Intensive Consolidation Chemotherapy Research Articles

The Outcome of Outpatient Intermediate and High Dose Cytarabine Consolidation Chemotherapy in Patients with Acute Myeloid Leukemia. The Experience of King Fahad Specialist Hospital in Dammam, Saudi Arabia

Background: Adult patients with Acute Myeloid Leukemia (AML) have traditionally been hospitalized for the duration of intensive consolidation chemotherapy until blood count recovery to avoid complications. Recently, there has been a trend to shift the care of AML patients treated with intensive chemotherapy from inpatient to outpatient settings to reduce treatment costs and save beds. Methods and materials: A retrospective study of AML patients who received cytarabine consolidation chemotherapy between the 1st of August 2016 and the 31st of December 2023 at King Fahad Specialist Hospital in Dammam, Saudi Arabia was performed. Results: Over a period of 7 years and 4 months, 62 patients received a total of 127 cycles of intensive consolidation chemotherapy at outpatient setting. At diagnosis: 12 patients had extramedullary disease, and 17 patients had adverse cytogenetic abnormalities. Following the 127 cycles of chemotherapy, 38 episodes of febrile neutropenia were encountered, and 46 hospital admissions were required. No complications were encountered following 62.2% of the cycles of consolidation therapy and no early mortality due to intensive consolidation therapy was reported. Out of 62 patients studied, 36 patients underwent various forms of hematopoietic stem cell transplantation. Disease relapses were encountered in 24 patients and the 5-year incidence of relapse for the entire group of patients was 42%. The 5-year leukemia-free survival for the: entire study patients, transplanted patients, and non-transplanted patients were: 43%, 38%, and 50% respectively. The 5-year overall survival for the: entire study patients, transplanted patients, and non-transplanted patients were: 44%, 34%, and 65% respectively. At the end of follow-up: 37 patients (59.68%) were alive, 24 patients (38.71%) were dead, and the fate of 1 patient (1.61%) was unknown as the patient moved to another hospital. Conclusion: Administration of intensive consolidation chemotherapy for patients with AML at outpatient setting is safe, feasible, and cost-effective. The incidence of infectious complications was relatively low. No early treatment-related mortality due to intensive consolidation therapy was encountered. Outpatient administration of intensive consolidation therapy can save beds, reduce hospital costs, and is associated with short-term and long-term outcomes that are comparable to inpatient administration of consolidation therapy.

Phase II Study of Lenalidomide Maintenance after Salvage Therapy for Relapsed or Refractory Peripheral T-Cell Lymphomas

