1
|
Urbino I, Secreto C, Olivi M, Apolito V, D'Ardia S, Frairia C, Giai V, Aydin S, Freilone R, Dellacasa C, Giaccone L, Ferrero D, Audisio E, Busca A, Cerrano M. Evolving Therapeutic Approaches for Older Patients with Acute Myeloid Leukemia in 2021. Cancers (Basel) 2021; 13:5075. [PMID: 34680226 DOI: 10.3390/cancers13205075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 09/06/2021] [Revised: 09/29/2021] [Accepted: 10/04/2021] [Indexed: 02/06/2023] Open
Abstract
Simple Summary The better understanding of disease biology, the availability of new effective drugs and the increased awareness of patients’ heterogeneity in terms of fitness and personal expectations has made the current treatment paradigm of AML in the elderly very challenging. Here, we discuss the evolving criteria used to define eligibility for induction chemotherapy and transplantation, the introduction of new agents in the treatment of patients with very different clinical conditions, the implications of precision medicine and the importance of quality of life and supportive care, proposing a simplified algorithm that we follow in 2021. Abstract Acute myeloid leukemia (AML) in older patients is characterized by unfavorable prognosis due to adverse disease features and a high rate of treatment-related complications. Classical therapeutic options range from intensive chemotherapy in fit patients, potentially followed by allogeneic hematopoietic cell transplantation (allo-HCT), to hypomethylating agents or palliative care alone for unfit/frail ones. In the era of precision medicine, the treatment paradigm of AML is rapidly changing. On the one hand, a plethora of new targeted drugs with good tolerability profiles are becoming available, offering the possibility to achieve a prolonged remission to many patients not otherwise eligible for more intensive therapies. On the other hand, better tools to assess patients’ fitness and improvements in the selection and management of those undergoing allo-HCT will hopefully reduce treatment-related mortality and complications. Importantly, a detailed genetic characterization of AML has become of paramount importance to choose the best therapeutic option in both intensively treated and unfit patients. Finally, improving supportive care and quality of life is of major importance in this age group, especially for the minority of patients that are still candidates for palliative care because of very poor clinical conditions or unwillingness to receive active treatments. In the present review, we discuss the evolving approaches in the treatment of older AML patients, which is becoming increasingly challenging following the advent of new effective drugs for a very heterogeneous and complex population.
Collapse
|
2
|
Daher-Reyes G, Kim T, Novitzky-Basso I, Kim KH, Smith A, Stockley T, Capochichi JM, Al-Shaibani Z, Pasic I, Law A, Lam W, Michelis FV, Gerbitz A, Viswabandya A, Lipton J, Kumar R, Mattsson J, Schimmer A, McNamara C, Murphy T, Maze D, Gupta V, Sibai H, Chan S, Yee K, Minden M, Zhang Z, Schuh A, Kim DDH. Prognostic impact of the adverse molecular-genetic profile on long-term outcomes following allogeneic hematopoietic stem cell transplantation in acute myeloid leukemia. Bone Marrow Transplant 2021; 56:1908-1918. [PMID: 33767401 DOI: 10.1038/s41409-021-01255-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 02/03/2021] [Accepted: 02/19/2021] [Indexed: 12/27/2022]
Abstract
The impact of adverse risk genetic profiles on outcomes in acute myeloid leukemia (AML) patients following allogeneic hematopoietic stem cell transplantation (HCT) has not been fully elucidated. Accordingly, we have profiled somatic mutations at diagnosis using next-generation sequencing (NGS) in 178 AML patients who received allogeneic HCT. NGS revealed 598 somatic mutations in 165/178 patients (92.7%). Frequently mutated genes include DNMT3A, TET2, NPM1, RUNX1, IDH2, and FLT3. Commonly detected cytogenetic profiles include normal karyotype, trisomy 8, monosomal karyotype (MK), deletion 5, complex karyotype (CK), and monosomy 7. In univariate analyses, TP53 mutation, MK, CK, and monosomy 7 were associated with decreased overall survival (OS), relapse-free survival (RFS), and a higher relapse incidence (RI). We defined adverse molecular-genetic profile as harboring at least one of the molecular/genetic abnormalities of TP53 mutation, MK, CK, monosomy 7, and deletion 5. The patients harboring adverse molecular-genetic profile (n = 30) showed a lower 2-year OS (24.9% vs. 57.9%; p = 0.003), RFS (23.7% vs. 57.9%; p = 0.002), and higher RI (47.2% and 17.2%; p = 0.001) after HCT when compared to patients without those lesions. Multivariate analysis confirmed adverse molecular-genetic profile as an independent prognostic factor, associated with decreased OS (HR 2.19), RFS (HR 2.23), and higher RI (HR 2.94).
Collapse
Affiliation(s)
- Georgina Daher-Reyes
- Department of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - TaeHyung Kim
- Department of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada.,Department of Computer Science, University of Toronto, Toronto, ON, Canada.,Donnelly Centre for Cellular and Biomolecular Research, University of Toronto, Toronto, ON, Canada
| | - Igor Novitzky-Basso
- Department of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Kyuoung Ha Kim
- Department of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada.,Department of Internal Medicine, Soonchunhyang University Hospital, Seoul, Korea
| | - Adam Smith
- Clinical Lab Genetics Division, Laboratory of Molecular Pathology, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Tracy Stockley
- Clinical Lab Genetics Division, Laboratory of Molecular Pathology, Toronto General Hospital, University Health Network, Toronto, ON, Canada.,Advanced Molecular Diagnostics Laboratory, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Jose-Mario Capochichi
- Advanced Molecular Diagnostics Laboratory, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Zeyad Al-Shaibani
- Department of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Ivan Pasic
- Department of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Arjun Law
- Department of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Wilson Lam
- Department of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Fotios V Michelis
- Department of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Armin Gerbitz
- Department of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Auro Viswabandya
- Department of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Jeffrey Lipton
- Department of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Rajat Kumar
- Department of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Jonas Mattsson
- Department of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Aaron Schimmer
- Department of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Caroline McNamara
- Department of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Tracy Murphy
- Department of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Dawn Maze
- Department of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Vikas Gupta
- Department of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Hassan Sibai
- Department of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Steven Chan
- Department of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Karen Yee
- Department of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Mark Minden
- Department of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Zhaolei Zhang
- Department of Computer Science, University of Toronto, Toronto, ON, Canada.,Donnelly Centre for Cellular and Biomolecular Research, University of Toronto, Toronto, ON, Canada.,Department of Molecular Genetics, University of Toronto, Toronto, ON, Canada
| | - Andre Schuh
- Department of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Dennis D H Kim
- Department of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada.
