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Farshbafnadi M, Razi S, Rezaei N. Transplantation. Clin Immunol 2023. [DOI: 10.1016/b978-0-12-818006-8.00008-6] [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: 01/20/2023]
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2
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Le Bourgeois A, Labopin M, Marçais A, de Latour RP, Blaise D, Chantepie S, N'Guyen S, Maillard N, Forcade E, Yakoub-Agha I, Huynh A, Marchand T, Bilger K, Ceballos P, Charbonnier A, Turlure P, Rubio MT, Béné MC, Guillaume T, Mohty M, Chevallier P. Sequential allogeneic hematopoietic stem cell transplantation for active refractory/relapsed myeloid malignancies: results of a reduced-intensity conditioning preceded by clofarabine and cytosine arabinoside, a retrospective study on behalf of the SFGM-TC. Ann Hematol 2020; 99:1855-1862. [PMID: 32564196 DOI: 10.1007/s00277-020-04074-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 05/04/2020] [Indexed: 10/24/2022]
Abstract
Allogeneic stem cell transplantation (allo-SCT) represents the most beneficial treatment for patients with active relapsed/refractory (R/R) hematologic malignancies. Recently, sequential regimens combining debulking chemotherapy followed by reduced-intensity conditioning (RIC) have shown encouraging results for these patients. In this retrospective study, we report the extended results of a sequential regimen of clofarabine, cytosine arabinoside, and RIC in 131 adults with active R/R myeloid disease at transplant. Conditioning consisted of clofarabine (30 mg/m2/day) and cytosine arabinoside (1 g/m2/day) for 5 days, followed, after a rest of 3 days, by an RIC combining cyclophosphamide (60 mg/kg) for 1 day, iv busulfan (3.2 mg/kg/day) for 2 days, and anti-thymocyte globulin (2.5 mg/kg/day) for 2 days. Between 2007 and 2016, 131 patients (males n = 75, median age: 52.6 years) were identified from the SFGM-TC registry. There were 111 acute myeloid leukemia (AML) patients and 20 cases with myelodysplastic or myeloproliferative syndrome. Status at transplant was known for all but 4 patients and was primary refractory (n = 81) and 1st or 2nd relapse (n = 46). All patients received allo-SCT from a matched donor (sibling n = 64, unrelated n = 67). Engraftment was observed in 105/122 (86%) evaluable cases and 63% of the patients achieved complete remission (CR) after transplant. The 1-year overall survival, disease-free survival, relapse incidence, non-relapse mortality, and graft-versus-host disease-free/relapse-free survival were 39.2%, 28.1%, 41.0%, 30.8%, and 22.2%, respectively. This study confirms that this sequential clofarabine-based regimen provides a high CR rate in this critical population, although relapse remains a matter of concern.
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Affiliation(s)
- Amandine Le Bourgeois
- Department of Hematology, CHU Hôtel Dieu, Place A. Ricordeau, 44093, Nantes Cedex, France.
| | - Myriam Labopin
- Department of Hematology, Hôpital Saint Antoine, Sorbonne University and INSERM UMRs 938, Paris, France
| | - Ambroise Marçais
- Department of Hematology, Hôpital Necker-Enfants Malades, Paris, France
| | - Regis Peffault de Latour
- Department of Hematology, Hôpital Saint Louis & Université Paris 7, Denis Diderot, Paris, France
| | - Didier Blaise
- Department of Hematology, Centre de Recherche en Cancérologie de Marseille, Institut Paoli Calmettes, Marseille, France
| | | | | | | | | | | | - Anne Huynh
- Department of Hematology, CHU de Toulouse, Toulouse, France
| | - Tony Marchand
- Department of Hematology, CHU de Rennes, Rennes, France
| | - Karin Bilger
- Department of Hematology, CHU de Strasbourg, Strasbourg, France
| | - Patrice Ceballos
- Department of Hematology, CHU de Montpellier, Montpellier, France
| | | | - Pascal Turlure
- Department of Hematology, CHU de Limoges, Limoges, France
| | | | - Marie Christine Béné
- Department of Hematology, CHU Hôtel Dieu, Place A. Ricordeau, 44093, Nantes Cedex, France
| | - Thierry Guillaume
- Department of Hematology, CHU Hôtel Dieu, Place A. Ricordeau, 44093, Nantes Cedex, France
| | - Mohamad Mohty
- Department of Hematology, Hôpital Saint Antoine, Sorbonne University and INSERM UMRs 938, Paris, France
| | - Patrice Chevallier
- Department of Hematology, CHU Hôtel Dieu, Place A. Ricordeau, 44093, Nantes Cedex, France.