Introduction Peripheral T-cell lymphomas (PTCLs) are a heterogeneous group of non-Hodgkin lymphomas. Their prognoses are still poor especially after they relapse or become refractory to the first-line treatment. Although salvage chemotherapy followed by autologous stem cell transplantation (ASCT) could be used for those relapsed or refractory patients, a substantial number of patients relapse even after ASCT. Furthermore, ASCT is not always possible because elderly or frail patients are not eligible for high-dose chemotherapy followed by ASCT. Thus, there are limited treatment option for patients who failed after ASCT or ineligible for ASCT because there is no established salvage treatment strategy and the impact of novel therapies in previous trials is unknown. Lenalidomide is widely used for the treatment of B-cell lymphomas as well as multiple myeloma, however, there are a few data about its efficacy in patients with PTCLs. Considering the mode of action is related with the immune modulatory effect on tumor microenvironment, lenalidomide might have a role in the management of relapsed or refractory PTCLs. Thus, we hypothesized that the use of lenalidomide as a maintenance therapy for patients who achieve response after salvage therapy might produce survival benefit comparable to that of ASCT after salvage therapy. Methods This is a prospective, open-labeled, single-arm, multi-center phase II study for relapsed or refractory PTCLs. The inclusion criteria are as follows: 1) Patients should have relapsed or refractory disease after at least one-line of prior chemotherapy; 2) Patients should not be eligible for ASCT; 3) Patients should have any subtypes of PTCLs including PTCL-not otherwise specified (PTCL-NOS), angioimmunoblastic T-cell lymphoma (AITL), anaplastic lymphoma kinase (ALK)-positive or -negative anaplastic large-cell lymphoma (ALCL), extranodal NK/T-cell lymphoma (ENKTL), monomorphic epitheliotropic intestinal T-cell lymphoma (MEITL), hepatosplenic T-cell lymphoma (HSTL), and mycosis fungoides (MF). When patients eligible for the study achieve complete response (CR) or partial response (PR) after four cycles of any kinds of salvage chemotherapy, they can receive lenalidomide as a maintenance therapy. One cycle is 28 days consisting of lenalidomide 25 mg (day 1 - day 21). The treatment can be repeated until progression or the occurrence of intolerable toxicities (up to 2 years). The primary end point is 1-year progression-free survival, and the target rate is 35%. Results A total of 58 patients were enrolled between February 2019 and May 2023. The median age was 62 years (range: 20 - 83 years) and male was dominant (male: 35, female: 23). Patients who failed after ASCT or could not undergo ASCT due to their health status participated in the study. Patients with AITL (n = 23) and PTCL-NOS (15) accounted for 66% of patients whereas other subtypes included ENKTL (n = 4), ALK-negative ALCL (n = 3), MEITL (n = 3), HSTL (n = 2) and MF (n = 7). Prior to the maintenance therapy with lenalidomide, their disease status was CR (n = 22, 38%) and PR (n = 36, 62%). At the median follow-up of 20.7 months (95% CI: 17.7 - 23.7 months), seven patients completed the planned treatment of 2 years, and three patients withdrew their informed consents. Disease progression was documented in 21 patients during the maintenance and the other 20 patients discontinued the treatment due to their adverse events. At the time of analysis, seven patients were maintaining their treatments. Out of 36 patients with PR before maintenance, five patients achieved CR and 13 patients showed PR. However, 18 patients showed disease progression during maintenance. On the other hand, only three patients showed disease progression among 22 patients with CR prior to lenalidomide maintenance. Thus, 1-year PFS after enrollment was 49% and the median OS was (34.1 months, 95% CI: 7.9 - 18.6 months, Figure 1). The most common hematologic toxicities were neutropenia and thrombocytopenia; thus, dose-reduction should be done in patients with grade 4 hematologic toxicity. The most frequent non-hematologic toxicities included skin rash (40%), nausea (35%), and diarrhea (20%) however, they were manageable. Conclusions The lenalidomide maintenance might be a feasible and effective treatment approach for patients with relapsed or refractory PTCLs who are ineligible for ASCT or intensive consolidation chemotherapy.

Outcomes of Children and Adolescents with Acute Myeloid Leukemia Given a Low-Versus Standard-Dose Chemotherapy Regimen for Remission Induction (CALSIII-AML18): A Multicenter, Phase 3, Randomized, Noninferiority Trial