| |
Collapse
|
3
|
Langenhorst JB, Dorlo TPC, van Kesteren C, van Maarseveen EM, Nierkens S, de Witte MA, Boelens JJ, Huitema ADR. Clinical Trial Simulation To Optimize Trial Design for Fludarabine Dosing Strategies in Allogeneic Hematopoietic Cell Transplantation. CPT Pharmacometrics Syst Pharmacol 2020; 9:272-281. [PMID: 31957334 PMCID: PMC7239337 DOI: 10.1002/psp4.12486] [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] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 12/03/2019] [Indexed: 12/12/2022]
Abstract
Optimal fludarabine exposure has been associated with improved treatment outcome in allogeneic hematopoietic cell transplantation, suggesting potential benefit of individualized dosing. A randomized controlled trial (RCT) comparing alternative fludarabine dosing strategies to current practice may be warranted, but should be sufficiently powered for a relevant end point, while still feasible to enroll. To find the optimal design, we simulated RCTs comparing current practice (160 mg/m2 ) to either covariate-based or therapeutic drug monitoring (TDM)-guided dosing with potential outcomes being nonrelapse mortality (NRM), graft failure, or relapse, and ultimately overall survival (covering all three aforementioned outcomes). The inclusion in each treatment arm (n) required to achieve 80% power was calculated for all combinations of end points and dosing comparisons. The trial requiring the lowest n for sufficient power compared TDM-guided dosing to current practice with NRM as primary outcome (n = 70, NRM decreasing from 21% to 5.7%). We conclude that a superiority trial is feasible.
Collapse
Affiliation(s)
- Jurgen B Langenhorst
- Pediatric Blood and Marrow Transplant Program, Princess Maxima Center for Pediatric Oncology, Utrecht, The Netherlands.,Laboratory of Translational Immunology, University Medical Centre Utrecht (UMCU), Utrecht University, Utrecht, The Netherlands.,Model-informed drug development consultant, Pharmetheus AB, Uppsala, Sweden
| | - Thomas P C Dorlo
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek Hospital, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Charlotte van Kesteren
- Pediatric Blood and Marrow Transplant Program, Princess Maxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Erik M van Maarseveen
- Department of Clinical Pharmacy, University Medical Centre Utrecht (UMCU), Utrecht University, Utrecht, The Netherlands
| | - Stefan Nierkens
- Pediatric Blood and Marrow Transplant Program, Princess Maxima Center for Pediatric Oncology, Utrecht, The Netherlands.,Laboratory of Translational Immunology, University Medical Centre Utrecht (UMCU), Utrecht University, Utrecht, The Netherlands
| | - Moniek A de Witte
- Department of Hematology, University Medical Centre Utrecht (UMCU), Utrecht University, Utrecht, The Netherlands
| | - Jaap Jan Boelens
- Pediatric Blood and Marrow Transplant Program, Princess Maxima Center for Pediatric Oncology, Utrecht, The Netherlands.,Stem Cell Transplant and Cellular Therapies, Pediatrics, Memorial Sloan Kettering Cancer Centre, New York, New York, USA
| | - Alwin D R Huitema
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek Hospital, Netherlands Cancer Institute, Amsterdam, The Netherlands.,Department of Clinical Pharmacy, University Medical Centre Utrecht (UMCU), Utrecht University, Utrecht, The Netherlands
| |
Collapse
|
4
|
Salvatore D, Labopin M, Ruggeri A, Battipaglia G, Ghavamzadeh A, Ciceri F, Blaise D, Arcese W, Sociè G, Bourhis JH, Van Lint MT, Bruno B, Huynh A, Santarone S, Deconinck E, Mohty M, Nagler A. Outcomes of hematopoietic stem cell transplantation from unmanipulated haploidentical versus matched sibling donor in patients with acute myeloid leukemia in first complete remission with intermediate or high-risk cytogenetics: a study from the Acute Leukemia Working Party of the European Society for Blood and Marrow Transplantation. Haematologica 2018; 103:1317-1328. [PMID: 29748438 PMCID: PMC6068036 DOI: 10.3324/haematol.2018.189258] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [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: 01/22/2018] [Accepted: 05/10/2018] [Indexed: 12/15/2022] Open
Abstract
Allogeneic hematopoietic stem cell transplantation is the optimal care for patients with high-risk or intermediate - acute myeloid leukemia. In patients lacking matched sibling donor, haploidentical donors are an option. We compared outcomes of unmanipulated (Haplo) to matched sibling donor transplant in acute myeloid leukemia patients in first complete remission. Included were intermediate and high-risk acute myeloid leukemia in first complete remission undergoing Haplo and matched sibling donor transplant from 2007-2015, and reported to the ALWP of the EBMT. A propensity score technique was used to confirm results of main analysis: 2 matched sibling donors were matched with 1 Haplo. We identified 2654 pts (Haplo =185; matched sibling donor =2469), 2010 with intermediate acute myeloid leukemia (Haplo=122; matched sibling donor =1888) and 644 with high-risk acute myeloid leukemia (Haplo =63; matched sibling donor =581). Median follow up was 30 (range 1-116) months. In multivariate analysis, in intermediate - acute myeloid leukemia patients, Haplo resulted in lower leukemia-free survival (Hazard Ratio 1.74; P<0.01), overall-survival (HR 1.80; P<0.01) and GvHD-free-relapse-free survival (Hazard Ratio 1.32; P<0.05) and higher graft-versus-host disease (GvHD) non-relapse mortality (Hazard Ratio 3.03; P<0.01) as compared to matched sibling donor. In high-risk acute myeloid leukemia, no differences were found in leukemia-free survival, overall-survival, and GvHD-free- relapse-free survival according to donor type. Higher grade II-IV acute GvHD was observed for Haplo in both high-risk (Hazard Ratio 2.20; P<0.01) and intermediate risk (Hazard Ratio 1.84; P<0.01). A trend for a lower Relapse-Incidence was observed in Haplo among high-risk acute myeloid leukemia (Hazard Ratio 0.56; P=0.06). The propensity score analysis confirmed results. Our results underline that matched sibling donor is the first choice for acute myeloid leukemia patients in first complete remission. On the other hand, results of Haplo transplants are similar to matched sibling donor transplants in acute myeloid leukemia patients with high risk cytogenetics.
