Unit GIGA-I3, University of Liège, Liège, Belgium
| | - Yves Beguin
- Department of Clinical Hematology, CHU of Liège, Liège, Belgium
- Hematology Research Unit GIGA-I3, University of Liège, Liège, Belgium
| | - Frédéric Baron
- Corresponding author: Baron Frédéric, Clinical Hematology Department, University of Liège, CHU of Liège (Sart-Tilman), 4000 Liège, Belgium. Tel: +32 4 366 72 01;
| |
Collapse
|