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Jethava YS, Sica S, Savani B, Socola F, Jagasia M, Mohty M, Nagler A, Bacigalupo A. Conditioning regimens for allogeneic hematopoietic stem cell transplants in acute myeloid leukemia. Bone Marrow Transplant 2017; 52:1504-11. [DOI: 10.1038/bmt.2017.83] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 02/06/2017] [Accepted: 02/24/2017] [Indexed: 12/24/2022]
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Takagi M, Ishiwata Y, Aoki Y, Miyamoto S, Hoshino A, Matsumoto K, Nishimura A, Tanaka M, Yanagimachi M, Mitsuiki N, Imai K, Kanegane H, Kajiwara M, Takikawa K, Mae T, Tomita O, Fujimura J, Yasuhara M, Tomizawa D, Mizutani S, Morio T. HLA haploidentical hematopoietic cell transplantation using clofarabine and busulfan for refractory pediatric hematological malignancy. Int J Hematol 2017; 105:686-691. [PMID: 28185203 DOI: 10.1007/s12185-017-2187-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 01/31/2017] [Accepted: 01/31/2017] [Indexed: 11/30/2022]
Abstract
Haploidentical hematopoietic cell transplantation (HCT) conditioning with clofarabine and target area under the blood concentration-time curve (AUC)-based busulfan adjustment was performed in three patients with refractory pediatric leukemia. The target AUC for two patients who had already received multiple transplantations was 3600 and 4000 μmol min/L, and that for the patient with Down's syndrome was 3000 μmol min/L. Regimen-related toxicity was well tolerated in all cases. All three maintained cytological remission throughout the follow-up period (between 31 and 167 weeks). Thus, haploidentical HCT conditioning with clofarabine and target AUC-based busulfan adjustment may be a preferable option for children with recurrent or refractory pediatric leukemia.
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Affiliation(s)
- Masatoshi Takagi
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Yushima 1-5-45, Bukyo-ku, Tokyo, 113-8510, Japan.
| | - Yasuyoshi Ishiwata
- Department of Hospital Pharmacy, Tokyo Medical and Dental University (TMDU), Yushima 1-5-45, Bunkyo-ku, Tokyo, Japan
| | - Yuki Aoki
- Department of Pediatric Oncology, National Cancer Research Center, Tsukiji 5-1-1, Chuo-ku, Tokyo, Japan
| | - Satoshi Miyamoto
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Yushima 1-5-45, Bukyo-ku, Tokyo, 113-8510, Japan
| | - Akihiro Hoshino
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Yushima 1-5-45, Bukyo-ku, Tokyo, 113-8510, Japan
| | - Kazuaki Matsumoto
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Yushima 1-5-45, Bukyo-ku, Tokyo, 113-8510, Japan
| | - Akira Nishimura
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Yushima 1-5-45, Bukyo-ku, Tokyo, 113-8510, Japan
| | - Mari Tanaka
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Yushima 1-5-45, Bukyo-ku, Tokyo, 113-8510, Japan
| | - Masakatsu Yanagimachi
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Yushima 1-5-45, Bukyo-ku, Tokyo, 113-8510, Japan
| | - Noriko Mitsuiki
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Yushima 1-5-45, Bukyo-ku, Tokyo, 113-8510, Japan
| | - Kohsuke Imai
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Yushima 1-5-45, Bukyo-ku, Tokyo, 113-8510, Japan
| | - Hirokazu Kanegane
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Yushima 1-5-45, Bukyo-ku, Tokyo, 113-8510, Japan
| | - Michiko Kajiwara
- Department of Transfusion Medicine, Tokyo Medical and Dental University (TMDU), Yushima 1-5-45, Bunkyo-ku, Tokyo, Japan
| | - Kanako Takikawa
- Department of Hospital Pharmacy, Tokyo Medical and Dental University (TMDU), Yushima 1-5-45, Bunkyo-ku, Tokyo, Japan
| | - Tsukasa Mae
- Department of Hospital Pharmacy, Tokyo Medical and Dental University (TMDU), Yushima 1-5-45, Bunkyo-ku, Tokyo, Japan
| | - Osamu Tomita
- Department of Pediatrics and Adolescent Medicine, Juntendo University, School of Medicine, Yushima 2-1-1, Bunkyo-ku, Tokyo, Japan
| | - Junya Fujimura
- Department of Pediatrics and Adolescent Medicine, Juntendo University, School of Medicine, Yushima 2-1-1, Bunkyo-ku, Tokyo, Japan
| | - Masato Yasuhara
- Department of Pharmacokinetics and Pharmacodynamics, Tokyo Medical and Dental University (TMDU), Yushima 1-5-45, Bunkyo-ku, Tokyo, Japan
| | - Daisuke Tomizawa
- Division of Leukemia and Lymphoma, Children's Cancer Center, National Center for Child Health and Development, Okura 2-10-1, Setagaya-ku, Tokyo, Japan
| | - Shuki Mizutani
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Yushima 1-5-45, Bukyo-ku, Tokyo, 113-8510, Japan
| | - Tomohiro Morio
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Yushima 1-5-45, Bukyo-ku, Tokyo, 113-8510, Japan