Collapse
Affiliation(s)
- Dalila Salvatore
- Service d'Hématologie et Thérapie Cellulaire Hôpital Saint Antoine, Paris, France.,Hematology Department, Federico II University, Naples, Italy
| | - Myriam Labopin
- Service d'Hématologie et Thérapie Cellulaire Hôpital Saint Antoine, Paris, France.,Hospital Saint-Antoine, Paris University UPMC, France.,Acute Leukemia Working Party of EBMT, Paris, France
| | - Annalisa Ruggeri
- Service d'Hématologie et Thérapie Cellulaire Hôpital Saint Antoine, Paris, France .,Department of Pediatric Hematology and Oncology, IRCCS Bambino Gesù Children's Hospital, Roma, Italy
| | - Giorgia Battipaglia
- Service d'Hématologie et Thérapie Cellulaire Hôpital Saint Antoine, Paris, France.,Hematology Department, Federico II University, Naples, Italy
| | | | - Fabio Ciceri
- Haematology and BMT Unit, IRCCS Ospedale San Raffaele, Milano, Italy
| | - Didier Blaise
- Programme de Transplantation &Therapie Cellulaire, Centre de Recherche en Cancérologie de Marseille, Institut Paoli Calmettes, France
| | - William Arcese
- Stem Cell Transplant Unit, Policlinico Universitario Tor Vergata, Rome, Italy
| | - Gerard Sociè
- Hopital St. Louis, Dept.of Hematology - BMT, Paris, France
| | | | | | | | - Anne Huynh
- Institut Universitaire du Cancer Toulouse, Oncopole, France
| | - Stella Santarone
- Unità Terapia Intensiva Ematologica per il Trapianto Emopoietico, Ospedale Civile, Pescara, Italia
| | - Eric Deconinck
- Hopital Jean Minjoz, Service d'Hématologie, Besançon, France
| | - Mohamad Mohty
- Service d'Hématologie et Thérapie Cellulaire Hôpital Saint Antoine, Paris, France.,Hospital Saint-Antoine, Paris University UPMC, France.,Acute Leukemia Working Party of EBMT, Paris, France
| | - Arnon Nagler
- Acute Leukemia Working Party of EBMT, Paris, France.,Chaim Sheba Medical Center, Tel-Hashomer, Israel
| |
Collapse
|
5
|
Jakubowski AA, Petrlik E, Maloy M, Hilden P, Papadopoulos E, Young JW, Boulad F, Castro-Malaspina H, Tamari R, Dahi PB, Goldberg J, Koehne G, Perales MA, Sauter CS, O'Reilly RJ, Giralt S. T Cell Depletion as an Alternative Approach for Patients 55 Years or Older Undergoing Allogeneic Stem Cell Transplantation as Curative Therapy for Hematologic Malignancies. Biol Blood Marrow Transplant 2017; 23:1685-1694. [PMID: 28734876 PMCID: PMC10715069 DOI: 10.1016/j.bbmt.2017.06.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [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: 02/16/2017] [Accepted: 06/28/2017] [Indexed: 12/27/2022]
Abstract
T cell-depleted (TCD) allogeneic hematopoietic stem cell transplantation (HSCT) is curative treatment for hematologic malignancies in adults, shown to reduce graft-versus-host disease (GVHD) without increased relapse. We retrospectively reviewed a single-center, 11-year experience of 214 patients aged ≥ 55 years to determine tolerability and efficacy in the older adult. Most patients (70%) had myeloid diseases, and most acute leukemias were in remission. Median age was 61 years, with related and unrelated donors ≥8/10 HLA matched. Hematopoietic cell transplantation-specific comorbidity index scores were intermediate and high for 84%. Conditioning regimens were all myeloablative. Grafts were peripheral blood stem cells (97%) containing CD3 dose ≤103-4/kg body weight, without pharmacologic GVHD prophylaxis. With median follow-up of 70 months among survivors, Kaplan-Meier estimates of overall and relapse-free survival were 44% and 41%, respectively (4 years). Cumulative incidence of nonrelapse mortality at day +100 was only 10%. Incidence of GVHD for acute (grades II to IV) was 9% at day +100 and for chronic was 7% at 2 and 4 years (8 extensive, 1 overlap). Median Karnofsky performance status for patients > 2 years post-transplant was 90%. As 1 of the largest reports for patients ≥2 aged ≥55 years receiving TCD HSCTs, it demonstrates curative therapy with minimal GVHD, similar to that observed in a younger population.
Collapse
Affiliation(s)
- Ann A Jakubowski
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, Cornell University, New York, New York.
| | - Erica Petrlik
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Molly Maloy
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Patrick Hilden
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Esperanza Papadopoulos
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, Cornell University, New York, New York
| | - James W Young
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, Cornell University, New York, New York
| | - Farid Boulad
- Weill Cornell Medical College, Cornell University, New York, New York; Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Hugo Castro-Malaspina
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, Cornell University, New York, New York
| | - Roni Tamari
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, Cornell University, New York, New York
| | - Parastoo B Dahi
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, Cornell University, New York, New York
| | - Jenna Goldberg
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, Cornell University, New York, New York
| | - Guenther Koehne
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, Cornell University, New York, New York
| | - Miguel-Angel Perales
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, Cornell University, New York, New York
| | - Craig S Sauter
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, Cornell University, New York, New York
| | - Richard J O'Reilly
- Weill Cornell Medical College, Cornell University, New York, New York; Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sergio Giralt
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, Cornell University, New York, New York
| |
Collapse
|
6
|
Aoki J, Kanamori H, Tanaka M, Yamasaki S, Fukuda T, Ogawa H, Iwato K, Ohashi K, Okumura H, Onizuka M, Maesako Y, Teshima T, Kobayashi N, Morishima Y, Hirokawa M, Atsuta Y, Yano S, Takami A. Impact of age on outcomes of allogeneic hematopoietic stem cell transplantation with reduced intensity conditioning in elderly patients with acute myeloid leukemia. Am J Hematol 2016; 91:302-7. [PMID: 26663096 DOI: 10.1002/ajh.24270] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 11/30/2015] [Accepted: 12/01/2015] [Indexed: 11/11/2022]
Abstract
Previous studies have repeatedly reported that increasing age is a significant risk factor for worse outcomes after allogeneic hematopoietic stem cell transplantation (allo-HSCT) among patients with acute myeloid leukemia (AML). However, more recent studies reported conflicting results regarding the association between age and outcomes in elderly patients. Therefore, we conducted a large-scale, nationwide retrospective study to examine the impact of age on outcomes of allo-HSCT with reduced intensity conditioning (RIC) for AML patients who were older than 50 years. Of the 757 patients, 89 patients (11.8%) were 50-54, 249 patients (32.9%) were 55-59, 301 patients (39.8%) were 60-64 and 118 patients (15.6%) were ≥65 years old. The 3-year overall survival (OS) (47.8, 45.2, 37.9, and 36.6% for patients aged 50-54, 55-59, 60-64, and ≥65 years, respectively, P = 0.24) and nonrelapse mortality (NRM) (24.0, 22.8, 29.2, and 27.6% for patients aged 50-54, 55-59, 60-64, and ≥65 years, respectively, P = 0.49) were not significantly different among the four age groups. Multivariate analysis revealed that increased age had no significant effect on OS or NRM after adjusting for covariates. These results suggested that advanced patient age is not a contraindication for RIC allo-HSCT in elderly AML patients.