Backgroun d: Intensive chemotherapy is recommended for remission induction of pediatric acute myeloid leukemia (AML). However, life-threatening complications are common especially in vulnerable populations. We investigated whether a low-dose chemotherapy (LDC) regimen would be noninferior to a standard-dose chemotherapy (SDC) regimen for induction remission.This study also aimed to assess whether LDC is not inferior to SDC in terms of survival outcomes. Methods: We conducted a randomized, noninferiority study in children with AML who were admitted to 14 medical centers in China. Patients were randomly assigned to receive two remission-induction courses of either low-dose chemotherapy (LDC) (cytarabine 10 mg/m 2, subcutaneous, q12 hours, 20 doses; mitoxantrone or idarubicin 5 mg/m 2, intravenous, days 1, 3 and 5; and G-CSF 5 mcg/kg, subcutaneous, daily, 10 doses) (n = 246) or standard-dose chemotherapy (SDC) (cytarabine 100 mg/m 2, intravenous, q12 hours, 20 doses; daunomycin 50 mg/m 2, intravenous, days 1, 3, 5; and etoposide 100 mg 2, intravenous, days 1 to 5) (n = 251). Depending on the risk of relapse, patients in complete remission (CR) in both arms received two to three cycles of intensive consolidation chemotherapy and/or underwent hematopoietic stem cell transplantation (HSCT). The primary endpoint was to compare CR rates in patients randomized to the LDC or SDC regimens. The secondary endpoints were to determine the safety of the LDC regimen and to compare the time to platelet and neutrophil count recovery in the two groups. Finally, in a multivariate analysis, we determined the impact of the type of remission induction on the outcome. This trial is registered at chictr.org as # ChiCTR-18000015883 and has been completed. Results: From June 2018 to June 2022,497 participants aged <18 years with de novo AML were randomized. Patients with Down syndrome, promyelocytic leukemia, or megakaryoblastic leukemia were excluded. There were no significant differences in age, sex, or genotype between the two arms. Complete morphologic remission with or without platelet recovery (CR/CRi) was attained in 72.8% and 70.3% of patients assigned to the LDC and SDC arms, respectively, after Induction I and in 95.5% and 95.7%, respectively, after Induction II ( P = .545 for Induction I and .898 for Induction II). Residual disease < 0.1%, as measured by flow cytometry, was observed in 54.8% and 58.9% of patients in the LDC and SDC arms, respectively, after Induction I and in 85.9% and 84.4%, respectively, after Induction II ( P = .229 for Induction I and .827 for induction II). Median time to neutrophil count recovery was 15 days for patients in the LDC arm vs. 22 days for those in the SCD arm after Induction I ( P< .001) and 12 days vs. 18 days for patients in the respective arms after Induction II ( P < .001). Median time to platelet count recovery was 13 days for patients in the LDC arm vs. 19 days for those in the SCD arm after Induction I ( P < .001) and 3 days vs. 8 days for patients in the respective arms after Induction II ( P< .001). Grade 3 and 4 toxicities were significantly lower in patients in the LDC arm than those in the SDC arm. In Induction I, febrile neutropenia occurred in 75.2% and 93.2% ( P < .001), colitis in 3.7% and 10.7% ( P = .003), and gastrointestinal hemorrhage in 0.4% and 4.4% ( P = .006) in the LDC and SDC arms, respectively. In Induction II, febrile neutropenia occurred in 34.4% and 66.9% ( P < .001), lung or sinus infection in 2.8% and 9.3% ( P = .008), and sepsis in 3.3% and 10.7% ( P = .004), in the LDC and SDC arms, respectively. There was no significant difference in treatment-related mortality between the two treatment arms ( P = 204).Compared to patients in the SDC arm, patients in the LDC arm had noninferior 3-year EFS of 61.9% (95% CI: 55.7 to 68.8) vs. 62.2% (95% CI: 56.1 to 68.8)( P = .994) (Figure 1A), and 3-year OS of 81.0% (95% CI: 75.7 to 86.6) vs. 83.2% (95% CI: 78.2 to 88.5) ( P = .485) (Figure 1B). In a multivariate analysis considering known prognostic indicators in pediatric AML, treatment arm was not associated with outcome. Conclusion: In children with AML, remission induction with a low-dose chemotherapy regimen with concurrent G-CSF administration was well tolerated and was associated with CR, EFS, and OS rates that were not inferior to those of patients treated with a standard chemotherapy regimen.

Relapse surveillance of acute myeloid leukemia patients in first remission after consolidation chemotherapy: diagnostic value of regular bone marrow aspirations

‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬The optimal follow-up care for relapse detection in acute myeloid leukemia (AML) patients in first remission after consolidation therapy with intensive chemotherapy is not established. In this retrospective study, we evaluate the diagnostic value of an intensive relapse surveillance strategy by regular bone marrow aspirations (BMA) in these patients. We identified 86 patients with newly diagnosed non-promyelocytic AML who had reached complete remission (CR) after intensive induction and consolidation chemotherapy between 2007 and 2019. Annual relapse rates were 40%, 17%, and 2% in years 1–3, respectively. Patients in CR were surveilled by BMA scheduled every 3 months for 2 years, followed by BMA every 6 months. This surveillance regimen detected 29 of 55 relapses (53%), 11 of which were molecular relapses (20%). The remaining 26 of 55 relapses (47%) were diagnosed by non-surveillance BMA prompted by specific suspicion of relapse. Most patients showed concurrent morphological abnormalities in peripheral blood (PB) at time of relapse. Seven percent of all morphological relapses occurred without simultaneous PB abnormalities and would have been delayed without surveillance BMA. Intensified monthly PB assessment paired with BMA every 3 months during the first 2 years may be a highly sensitive relapse surveillance strategy.