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Goyal G, Gundabolu K, Vallabhajosyula S, Silberstein PT, Bhatt VR. Reduced-intensity conditioning allogeneic hematopoietic-cell transplantation for older patients with acute myeloid leukemia. Ther Adv Hematol 2016; 7:131-41. [PMID: 27247754 DOI: 10.1177/2040620716643493] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Elderly patients (>60 years) with acute myeloid leukemia have a poor prognosis with a chemotherapy-alone approach. Allogeneic hematopoietic-cell transplantation (HCT) can improve overall survival (OS). However, myeloablative regimens can have unacceptably high transplant-related mortality (TRM) in an unselected group of older patients. Reduced-intensity conditioning (RIC) or nonmyeloablative (NMA) conditioning regimens preserve the graft-versus-leukemia effects but reduce TRM. NMA regimens result in minimal cytopenia and may not require stem cell support for restoring hematopoiesis. RIC regimens, intermediate in intensity between NMA and myeloablative regimens, can cause prolonged myelosuppresion and usually require stem cell support. A few retrospective and prospective studies suggest a possibility of lower risk of relapse with myeloablative HCT in fit older patients with lower HCT comorbidity index; however, RIC and NMA HCTs have an important role in less-fit patients and those with significant comorbidities because of lower TRM. Whether early tapering of immunosuppression, monitoring of minimal residual disease, and post-transplant maintenance therapy can improve the outcomes of RIC and NMA HCT in elderly patients will require prospective trials.
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Affiliation(s)
- Gaurav Goyal
- Creighton University Medical Center, 601 North 30th Street, Ste 5850, Omaha, NE 68131, USA
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Aoki Y, Miyawaki R, Imai K, Takagi M, Kajiwara M, Ishiwata Y, Yasuhara M, Morio T, Mizutani S, Tomizawa D. Haploidentical Bone Marrow Transplantation With Clofarabine and Busulfan Conditioning for a Child With Multiple Recurrent Acute Lymphoblastic Leukemia. J Pediatr Hematol Oncol 2016; 38:e39-41. [PMID: 26523380 DOI: 10.1097/MPH.0000000000000454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Outcome of children with acute lymphoblastic leukemia (ALL) has improved over the years, but not for those with multiple recurrences because of high therapy resistance and heavily pretreated history that potentially cause physical damages. We describe the case of an 11-year-old boy with a third relapse of ALL and a history of 2 allogeneic bone marrow transplantations. He was successfully treated with clofarabine combination chemotherapy and achieved a fourth remission at 16 months following haploidentical bone marrow transplantation with conditioning regimen of clofarabine and busulfan. Clofarabine/busulfan conditioning might be a preferable option for children with multiple recurrent ALL, and warrants further investigation.
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Middeke JM, Herbst R, Parmentier S, Bug G, Hänel M, Stuhler G, Schäfer-Eckart K, Rösler W, Klein S, Bethge W, Bitz U, Büttner B, Knoth H, Alakel N, Schaich M, Morgner A, Kramer M, Sockel K, von Bonin M, Stölzel F, Platzbecker U, Röllig C, Thiede C, Ehninger G, Bornhäuser M, Schetelig J. Clofarabine salvage therapy before allogeneic hematopoietic stem cell transplantation in patients with relapsed or refractory AML: results of the BRIDGE trial. Leukemia 2016; 30:261-7. [PMID: 26283567 DOI: 10.1038/leu.2015.226] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 08/04/2015] [Accepted: 08/06/2015] [Indexed: 12/29/2022]
Abstract
In patients with relapsed or refractory (r/r) acute myeloid leukemia (AML), long-term disease control can only be achieved by allogeneic hematopoietic stem cell transplantation (HSCT). We studied the safety and efficacy of clofarabine-based salvage therapy. The study was designed as phase II, multicenter, intent-to-transplant (ITT) study. A total of 84 patients with r/r AML were enrolled. All patients received at least one cycle of CLARA (clofarabine 30 mg/m(2) and cytarabine 1 g/m(2), days 1-5). Chemo-responsive patients with a donor received HSCT in aplasia after first CLARA. Generally, HSCT was performed as soon as possible. The conditioning regimen consisted of clofarabine (4 × 30 mg/m(2)) and melphalan (140 mg/m(2)). The median patient age was 61 years (range 40-75). On day 15 after start of CLARA, 26% of patients were in a morphologically leukemia-free state and 79% exposed a reduction in bone marrow blasts. Overall, 67% of the patients received HSCT within the trial. The primary end point, defined as complete remission after HSCT, was achieved by 60% of the patients. According to the ITT, overall survival at 2 years was 43% (95% confidence interval (CI), 32-54%). The 2-year disease-free survival for transplanted patients was 52% (95% CI, 40-69%). Clofarabine-based salvage therapy combined with allogeneic HSCT in aplasia shows promising results in patients with r/r AML.