Collapse
Affiliation(s)
- Jun Aoki
- Department of Hematology; Kanagawa Cancer Center; Yokohama Japan
| | - Heiwa Kanamori
- Department of Hematology; Kanagawa Cancer Center; Yokohama Japan
| | - Masatsugu Tanaka
- Department of Hematology; Kanagawa Cancer Center; Yokohama Japan
| | - Satoshi Yamasaki
- Department of Hematology and Clinical Research Institute; National Hospital Organization Kyushu Medical Center; Fukuoka Japan
| | - Takahiro Fukuda
- Division of Hematopoietic Stem Cell Transplantation; National Cancer Center Hospital; Tokyo Japan
| | - Hiroyasu Ogawa
- Division of Hematology; Department of Internal Medicine; Hyogo College of Medicine; Hyogo Japan
| | - Koji Iwato
- Department of Hematology; Hiroshima Red Cross Hospital and Atomic-Bomb Survivors Hospital; Hiroshima Japan
| | - Kazuteru Ohashi
- Department of Hematology; Tokyo Metropolitan Cancer and Infectious Disease Center Komagome Hospital; Tokyo Japan
| | - Hirokazu Okumura
- Department of Internal Medicine; Toyama Prefectural Central Hospital; Toyama Japan
| | - Makoto Onizuka
- Department of Hematology/Oncology; Tokai University School of Medicine; Isehara Japan
| | | | - Takanori Teshima
- Department of Hematology; Hokkaido University Hospital; Sapporo Japan
| | - Naoki Kobayashi
- Department of Hematology; Sapporo Hokuyu Hospital; Sapporo Japan
| | - Yasuo Morishima
- Division of Epidemiology and Prevention; Aichi Cancer Center Research Institute; Aichi Japan
| | - Makoto Hirokawa
- Department of General Internal Medicine and Clinical Laboratory Medicine; Akita University Graduate School of Medicine; Akita Japan
| | - Yoshiko Atsuta
- Japanese Data Center for Hematopoietic Cell Transplantation; Nagoya Japan
- Department of Healthcare Administration; Nagoya University Graduate School of Medicine; Nagoya Japan
| | - Shingo Yano
- Division of Clinical Oncology and Hematology; Department of Internal Medicine; Jikei University School of Medicine; Tokyo Japan
| | - Akiyoshi Takami
- Division of Hematology; Department of Internal Medicine; Aichi Medical University; Aichi Japan
| |
Collapse
|
7
|
Wang Y, Liu QF, Xu LP, Liu KY, Zhang XH, Ma X, Fan ZP, Wu DP, Huang XJ. Haploidentical vs identical-sibling transplant for AML in remission: a multicenter, prospective study. Blood. 2015;125:3956-3962. [PMID: 25940714 DOI: 10.1182/blood-2015-02-627786] [Citation(s) in RCA: 332] [Impact Index Per Article: 36.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2015] [Accepted: 04/29/2015] [Indexed: 01/06/2023] Open
Abstract
The effects of HLA-identical sibling donor (ISD) hematopoietic stem cell transplantation (HSCT) on adults with intermediate- or high-risk acute myeloid leukemia (AML) in the first complete remission (CR1) are well established. Previous single-center studies have demonstrated similar survival after unmanipulated haploidentical donor (HID) vs ISD HSCT for hematologic malignancies. To test the hypothesis that haploidentical HSCT would be a valid option as postremission therapy for AML patients in CR1 lacking a matched donor, we designed a disease-specific, prospective, multicenter study. Between July 2010 and November 2013, 450 patients were assigned to undergo HID (231 patients) or ISD HSCT (219 patients) according to donor availability. Among HID and ISD recipients, the 3-year disease-free survival rate was 74% and 78% (P = .34), respectively; the overall survival rate was 79% and 82% (P = .36), respectively; cumulative incidences of relapse were 15% and 15% (P = .98); and those of the nonrelapse-mortality were 13% and 8% (P = .13), respectively. In conclusion, unmanipulated haploidentical HSCT achieves outcomes similar to those of ISD HSCT for AML patients in CR1. Such transplantation was demonstrated to be a valid alternative as postremission treatment of intermediate- or high-risk AML patients in CR1 lacking an identical donor. This trial was registered at www.chictr.org as #ChiCTR-OCH-10000940.
Collapse
|
8
|
Chen Y, Wang Y, Xu LP, Liu KY, Chen H, Chen YH, Zhang XH, Wang FR, Han W, Wang JZ, Yan CH, Zhang YY, Sun YQ, Huang XJ. Haploidentical stem cell transplantation in patients aged 50 yr and older with leukemia: similar outcomes compared to younger adults. Clin Transplant 2015; 29:523-30. [PMID: 25809115 DOI: 10.1111/ctr.12545] [Citation(s) in RCA: 12] [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] [Accepted: 03/20/2015] [Indexed: 01/21/2023]
Abstract
AIM We aimed to analyze the complications and survival associated with myeloablative haploidentical SCT in patients aged ≥ 50 yr and compare these results with a younger group population. DESIGN AND METHODS In this case-control study, enrolled patients with leukemia were identified from 1262 patients between May 2002 and May 2013 at a single institution. RESULTS Thirty-one patients were aged ≥ 50 yr (the older group) and 165 patients were aged 18-49 yr (the younger group). Of the older group, 20 of 31 (64.5%) had a hematopoietic cell transplantation comorbidity index (HCT-CI) of 0 or 2. Statistical analysis showed no significant differences in the incidences of grades II to IV acute GVHD, extensive chronic GVHD, and non-relapse mortality (NRM), or probability of relapse between the two groups. Furthermore, the 3-yr overall survival (OS) and leukemia-free survival (LFS) were not significantly different between the older and younger groups: 67.0 ± 9.3% vs. 75.3 ± 3.4% (p = 0.406) and 60.5 ± 9.6% vs. 72.5 ± 3.5% (p = 0.183), respectively. CONCLUSION Selected older patients aged ≥ 50 yr with low HCT-CI and good performance status could safely undergo haploidentical SCT.