Comparison of Autologous Bone Marrow Transplantation and Intensive Chemotherapy as Postremission Therapy in Adult Acute Myeloid Leukemia

AbstractThree intensive consolidation strategies are currently proposed to younger adults with acute myeloid leukemia (AML) in first complete remission (CR): allogeneic or autologous bone marrow transplantation (BMT) and intensive consolidation chemotherapy (ICC). Patients aged 15 to 50 years with de novo AML received an induction treatment with 7 days of cytarabine and either idarubicin or rubidazone. After achievement of a CR, patients up to the age of 40 and having an HLA-identical sibling were assigned to undergo an allogeneic BMT. All the other patients received a first course of ICC with high-dose cytarabine and the same anthracycline as for induction. They were then randomly assigned to either receive a second course of ICC with amsacrine and etoposide or a combination of busulfan and cyclosphosphamide followed by an unpurged autologous BMT. Of 517 eligible patients, 367 had a CR, but only 219 (59.5%) actually received the planned intensive postremission treatment (73 allogeneic BMT, 75 autologous BMT, and 71 ICC). With a median follow-up of 62 months, the 4-year disease-free survival (DFS) of the 367 patients in CR was 39.5%. The 4-year overall survival (OS) of the 517 eligible patients was 40.5%. In multivariate analysis, DFS and OS were influenced only by the initial white blood cell count and by the French-American-British classification. The type of postremission therapy had no significant impact on the outcome. There was no difference in the 4-year DFS and OS between 88 patients for whom an allogeneic BMT was scheduled (respectively, 44% and 53%) and 134 patients of the same age category and without an HLA-identical sibling (respectively, 38% and 53%). Similarly, there was no difference in the outcome between autologous BMT and ICC. The 4-year DFS was 44% for the 86 patients randomly assigned to autologous BMT and 40% for the 78 patients assigned to ICC (P = .41). The 4-year OS was similar in the two groups (50% v 54.5%, P = .72). The median duration of hospitalization and thrombocytopenia were longer after autologous BMT (39 v 32 days, P = .006, and 109.5 v 18.5 days, P = .0001, respectively). After a first course of ICC, a second course of chemotherapy is less myelotoxic than an unpurged autologous BMT but yields comparable DFS and OS rates.

Very Long Term Follow up a Phase II Study of Post-Remission Subcutaneous (SC) Azacitidine (AZA) in Patients with AML Post-MDS or Higher-Risk (HR) MDS