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Pingali SR, Champlin RE. Pushing the envelope-nonmyeloablative and reduced intensity preparative regimens for allogeneic hematopoietic transplantation. Bone Marrow Transplant 2015; 50:1157-67. [PMID: 25985053 DOI: 10.1038/bmt.2015.61] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Accepted: 11/17/2014] [Indexed: 12/30/2022]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) was originally developed to allow delivery of myeloablative doses of chemotherapy and radiotherapy. With better understanding of disease pathophysiology, the graft vs malignancy (GVM) effect of allogeneic hematopoietic transplantation and toxicities associated with myeloablative conditioning (MAC) regimens, the focus shifted to developing less toxic conditioning regimens to reduce treatment-related morbidity without compromising survival. Although HCT with MAC is preferred to reduced intensity conditioning (RIC) for most patients ⩽60 years with AML/myelodysplastic syndrome and ALL, RIC and nonmyeloablative (NMA) regimens allow HCT for many otherwise ineligible patients. Reduced intensity preparative regimens have produced high rates of PFS for diagnoses, which are highly sensitive to GVM. Relapse of the malignancy is the major cause of treatment failure with RIC/NMA HCT. Incorporation of novel agents like bortezomib or lenalidomide, addition of cellular immunotherapy and use of targeted radiation therapies could further improve outcome. In this review, we discuss commonly used RIC/NMA regimens and promising novel regimens.
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Affiliation(s)
- S R Pingali
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - R E Champlin
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Reshef R, Porter DL. Reduced-intensity conditioned allogeneic SCT in adults with AML. Bone Marrow Transplant 2015; 50:759-69. [PMID: 25730186 DOI: 10.1038/bmt.2015.7] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 01/13/2015] [Accepted: 01/14/2015] [Indexed: 02/08/2023]
Abstract
AML is currently the most common indication for reduced-intensity conditioned (RIC) allo-SCT. Reduced-intensity regimens allow a potent GVL response to occur with minimized treatment-related toxicity in patients of older age or with comorbidities that preclude the use of myeloablative conditioning. Whether RIC SCT is appropriate for younger and more standard risk patients is not well defined and the field is changing rapidly; a prospective randomized trial of myeloablative vs RIC (BMT-CTN 0901) was recently closed when early results indicated better outcomes for myeloablative regimens. However, detailed results are not available, and all patients in that study were eligible for myeloablative conditioning. RIC transplants will likely remain the standard of care as many patients with AML are not eligible for myeloablative conditioning. Recent publication of mature results from retrospective and prospective cohorts provide contemporary efficacy and toxicity data for these attenuated regimens. In addition, recent studies explore the use of alternative donors, introduce regimens that attempt to reduce toxicity without reducing intensity, and identify predictive factors that pave the way to personalized approaches. These studies paint a picture of the future of RIC transplants. Here we review the current status of RIC allogeneic SCT in AML.
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Roberts DA, Wadleigh M, McDonnell AM, DeAngelo DJ, Stone RM, Steensma DP. Low efficacy and high mortality associated with clofarabine treatment of relapsed/refractory acute myeloid leukemia and myelodysplastic syndromes. Leuk Res 2014; 39:204-10. [PMID: 25554239 DOI: 10.1016/j.leukres.2014.11.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2014] [Revised: 11/26/2014] [Accepted: 11/29/2014] [Indexed: 10/24/2022]
Abstract
Clofarabine, a second-generation nucleoside analog, has clinical activity in relapsed or refractory acute myelogenous leukemia (AML) and higher-risk myelodysplastic syndromes (MDS). However, there are few data evaluating performance of clofarabine in populations of patients not enrolled in clinical trials. We reviewed outcomes for 84 patients treated with clofarabine for relapsed or refractory AML or MDS, either with clofarabine as monotherapy (n=19) or in combination with cytarabine (n=65). Using International Working Group (IWG) response criteria, the overall response rate (ORR) of all treated patients was 21%, with a complete response rate with either complete or incomplete hematopoietic recovery (CRR=CR+CRi) of 14%. For combination therapy, ORR was 22% with CRR of 18%, and monotherapy patients had an ORR of 21% with CRR of 11%. Although limited by small numbers, subgroup analysis did not reveal variation in response rates when comparing different risk factors. The 30-day mortality was 21% and median survival was 3 months; a subset of 12 patients who were able to go to transplant had an 18-month median survival. Clofarabine's efficacy in a "real-world" setting appears to be less than has been reported in clinical trials, and treatment is associated with a high early mortality rate.