Collapse
Affiliation(s)
- Yao Chen
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Yu Wang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Lan-Ping Xu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Kai-Yan Liu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Huan Chen
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Yu-Hong Chen
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Xiao-Hui Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Feng-Rong Wang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Wei Han
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Jing-Zhi Wang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Chen-Hua Yan
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Yuan-Yuan Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Yu-Qian Sun
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Xiao-Jun Huang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,Peking-Tsinghua Center for Life Sciences, Beijing, China
| |
Collapse
|
9
|
Takasaki H, Tanaka M, Tachibana T, Numata A, Fujimaki K, Sakai R, Fujisawa S, Tomita N, Fujita H, Maruta A, Ishigatsubo Y, Kanamori H. Prognostic factors in patients aged 50 years or older undergoing allogeneic hematopoietic stem cell transplantation for hematologic malignancy. Int J Hematol 2012; 95:291-8. [PMID: 22302471 DOI: 10.1007/s12185-012-1009-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2011] [Revised: 01/05/2012] [Accepted: 01/10/2012] [Indexed: 11/28/2022]
Abstract
We retrospectively analyzed patients aged C 50 years with hematologic malignancies who underwent allogeneic hematopoietic stem cell transplantation (allo-HSCT) to identify preoperative variables predicting the outcome. There were 71 patients with a median age of 57 years (range: 50-63 years) who had acute leukemia (n = 53) or myelodysplastic syndrome (n = 18). Myeloablative conditioning was done in 35 patients and 36 patients had reduced-intensity conditioning. The 5-year overall survival rate (OS), cumulative relapse rate, and non-relapse mortality rate (NRM) were 45, 24, and 33%, respectively. According to multivariate analysis, high-risk disease (HR 3.50, 95% CI 1.43-8.56, P = 0.006), a hematopoietic cell transplantation comorbidity index (HCT-CI) score ≥ 3 (HR 4.41, 95% CI 1.31-14.77, P = 0.016), and an HLA-mismatched unrelated donor (HR 4.03, 95% CI 1.46-11.10, P = 0.007) were significant predictors of worse OS. Highrisk disease was also significantly associated with a higher cumulative relapse rate (HR 4.59, 95% CI 0.94-6.92, P = 0.065). Furthermore, an HCT-CI score ≥ 3 (HR 3.02, 95% CI 1.01-20.78, P = 0.048) and an HLA-mismatched unrelated donor (HR 3.02, 95% CI 1.04-8.74, P = 0.042) were risk factors for NRM. These results suggest that the disease risk, HCT-CI score, and donor type/histocompatibility are prognostic factors for elderly patients, while the conditioning regimen and age are not predictors.
Collapse
Affiliation(s)
- Hirotaka Takasaki
- Department of Hematology, Kanagawa Cancer Center, 1-1-2 Nakao, Asahi-ku, Yokohama 241-0815, Japan.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
10
|
Christopoulos P, Bertz H, Ihorst G, Marks R, Wäsch R, Finke J. Radiation-free allogeneic conditioning with fludarabine, carmustine, and thiotepa for acute lymphoblastic leukemia and other hematologic malignancies necessitating enhanced central nervous system activity. Biol Blood Marrow Transplant 2012; 18:1430-7. [PMID: 22430085 DOI: 10.1016/j.bbmt.2012.02.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2011] [Accepted: 02/28/2012] [Indexed: 10/28/2022]
Abstract
Total body irradiation has been the mainstay of conditioning since the inception of allogeneic hematopoietic cell transplantation, but toxicity often precludes its use. For less-fit patients with acute lymphoblastic leukemia and other hematologic malignancies frequently affecting the central nervous system, we designed a radiation-free regimen with fludarabine (25 mg/m2/day on days -6 to -4), carmustine (400 mg/m2 on day -6), and thiotepa (5 mg/kg twice daily on days -5 and -4), all of which readily penetrate the blood-brain barrier and have potent antileukemic and lymphotoxic activity. Here we present a series of 30 consecutive patients with high-risk or relapsed disease who underwent allogeneic hematopoietic cell transplantation with this protocol. The median patient age was 60 years (range, 42-70 years), and the median follow-up was 968 days (range, 58-1989 days). Graft-versus-host disease prophylaxis consisted of cyclosporine A and alemtuzumab (10-20 mg). At 2 years, overall survival was 52% (95% confidence interval [CI], 34%-71%), event-free survival was 39% (95% CI, 22%-57%), cumulative incidence of relapse/progression was 30% (95% CI, 17%-52%), and treatment-related mortality was 31% (95% CI, 18%-53%). Neurologic toxicity is a concern, especially in older and heavily pretreated patients. Our experience indicates the feasibility of this regimen as an alternative to total body irradiation and a potentially curative option for less-fit patients who need a highly central nervous system-active conditioning.
Collapse
Affiliation(s)
- Petros Christopoulos
- Department of Hematology/Oncology, University Medical Center Freiburg, Freiburg, Germany
| | | | | | | | | | | |
Collapse
|
11
|
|
12
|
Abstract
Most of patients with hematological malignancies are elderly (more than 60 years). Allogeneic stem cell transplantation is an important and effective treatment for most of these diseases. However, the toxicity and the supposed frailty of elderly patients, have limited the applicability of allogeneic transplantation for these patients. Elderly patients are at high risk to develop life-threatening complications, if allogeneic transplantation is performed with myeloablative conditioning regimens and using bone marrow stem source. Since more than 10 years, reduced intensity conditioning regimen have been developed, allowing to overcome the age as contra-indication for allogeneic transplantation. On the other hand, it is the presence of comorbidities which identify frail patients. For these subjects, allogeneic transplantation should be not indicated. Furthermore, advances in the supportive care and the development of new molecules could allow to reduce the toxicity of myeloablative conditioning regimens and thus to offer more intensive regimens before transplantation also in elderly population.