Background: Results of the phase III QUAZAR trial suggest that post-remission treatment with an oral form (CC-486) of azacitidine (AZA) can prolong CR duration and overall survival(OS) in AML patients reaching at least PR with intensive chemotherapy (IC) (Wei et al, ASH 2019). Maintenance treatment with subcutaneous (SC) AZA was recently shown to improve DFS in elderly AML (Huls et al, Blood 2019, a study that also included 10% MDS). We report very long term results of a study evaluating SC AZA as post-remission treatment in patients with AML post-MDS or high-risk MDS (HR-MDS) who achieved at least PR after IC, a population known to have short responses with IC. Methods: Inclusion criteria were (1) HR-MDS according to IPSS, or AML after a documented phase of MDS(2) who entered CR, CRi or PR after IC with anthracycline and AraC within 28 days of inclusion (3) ECOG <= 2, absence of infection or organ toxicity from IC (4) no identified donor for allo SCT at inclusion. Dosing of SC AZA was 60mg/m2/d for 5 days every 28 days, with adjustments according to tolerance, and until relapse or toxicity. Results: From July 2006 to June 2009, 51 pts (M:31/F:20) were included. The 46 evaluable pts had achieved CR (n=28), CRi (n=11), and PR (n=7) before study entry. Median age was 66y (range 55-78). Diagnosis at IC onset was MDS (n=13) and AML (n=33), IPSS cytogenetics was normal (n= 28), intermediate (n=10), high (n= 6), and failed (n=2). Median time from diagnosis of MDS to IC was 8 months (range 0.5-101). Median number of AZA maintenance cycles was 7.5 (1-76) in CR pts (>23 cycles in 5 of them) and 4.5 (1-24) in CRi or PR pts (> 23 cycles in 1). Two patients were allografted and censored at allo SCT. Median follow-up was 16.5 months As of May 2020 (cut off date of analysis) median DFS and OS from response were 6.9 m and 16.9 m, respectively (figure). In CR patients, median and 18 months OS were 18.9 months and 58%, versus 12.8 months and 50% in CRi-PR patients (p=0.33) All non allografted patients eventually relapsed. 7 had a response duration >18 months (6 CR patients: 22, 23, 25, 36, 40, and 84 months; 1 CRi patient: 24 months) OS from inclusion was >3 years in 7 patients (CR pts: 150, 126,74, 51, 50,40 months; CRi pt:58 months), in addition to the 2 allografted pts who remained alive in CR at 156+ and 159+ months No baseline factor including cytogenetics, diagnosis at IC onset (MDS vs AML), % bone marrow blasts, age or time from MDS diagnosis to treatment, significantly predicted DFS or OS. AZA dosing in CR patients was escalated in 9 pts to 75mg/m2/d due to good tolerance but had to be reduced in 6 pts, due to GI toxicity (n=1) and cytopenias (n=5). During SC AZA maintenance, 2/28 CR pts developed febrile neutropenia, compared to 4/18 pts in CRi or PR (including 1 fatal case). In the 22 AML post MDS pts who reached CR, DFS and OS were similar to those observed in 46 AML post AML pts included in a previous ALFA study where pts in CR after IC received DNR/IDA-AraC post-remission therapy (Gardin, Blood 2007). Conclusion: In the very long term analysis of this trial in AML post MDS and HR-MDS treated with induction intensive chemotherapy, post-remission therapy with SC AZA alone was associated with a median DFS and OS of 6.9 and 16.9 months, respectively, with some prolonged response. Results appeared similar to those we had reported with intensive consolidation chemotherapy, but using an ambulatory treatment with limited myelosuppression. Figure Disclosures Braun: Daiichy-Sankyo: Honoraria; Servier: Research Funding. Bouabdallah:Takeda: Consultancy, Honoraria; Roche: Consultancy, Honoraria; Gilead Sciences: Consultancy, Honoraria. Ades:Celgene/BMS: Research Funding; novartis: Research Funding; takeda: Honoraria, Membership on an entity's Board of Directors or advisory committees; jazz: Membership on an entity's Board of Directors or advisory committees, Research Funding; Abbvie: Honoraria, Membership on an entity's Board of Directors or advisory committees; Amgen: Research Funding. Fenaux:Abbvie: Honoraria, Research Funding; Novartis: Honoraria, Research Funding; BMS: Honoraria, Research Funding; Jazz: Honoraria, Research Funding.

Comparison of Outcomes after Early Hospital Discharge (EHD) Following Intensive Induction Vs. Post-Remission Chemotherapy for Adults with Acute Myeloid Leukemia (AML) and Other High-Grade Myeloid Neoplasms

Comparison of Outcomes after Early Hospital Discharge (EHD) Following Intensive Induction Vs. Post-Remission Chemotherapy for Adults with Acute Myeloid Leukemia (AML) and Other High-Grade Myeloid Neoplasms

Treatment of Primary Central Nervous System Lymphoma in Immunocompetent Patients.