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Affiliation(s)
- Daniel A Roberts
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Martha Wadleigh
- Division of Hematological Malignancies, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Anne M McDonnell
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Daniel J DeAngelo
- Division of Hematological Malignancies, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Richard M Stone
- Division of Hematological Malignancies, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - David P Steensma
- Division of Hematological Malignancies, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.
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Fozza C. The role of Clofarabine in the treatment of adults with acute myeloid leukemia. Crit Rev Oncol Hematol 2014; 93:237-45. [PMID: 25457773 DOI: 10.1016/j.critrevonc.2014.10.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Revised: 09/08/2014] [Accepted: 10/14/2014] [Indexed: 10/24/2022] Open
Abstract
The therapeutic scenario available for adult patients with acute myeloid leukemia (AML) has shown only partial progresses over the last few years. This is especially true for refractory and relapsed AML whose outcome is still extremely disappointing. In this context Clofarabine has offered new promising perspectives within first and second line protocols. This review will firstly describe the initial development in monotherapy, considering then the different potential combination strategies which include both polichemotherapeutic regimens and less conventional approaches with new generation drugs. The potential use of Clofarabine as induction treatment for patients candidate to stem cell transplantation and within conditioning regimens will be finally evaluated.
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Affiliation(s)
- Claudio Fozza
- Hematology, Department of Biomedical Sciences, University of Sassari, Viale San Pietro 12, 07100 Sassari, Italy.
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Abstract
Allogeneic stem cell transplantation (SCT) is an increasingly important therapeutic option for the treatment of adult patients with acute myeloid leukemia. Here we review the current indications of SCT in this disease. While patients with favorable cytogenetics should receive consolidation chemotherapy, patients with unfavorable karyotype are prime candidates for SCT or new approaches to SCT (which should be done in first complete remission). Patients with intermediate prognoses should also receive SCT in first complete remission. In the absence of a suitable matched related donor, most patients will be able to find an alternative donor to proceed to a potentially curative allogeneic transplantation. The use of reduced-intensity conditioning regimens before SCT has allowed patients in the sixth or seventh decades of life to be routinely transplanted. Despite major differences among transplant centers in the intensity and composition of the conditioning regimen and immunosuppression, choice of graft source, postgraft immune-modulation, and supportive care, there has been a dramatic improvement in terms of tolerance. Although it is presumed to be a curative strategy, major complications of SCT remain graft-versus-host disease, delayed immune recovery, multiple comorbidities, and relapse after transplant.
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Visani G, Malagola M, Guiducci B, Lucesole M, Loscocco F, Gabucci E, Paolini S, Piccaluga PP, Isidori A. Conditioning regimens in acute myeloid leukemia. Expert Rev Hematol 2014; 7:465-479. [PMID: 25025371 DOI: 10.1586/17474086.2014.939066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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] [Indexed: 11/03/2023]
Abstract
Current intensive consolidation chemotherapy for patients with acute myeloid leukemia (AML) produces median remission duration of 12-18 months, with less than 30% of patients surviving 5 years free of disease. Post-remission therapy is necessary to prevent relapse in most patients with AML; therefore, the aim of post-remission treatment is to eradicate the minimal residual disease. Nevertheless, the optimal form of treatment is still under debate. The choice among the possible approaches (intensive chemotherapy, autologous or allogeneic hematopoietic stem cell transplantation) relies on two main factors: the expected risk of relapse, as determined by biological features, and expected morbidity and mortality associated with a specific option. In this review, we focus on the different preparative regimens before autologous and allogeneic hematopoietic stem cell transplantation in patients with AML, stressing the importance of an adequate conditioning regimen as a mandatory element of a successful AML therapy, in both the allogeneic and the autologous transplant setting.