Collapse
|
13
|
Kim CG, Kwak EK, Lee SI. The relationship between hospital volume and outcome of gastrointestinal cancer surgery in Korea. J Surg Oncol 2011; 104:116-23. [PMID: 21520095 DOI: 10.1002/jso.21946] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2010] [Accepted: 03/28/2011] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To assess the relationship between hospital volume and in-hospital mortality of patients undergoing four surgical procedures for gastrointestinal cancers in Korea. METHODS Using the database of the Health Insurance Review and Assessment Service, we identified 66,201 patients who underwent the four types of gastrointestinal resection during the period 2005-2006. Participating hospitals were divided into five groups according to their surgical volume. The primary outcome was in-hospital mortality, defined as death from any cause before discharge. Multivariate logistic regression analysis was performed to determine the effect of hospital volume on risk-adjusted in-hospital mortality. RESULTS We observed a significant relationship between hospital volume and in-hospital mortality rate for patients undergoing the four types of cancer-related gastrointestinal surgeries. The in-hospital mortality rate was lower for high-volume than for low-volume hospitals after adjusting for patient characteristics. The differences between very-high-volume and very-low-volume hospitals ranged from 0.94% to 2.77% for the four procedures, with the largest difference observed for pancreatic resection (3.75% vs. 0.98%). CONCLUSION High-volume hospitals had better short-term surgical outcome than low-volume hospitals. We confirmed the volume-outcome relationship for four cancer-related gastrointestinal resections in Korea.
Collapse
Affiliation(s)
- Chul-Gyu Kim
- Department of Nursing, Cheongju University, Cheongju, Korea
| | | | | |
Collapse
|
14
|
Naik S, Wong R, Arai S, Brown J, Laport G, Lowsky R, Miklos D, Shizuru J, Blume K, Negrin R, Johnston L. Long-term outcomes in patients with high-risk myeloid malignancies following matched related donor hematopoietic cell transplantation with myeloablative conditioning of BU, etoposide and CY. Bone Marrow Transplant 2011; 46:192-9. [PMID: 20498648 DOI: 10.1038/bmt.2010.114] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Patients with high-risk or advanced myeloid malignancies have limited effective treatment options. These include high-dose therapy followed by allogeneic hematopoietic cell transplantation (HCT). We report a single-institution, long-term follow-up of 96 patients, median age 50 (range, 20-60) years, who received HLA-matched related HCT between 1992 and 2007. All patients were treated with a uniform preparatory regimen intended to enhance the widely used regimen of BU and CY that included: BU 16.0 mg/kg (days -8 to -5), etoposide 60 mg/kg (day -4), CY 60 mg/kg (day -2) with GVHD prophylaxis of CsA or FK506 and prednisone. Disease status at transplantation was high-risk AML (n=41), CML in second chronic phase or blast crisis (n=8), myelofibrosis and myeloproliferative disorders (n=8), and myelodysplasia (n=39). Thirty-six percent (n=35) of patients received BM whereas 64% (n=61) received G-CSF-mobilized PBPC. With a median follow-up of 5.6 years (range, 1.6-14.6 years) actuarial 5-year OS was 32% (95% CI 22-42) and 5-year EFS was 31% (95% CI 21-41). Relapse rate was 24% (95% CI 15-33) at 2 and 5 years. Nonrelapse mortality was 29% (95% CI 20-38) at day 100 and 38% (95% CI 29-47) at 1 year. Cumulative incidence of acute (grade II-IV) and extensive chronic GVHD was 27% (95% CI 18-36) and 29% (95% CI 18-40), respectively. There was no statistically significant difference in OS (31 vs 32%, P=0.89) or relapse rates (17 vs 28%, P=0.22) for recipients of BM vs PBPC, respectively. These results confirm that patients with high-risk or advanced myeloid malignancies can achieve long-term survival following myeloablative allogeneic HCT with aggressive conditioning.
Collapse
|
15
|
McClune BL, Weisdorf DJ. Reduced-intensity conditioning allogeneic stem cell transplantation for older adults: is it the standard of care? Curr Opin Hematol. 2010;17:133-138. [PMID: 20071984 DOI: 10.1097/moh.0b013e3283366ba4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW We reviewed reduced-intensity hematopoietic cell transplantation for older patients in the context of recently published studies. RECENT FINDINGS Most studies describe applicability of reduced-intensity transplantation to older patients with overall survival rates that compare favorably to chemotherapy alone, though relapse and graft-versus-host disease remain complicating factors. Though transplant recipients likely represent a highly selected population, current studies do not demonstrate an upper age for transplantation and suggest that myeloablative regimens may be considered in older patients with limited comorbidities. Avenues being pursued to improve transplant outcomes include natural killer cell immunotherapy and regulatory T-cell modulation. SUMMARY Until prospective studies show otherwise, transplant conditioning intensity for the older patient should be based on individual patient and disease characteristics. Enrollment into clinical trials is paramount in efforts to reduce transplant-related mortality and improve outcomes.
Collapse
|
16
|
Artz AS, Wickrema A, Dinner S, Godley LA, Kocherginsky M, Odenike O, Rich ES, Stock W, Ulaszek J, Larson RA, van Besien K. Pretreatment C-reactive protein is a predictor for outcomes after reduced-intensity allogeneic hematopoietic cell transplantation. Biol Blood Marrow Transplant 2008; 14:1209-16. [PMID: 18940674 DOI: 10.1016/j.bbmt.2008.08.004] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [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: 07/01/2008] [Accepted: 08/06/2008] [Indexed: 11/17/2022]
Abstract
We tested the independent prognostic impact of 2 commonly used biomarkers, C-reactive protein (CRP) and interleukin (IL)-6, on the outcomes of allogeneic hematopoietic cell transplantation (HCT). Consecutive patients who underwent a uniform reduced-intensity conditioning (RIC) regimen of fludarabine (Flu), melphalan (Mel), and alemtuzumab were evaluated retrospectively. Cryopreserved serum samples drawn before the RIC were available to measure CRP levels in 81 patients and IL-6 levels in 79 patients. Patients with CRP levels above the median of 18.5 mg/L had significantly more grade 3-4 hepatic toxicity (P=.01), longer HCT hospital stay (P=.005), more acute graft-versus-host disease (aGVHD) (P=.003), greater nonrelapse mortality (NRM) (P=.01), and inferior overall survival (OS; P=.02). Higher baseline CRP showed no significant correlation with grade 3-4 infectious toxicity (P=.09). In contrast to CRP, pre-HCT IL-6 levels above the median of 78.3 pg/mL did not confer a statistically significant increased risk of toxicity or mortality. An elevated HCT comorbidity index (HCT-CI) did not predict for any measure of HCT morbidity. After adjustment for disease status, comorbidity, performance status, and age, elevated CRP concentration remained predictive of NRM. These data require confirmation in non-T cell-depleted conditioning regimens. If validated, they suggest that preconditioning CRP holds promise for enhancing estimates of transplantation tolerance.
Collapse
Affiliation(s)
- Andrew S Artz
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, The University of Chicago Cancer Research Center, Chicago, Illinois 60637, USA.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Konuma T, Takahashi S, Ooi J, Tomonari A, Tsukada N, Kato S, Sato A, Monma F, Kasahara S, Nagamura-inoue T, Uchimaru K, Iseki T, Tojo A, Yamaguchi T, Asano S. Myeloablative unrelated cord blood transplantation for acute leukemia patients between 50 and 55 years of age: single institutional retrospective comparison with patients younger than 50 years of age. Ann Hematol 2009; 88:581-8. [DOI: 10.1007/s00277-008-0641-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2008] [Accepted: 11/04/2008] [Indexed: 10/21/2022]
|
18
|
Fujimaki K, Tanaka M, Takasaki H, Hyo R, Kawano T, Sakai R, Fujita H, Fujisawa S, Kanamori H, Maruta A, Ishigatsubo Y. Thiotepa/cyclophosphamide/TBI as a conditioning regimen for allogeneic hematopoietic stem cell transplantation in patients aged 50 years and over. Intern Med 2008; 47:379-83. [PMID: 18310967 DOI: 10.2169/internalmedicine.47.0598] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE To reduce the relapse rate for hematological malignancies after allogeneic hematopoietic stem cell transplantation, we employed a myeloablative regimen comprising thiotepa 400 mg/m(2), cyclophosphamide 3,600 mg/m(2) and total body irradiation 10 Gy. MATERIALS AND METHODS Subjects comprised 17 patients (median age, 53 years; range, 50-56 years) with hematological malignancies who received allogeneic hematopoietic stem cell transplantation from HLA-identical related (n=6), HLA-mismatched family (n=2) or unrelated donors (n=9). Prophylaxis of acute graft-versus-host disease (GVHD) consisted of short-term methotrexate and cyclosporine (n=4) or short-term methotrexate and tacrolimus (n=13). RESULTS No grade IV regimen-related toxicities as determined by Bearman's criteria were encountered. Acute grade II-IV GVHD developed in 7 patients, with chronic GVHD in 11 patients. With a median follow-up of 39 months, 3 years survival rate after transplantation was 59%. Two patients died due to infection by 100 days after transplantation. Only 1 patient with Philadelphia-positive acute lymphoblastic leukemia experienced relapse. Eight patients died of non-leukemic causes (sepsis, n=2; liver dysfunction, n=2; idiopathic interstitial pneumonia, n=1; bacterial pneumonia, n=1; bronchiolitis obliterans resulting from chronic GVHD, n=1; and disseminated infection with varicella zoster virus, n=1). CONCLUSIONS This regimen was tolerable, but a large trial is warranted to confirm the efficacy of this conditioning.
Collapse
Affiliation(s)
- Katsumichi Fujimaki
- Department of Internal Medicine and Clinical Immunology, Yokohama City University School of Medicine, Yokohama.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
19
|
Atsuta Y, Suzuki R, Yoshimi A, Gondo H, Tanaka J, Hiraoka A, Kato K, Tabuchi K, Tsuchida M, Morishima Y, Mitamura M, Kawa K, Kato S, Nagamura T, Takanashi M, Kodera Y. Unification of hematopoietic stem cell transplantation registries in Japan and establishment of the TRUMP System. Int J Hematol 2007; 86:269-74. [PMID: 17988995 DOI: 10.1532/ijh97.06239] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
There are 4 registries of hematopoietic cell transplantation in Japan; the Japan Society for Hematopoietic Cell Transplantation (JSHCT), Japanese Society of Pediatric Hematology, Japan Marrow Donor Program, and Japan Cord Blood Bank Network; each play an important role in society by reporting the number and outcomes of transplantations and contributing new findings obtained from studies on individual topics. However, there have been a number of issues with the difficulty of analyzing data in overlapping registries and multiple databases at centers affiliated with each of the 4 registry organizations. JSHCT was pivotal in orchestrating the computerization and unification of hematopoietic stem cell transplantation registries for the purpose of resolving these issues and providing a more accurate awareness of hematopoietic stem cell transplantations being performed in Japan. JSHCT played a central role in developing the "Transplant Registry Unified Management Program (TRUMP)" to enable transplantation institutes to manage patient information with emphases on convenience to institutes, safety of patient information, and quality of data management. While enhancing domestic registries, the program seeks to coordinate with other hematopoietic cell transplantation registries around the world to contribute to the development of registries throughout Asia.
Collapse
Affiliation(s)
- Yoshiko Atsuta
- Department of HSCT Data Management, Nagoya University, School of Medicine, Nagoya, Japan
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
20
|
Shapira MY, Tsirigotis P, Resnick IB, Or R, Abdul-Hai A, Slavin S. Allogeneic hematopoietic stem cell transplantation in the elderly. Crit Rev Oncol Hematol 2007; 64:49-63. [PMID: 17303434 DOI: 10.1016/j.critrevonc.2007.01.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [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: 08/22/2006] [Revised: 12/14/2006] [Accepted: 01/24/2007] [Indexed: 11/23/2022] Open
Abstract
The development of reduced intensity or non-myeloablative conditioning (NST) in preparation for allogeneic stem cell transplantation (SCT) revolutionized the field and led to reconsideration of the dogma of upper age limit that was set up by the transplant centers as an eligibility parameter. Analysis of the literature data showed that NST regimens are associated with decreased transplant related mortality, and graft-versus-host disease, in comparison with standard myeloablative conditioning, in patients above the age of 50-55 years, or in younger patients with significant comorbidities. However we have to mention, that our considerations are based on the retrospective analysis of the literature data, and that well controlled prospective randomized studies are needed in order to definitely assess the role of NST. Comorbidity indices might be proved as the most important parameters for the choice of the most proper regimen for each patient in need and should be included in future trials.