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Chevallier P, Labopin M, Socié G, Tabrizi R, Furst S, Lioure B, Guillaume T, Delaunay J, de La Tour RP, Vigouroux S, El-Cheikh J, Blaise D, Michallet M, Bilger K, Milpied N, Moreau P, Mohty M. Results from a clofarabine-busulfan-containing, reduced-toxicity conditioning regimen prior to allogeneic stem cell transplantation: the phase 2 prospective CLORIC trial. Haematologica 2014; 99:1486-91. [PMID: 24951467 DOI: 10.3324/haematol.2014.108563] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
We prospectively evaluated the safety and efficacy of a clofarabine, intravenous busulfan and antithymocyte globulin-based reduced-toxicity conditioning (CloB2A2) regimen before allogeneic stem cell transplantation. Thirty high-risk patients (median age: 59 years; acute myeloid leukemia n=11, acute lymphoblastic leukemia n=13; myelodysplastic syndrome n=5, bi-phenotypic leukemia n=1) were included in this phase 2 study. At time of their transplant, 20 and seven patients were in first and second complete remission, respectively, while three patients with myelodysplastic syndrome were responding to chemotherapy or who had not been previously treated. The CloB2A2 regimen consisted of clofarabine 30 mg/m(2)/day for 4 days, busulfan 3.2 mg/kg/day for 2 days and antithymocyte globulin 2.5 mg/kg/day for 2 days. The median follow-up was 23 months. Engraftment occurred in all patients. The 1-year overall survival, leukemia-free survival, relapse incidence and non-relapse mortality rates were 63±9%, 57±9%, 40±9%, and 3.3±3%, respectively. Comparing patients with acute myeloid leukemia/myelodysplastic syndrome versus those with acute lymphoblastic leukemia/bi-phenotypic leukemia, the 1-year overall and leukemia-free survival rates were 75±10% versus 50±13%, respectively (P=0.07) and 69±12% versus 43±13%, respectively (P=0.08), while the 1-year relapse incidence was 25±11% versus 57±14%, respectively (P=0.05). The CloB2A2 regimen prior to allogeneic stem cell transplantation is feasible, allowing for full engraftment and low toxicity. Disease control appears to be satisfactory, especially in patients with acute myeloid leukemia/myelodysplastic syndrome. The trial was registered at www.clinicaltrials.gov no. NCT00863148.
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Affiliation(s)
| | - Myriam Labopin
- Université Pierre & Marie Curie, Paris INSERM, UMRs 938, Paris Hôpital Saint-Antoine, AP-HP, Paris
| | - Gérard Socié
- Hematology Department, Hopital Saint-Louis, Paris
| | | | - Sabine Furst
- Hematology Department, Institut Paoli-Calmette, Marseille
| | | | | | | | | | | | - Jean El-Cheikh
- Hematology Department, Institut Paoli-Calmette, Marseille
| | - Didier Blaise
- Hematology Department, Institut Paoli-Calmette, Marseille
| | | | | | | | | | - Mohamad Mohty
- Hematology Department, CHU Hotel-Dieu, Nantes Université Pierre & Marie Curie, Paris INSERM, UMRs 938, Paris Hôpital Saint-Antoine, AP-HP, Paris
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15
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Abstract
An essential component of allogeneic and autologous hematopoietic cell transplantation (HCT) is the conditioning regimen administered before the hematopoietic cell infusion. Early regimens relied on dose intensity, assuming that high-dose chemoradiotherapy would eliminate malignant disease and reinfusion of the graft would then restore hematopoiesis. However, as the contribution of graft-versus-tumor effects to the success of allogeneic HCT was recognized over time, in an effort to exploit these, many investigators lowered the dose of radiation and chemotherapeutic agents in the preparative regimen. This resulted in a major paradigm shift, and consequently, the pool of eligible patients underwent a remarkable expansion. In this article, we provide a review of the definition of high-dose, reduced-intensity, and nonmyeloablative conditioning regimens, the most commonly used agents and combinations, and the evolution of some early regimens. We also provide a brief review of the toxicities associated with these regimens.