Collapse
Affiliation(s)
- Michael Y Shapira
- Department of Bone Marrow Transplantation & Cancer Immunotherapy, Hadassah-Hebrew University Hospital, Jerusalem 91120, Israel.
| | | | | | | | | | | |
Collapse
|
21
|
Atsuta Y, Suzuki R, Yoshimi A, Gondo H, Tanaka J, Hiraoka A, Kato K, Tabuchi K, Tsuchida M, Morishima Y, Mitamura M, Kawa K, Kato S, Nagamura T, Takanashi M, Kodera Y. Unification of hematopoietic stem cell transplantation registries in Japan and establishment of the TRUMP system. Int J Hematol 2007. [DOI: 10.1007/bf03006932] [Citation(s) in RCA: 177] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
22
|
Ditschkowski M, Elmaagacli AH, Trenschel R, Steckel NK, Koldehoff M, Beelen DW. Myeloablative allogeneic hematopoietic stem cell transplantation in elderly patients. Clin Transplant 2006; 20:127-31. [PMID: 16556167 DOI: 10.1111/j.1399-0012.2005.00453.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
This study aimed to evaluate the outcome following myeloablative allogeneic hematopoietic stem cell transplantation (SCT) among patients older than 50 yr of age. A total of 215 patients with a median age of 57 yr underwent allogeneic hematopoietic SCT for early (41%) or advanced (59%) hematologic malignancies. After a median follow-up of 36 months a 10-yr survival estimate of 56 +/- 6% could be assessed for patients in early disease stages while patients with advanced diseases showed a significantly decreased survival probability of 31 +/- 5% (p < 0.0002). Transplant related mortality (TRM) at day 100 and 365 post-transplant was 13% and 30% for early but increased to 21% and 49% for advanced disease stages. As major determinants of TRM advanced disease stage (p < 0.0001) and occurrence of grades II-IV graft-vs.-host disease (GVHD) (p < 0.0001) were identified. These results show that hematopoietic SCT following myeloablative conditioning is also applicable to elderly patients whereas disease stage and high-grade GVHD represent the essential prognostic factors for outcome.
Collapse
MESH Headings
- Aged
- Female
- Hematopoietic Stem Cell Transplantation/mortality
- Humans
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/mortality
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/surgery
- Leukemia, Myeloid, Acute/mortality
- Leukemia, Myeloid, Acute/surgery
- Lymphoma, Non-Hodgkin/mortality
- Lymphoma, Non-Hodgkin/surgery
- Male
- Middle Aged
- Multiple Myeloma/mortality
- Multiple Myeloma/surgery
- Myelodysplastic Syndromes/mortality
- Myelodysplastic Syndromes/surgery
- Myeloproliferative Disorders/mortality
- Myeloproliferative Disorders/surgery
- Risk Factors
- Survival Analysis
- Treatment Outcome
Collapse
Affiliation(s)
- M Ditschkowski
- Department of bone marrow transplantation, University Hospital of Essen, Hufelandstr, Essen, Germany.
| | | | | | | | | | | |
Collapse
|
23
|
Yanada M, Naoe T, Iida H, Sakamaki H, Sakura T, Kanamori H, Kodera Y, Okamoto S, Kanda Y, Sao H, Asai O, Nakai K, Maruta A, Kishi K, Furukawa T, Atsuta Y, Yamamoto K, Tanaka J, Takahashi S. Myeloablative allogeneic hematopoietic stem cell transplantation for Philadelphia chromosome-positive acute lymphoblastic leukemia in adults: significant roles of total body irradiation and chronic graft-versus-host disease. Bone Marrow Transplant 2005; 36:867-72. [PMID: 16113659 DOI: 10.1038/sj.bmt.1705148] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Disease-free survival in Philadelphia chromosome-positive ALL (Ph + ALL) is very poor, and allogeneic hematopoietic stem cell transplantation (allo-HSCT) is currently considered the only procedure with curative potential. To identify factors affecting transplant outcome, we analyzed the data from 197 Ph + ALL patients aged 16 years or older who had undergone allo-HSCT. The 5-year survival rates were 34% for patients in first complete remission (CR), 21% for those in second or subsequent CR, and 9% for those with active disease (P < 0.0001). Multivariate analysis showed four pre-transplant factors as significantly associated with better survival: younger age, CR at the time of transplantation, conditioning with total body irradiation, and HLA-identical sibling donor (P < 0.0001, P < 0.0001, P = 0.0301, P = 0.0412, respectively). Severe acute GVHD increased the risk of treatment-related mortality (TRM) without diminishing the risk of relapse, whereas chronic GVHD reduced the risk of relapse without increasing the risk of TRM. Thus, patients who developed extensive chronic GVHD had better survivals (P = 0.0217), and those who developed grade III-IV acute GVHD had worse survivals (P = 0.0023) than did the others.
Collapse
Affiliation(s)
- M Yanada
- Department of Hematology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Novitzky N, Thomas V, Hale G, Waldmann H. Myeloablative conditioning is well tolerated by older patients receiving T-cell-depleted grafts. Bone Marrow Transplant 2005; 36:675-82. [PMID: 16113675 DOI: 10.1038/sj.bmt.1705119] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Older age has been linked to increased transplant-related mortality from graft-versus-host disease (GvHD). Depletion of T cells from stem cell grafts seems to protect from complications of GvHD particularly in older patients. After myeloablative conditioning, patients with haematological malignancies received allogeneic grafts from HLA identical siblings. For GvHD prophylaxis, PBPC grafts were treated ex vivo with anti-CD52, and therapeutic doses of cyclosporin until day +90. Survival of patients younger or older than the population age median was analysed. In all, 62 consecutive patients with a median age of 42.5 years were studied. Death was procedure related in 17% and from relapse of malignancy in five. At a median, follow-up is 662 (7-2316) days, 74% survive disease free. The rate of haematopoietic recovery and treatment-related mortality was similar in both groups. A total of 73% of 30 individuals in the younger group and 75% (P=0.8) in the older cohort survive at a median follow-up of 444 and 806 days (P=0.4). GvHD occurred in 13% and was the only adverse factor for survival (P<0.04). Myeloablative conditioning is well tolerated up to the age of 59 in patients receiving T-cell-depleted grafts. This information is useful to more precisely select patients who would benefit most from reduced intensity conditioning schedules.
Collapse
Affiliation(s)
- N Novitzky
- The University of Cape Town Leukaemia Centre and the Department of Haematology, Groote Schuur Hospital, Observatory, Cape, Cape Town, South Africa.
| | | | | | | |
Collapse
|
25
|
Kurita N, Nagasawa T, Komatsu T. Unrelated Cord Blood Transplantation Using a Reduced-Intensity Conditioning Regimen without Total Body Irradiation in Two Patients with Multiple Myeloma. J Clin Exp Hematop 2005. [DOI: 10.3960/jslrt.45.93] [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: 10/21/2022] Open
|