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16
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Guenounou S, Delabesse E, Récher C. Sorafenib plus all-trans retinoic acid for AML patients withFLT3-ITDandNPM1mutations. Eur J Haematol 2014; 93:533-6. [DOI: 10.1111/ejh.12334] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2014] [Indexed: 01/25/2023]
Affiliation(s)
- Sarah Guenounou
- Service d'Hématologie; Centre Hospitalier Universitaire de Toulouse; Hôpital Purpan; Toulouse France
| | - Eric Delabesse
- Université Toulouse III Paul Sabatier; Toulouse France
- Laboratoire d'Hématologie; Centre Hospitalier Universitaire de Toulouse; Hôpital Purpan; Toulouse France
| | - Christian Récher
- Service d'Hématologie; Centre Hospitalier Universitaire de Toulouse; Hôpital Purpan; Toulouse France
- Université Toulouse III Paul Sabatier; Toulouse France
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17
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Lucchini G, Bader P. Hematopoietic stem cell transplantation and immunotherapy for pediatric acute myeloid leukemia: an open challenge. Expert Rev Hematol 2014; 7:291-300. [DOI: 10.1586/17474086.2014.878644] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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19
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Tischer J, Stemmler HJ, Engel N, Hubmann M, Fritsch S, Prevalsek D, Schulz C, Zoellner AK, Bücklein V, Hill W, Ledderose G, Hausmann A. Feasibility of clofarabine cytoreduction followed by haploidentical hematopoietic stem cell transplantation in patients with relapsed or refractory advanced acute leukemia. Ann Hematol 2013; 92:1379-88. [PMID: 23928857 DOI: 10.1007/s00277-013-1862-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Accepted: 07/22/2013] [Indexed: 10/26/2022]
Abstract
Clofarabine is a novel purine nucleoside analogue with immunosuppressive and anti-leukemic activity in acute lymphoblastic and myeloid leukemia (AML, ALL). This retrospective study was performed to evaluate the feasibility and anti-leukemic activity of a sequential therapy using clofarabine for cytoreduction followed by conditioning for haploidentical hematopoietic stem cell transplantation (HSCT) in patients with non-remission acute leukemia. Patients received clofarabine (5 × 30 mg/m² IV) followed by a T cell replete haploidentical transplantation for AML (n = 15) or ALL (n = 3). Conditioning consisted of fludarabine, cyclophosphamide plus either melphalan, total body irradiation or treosulfan/etoposide. High-dose cyclophosphamide was administered for post-grafting immunosuppression. Neutrophil engraftment was achieved in 83 % and complete remission in 78% at day +30. The rate of acute graft versus host disease (GvHD) grade II-IV was 22%, while chronic GvHD occured in five patients (28%). Non-relapse mortality (NRM) after 1 year was 23%. At a median follow-up of 19 months, estimated overall survival and relapse-free survival at 1 year from haploidentical HSCT were 56 and 39%, respectively. Non-hematological regimen-related grade III-IV toxicity was observed in ten patients (56%) and included most commonly transient elevation of liver enzymes (44%), mucositis (40%), and skin reactions including hand-foot syndrome (17%), creatinine elevation (17%), and nausea/vomiting (17%). The concept of a sequential therapy using clofarabine for cytoreduction followed by haploidentical HSCT proved to be feasible and allows successful engraftment, while providing an acceptable toxicity profile and anti-leukemic efficacy in patients with advanced acute leukemia. NRM and rate of GvHD were comparable to results after HSCT from HLA-matched donors.
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20
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Valdez BC, Wang G, Murray D, Nieto Y, Li Y, Shah J, Turturro F, Wang M, Weber DM, Champlin RE, Qazilbash MH, Andersson BS. Mechanistic studies on the synergistic cytotoxicity of the nucleoside analogs gemcitabine and clofarabine in multiple myeloma: relevance of p53 and its clinical implications. Exp Hematol 2013; 41:719-30. [PMID: 23648290 DOI: 10.1016/j.exphem.2013.04.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [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: 04/16/2013] [Accepted: 04/18/2013] [Indexed: 01/30/2023]
Abstract
Hematopoietic stem cell transplantation (HSCT) is an established treatment for multiple myeloma (MM), a plasma cell malignancy. To identify an improved pretransplant conditioning regimen, we investigated the cytotoxicity of gemcitabine (Gem) and clofarabine (Clo) combinations toward MM cell lines and patient cell samples. A strong synergism of the two nucleoside analogs, when combined at their approximate IC10 concentrations, was observed. This synergism could be partly due to the observed Gem-mediated phosphorylation and activation of deoxycytidine kinase, resulting in enhanced phosphorylation of Gem and Clo. Their cytotoxicity correlated with a robust activation of the DNA damage response pathway. [Gem+Clo] decreased the mitochondrial membrane potential with a concomitant release of proapoptotic factors into the cytoplasm and nucleus and the activation of apoptosis. Exposure of MM cells to [Gem+Clo] also decreased the level of ribosomal RNA (rRNA), which might have resulted in nucleolar stress, as reported previously, and caused a p53-dependent cell death. A reduction by approximately 50% in the cytotoxicity of Gem and Clo was observed in the presence of pifithrin α, a p53 inhibitor. Furthermore, MM cell lines with mutant p53 exhibited greater resistance to Gem and Clo, supporting a role for the p53 protein in these cytotoxic responses. Our results provide a rationale for clinical trials incorporating [Gem+Clo] combinations as part of conditioning therapy for high-risk patients with MM undergoing HSCT.
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Affiliation(s)
- Benigno C Valdez
- Departments of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
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21
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Le Bourgeois A, Lestang E, Guillaume T, Delaunay J, Ayari S, Blin N, Clavert A, Tessoulin B, Dubruille V, Mahe B, Roland V, Gastinne T, Le Gouill S, Moreau P, Mohty M, Planche L, Chevallier P. Prognostic impact of immune status and hematopoietic recovery before and after fludarabine, IV busulfan, and antithymocyte globulins (FB2 regimen) reduced-intensity conditioning regimen (RIC) allogeneic stem cell transplantation (allo-SCT). Eur J Haematol 2013; 90:177-86. [DOI: 10.1111/ejh.12049] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2012] [Indexed: 11/28/2022]
Affiliation(s)
- Amandine Le Bourgeois
- Centre Hospitalier et Universitaire (CHU) de Nantes, Hématologie Clinique; Centre d'Investigation Clinique en Cancérologie (CI2C); Nantes; France
| | - Elsa Lestang
- Centre Hospitalier et Universitaire (CHU) de Nantes, Hématologie Clinique; Centre d'Investigation Clinique en Cancérologie (CI2C); Nantes; France
| | - Thierry Guillaume
- Centre Hospitalier et Universitaire (CHU) de Nantes, Hématologie Clinique; Centre d'Investigation Clinique en Cancérologie (CI2C); Nantes; France
| | - Jacques Delaunay
- Centre Hospitalier et Universitaire (CHU) de Nantes, Hématologie Clinique; Centre d'Investigation Clinique en Cancérologie (CI2C); Nantes; France
| | - Sameh Ayari
- Centre Hospitalier et Universitaire (CHU) de Nantes, Hématologie Clinique; Centre d'Investigation Clinique en Cancérologie (CI2C); Nantes; France
| | - Nicolas Blin
- Centre Hospitalier et Universitaire (CHU) de Nantes, Hématologie Clinique; Centre d'Investigation Clinique en Cancérologie (CI2C); Nantes; France
| | - Aline Clavert
- Centre Hospitalier et Universitaire (CHU) de Nantes, Hématologie Clinique; Centre d'Investigation Clinique en Cancérologie (CI2C); Nantes; France
| | - Benoit Tessoulin
- Centre Hospitalier et Universitaire (CHU) de Nantes, Hématologie Clinique; Centre d'Investigation Clinique en Cancérologie (CI2C); Nantes; France
| | - Viviane Dubruille
- Centre Hospitalier et Universitaire (CHU) de Nantes, Hématologie Clinique; Centre d'Investigation Clinique en Cancérologie (CI2C); Nantes; France
| | - Beatrice Mahe
- Centre Hospitalier et Universitaire (CHU) de Nantes, Hématologie Clinique; Centre d'Investigation Clinique en Cancérologie (CI2C); Nantes; France
| | - Virginie Roland
- Centre Hospitalier et Universitaire (CHU) de Nantes, Hématologie Clinique; Centre d'Investigation Clinique en Cancérologie (CI2C); Nantes; France
| | - Thomas Gastinne
- Centre Hospitalier et Universitaire (CHU) de Nantes, Hématologie Clinique; Centre d'Investigation Clinique en Cancérologie (CI2C); Nantes; France
| | - Steven Le Gouill
- Centre Hospitalier et Universitaire (CHU) de Nantes, Hématologie Clinique; Centre d'Investigation Clinique en Cancérologie (CI2C); Nantes; France
| | - Philippe Moreau
- Centre Hospitalier et Universitaire (CHU) de Nantes, Hématologie Clinique; Centre d'Investigation Clinique en Cancérologie (CI2C); Nantes; France
| | | | - Lucie Planche
- Cellule de Promotion à la Recherche Clinique; CHU de Nantes; Nantes; France
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22
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Abstract
Allogeneic stem cell transplantation is an increasingly important treatment option in patients with high-risk acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS). Although there has been substantial progress in reducing transplantation-related mortality (TRM), little progress has been made in reducing the risk of disease relapse, which continues to represent the major cause of treatment failure in patients allografted for AML and MDS. Experience with myeloablative conditioning regimens has demonstrated that, although intensification of the preparative regimen reduces relapse risk, any survival benefit is blunted by a concomitant increase in TRM. A similar inverse correlation between relapse risk and TRM is observed in patients allografted using a reduced-intensity conditioning regimen. However, the markedly lower toxicity of such regimens has permitted the design of novel conditioning strategies aimed at maximizing antitumor activity without excessive transplant toxicity. Coupled with recent advances in drug delivery and design, this has allowed the development of a spectrum of new conditioning regimens in patients with high-risk AML and MDS. At the same time, the optimization of a graft-versus-leukemia (GVL) effect by minimizing posttransplantation immunosuppression, with or without the infusion of donor lymphocytes, is essential if the risk of disease relapse is to be reduced. Recently, the delivery of adjunctive posttransplantation therapies has emerged as a promising method of augmenting antileukemic activity, either through a direct antitumor activity or consequent upon pharmacological manipulation of the alloreactive response. Taken together these advances present a realistic possibility of delivering improved outcome in patients allografted for high-risk AML or MDS.
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