This review focuses on the findings of recent randomized prospective trials evaluating new therapeutic options for primary central nervous system lymphoma (PCNSL) in first-line treatment and on the most promising novel agents. The current standard treatment of newly diagnosed PCNSL has long been depending on high-dose methotrexate (HD-MTX)-based polychemotherapy followed by whole-brain radiotherapy (WBRT). Recent randomized trials have provided evidence that high-dose chemotherapy with autologous stem cell transplantation (ASCT) is a valuable alternative option to WBRT as consolidation after induction HD-MTX-based chemotherapy. For the elderly, cumulative studies confirm that chemotherapy alone as initial treatment is the best approach in this frail population in order to reduce chemoradiation neurotoxicity. If the role of rituximab needs to be further investigated, novel agents such as imids and ibrutinib have shown to be promising drugs to be incorporated in innovative combination treatment. The role of WBRT, at least at conventional dose, is declining in first-line treatment in favor of intensive consolidation chemotherapy with or without ASCT and possibly maintenance chemotherapy in the elderly. Despite their rarity, it has been shown that ambitious randomized trials in PCNSL are feasible thanks to collaborative networks.

Chromosome t(7;11)(p15;p15) translocation in acute myeloid leukemia coexisting with multilineage dyspoiesis and mutations in NRAS and WT1: A case report and literature review.

The chromosomal translocation t(7;11)(p15;p15) and the resulting nucleoporin 98-homeobox A9 (NUP98-HOXA9) gene fusion is rare but recurrent genetic abnormity in acute myeloid leukemia (AML). The present study describes a case of AML plus maturation (−M2) with multilineage dyspoiesis in a 30-year-old male in whom a 46,XY,t(7;11)(p15;p15) karyotype was detected through chromosome analysis. Subsequent molecular and sequencing analysis demonstrated a NUP98-HOXA9 fusion gene with a type I fusion between NUP98 exon 12 and HOXA9 exon 1b, and mutations in neuroblastoma V-Ras oncogene homolog and Wilms tumor 1. The patient achieved hematological complete remission (CR) following two courses of induction chemotherapy. However, the NUP98-HOXA9 fusion gene remained detectable during the hematological CR period and following intensive consolidation chemotherapy. The disease relapsed 11 months after diagnosis, and the patient became refractory, with complications from an infection causing eventual mortality. The present case and literature review suggest that patients with AML and t(7;11) may have unique biological and clinical characteristics, and a poor prognosis.

Effective Dendritic Cell-based Immunotherapeutic Vaccines for Acute Myeloid Leukemia (AML)

Hematological malignancies are cancers that affect blood and different organs like bone marrow and lymph nodes. Considering the close relationship between the immune system cells, a disease disturbing one of the three compartments will often influence the others as well [1]. While unusual in solid tumors, chromosomal translocations are a common cause of liquid tumors. This feature leads to a different approach in diagnosis and treatment of hematological malignancies [2]. AML is a type of hematological malignancies characterized by heterogeneous clonal disorder of hematopoietic progenitor cells and the most common acute in adults, with a poor prognosis and an overall survival rate of only 23.6 % at 5 years [3, 4]. It is also known by an increase in the number of myeloid cells in the marrow and an arrest in their maturation, frequently resulting in hematopoietic insufficiency (i.e. granulocytopenia, thrombocytopenia, or anemia) with or without leukocytosis [5]. Recent studies have revealed that the heterogeneity of malignant cells relates to the previously defined immature progenitors within the bulk of leukemic cells which are intrinsically resistant to chemotherapy and are able to repopulate the stem cells [6]. These newly-adopted leukemia stem cells (LSCs) share the most relevant features of the normal hematopoetic stem cells (HSCs) such as the selfrenewal potential and dormant status. It would be difficult to find various pools of leukemic stem cells within the individual patients which differ both phenotypically and molecularly [7, 8]. Despite intensive consolidation chemotherapy in AML patients, the relapses occur in 50% of the patients due to the presence of minimal residual disease (MRD) [3, 9, 10]. Since leukemic stem cells are thought to consist the most of cell population in MRDs, their study also has potentially promising clinical implications. On the other hand, while achieving complete remission (CR) mainly depends on high-dose chemotherapy, the maintenance protocols as well as different strategies for the induction or restoration of the immune pressure against LSCs are needed for several months or years after intensive chemotherapies [3]. Based on the major role of the immune system in the prevention and control of leukemia, alternative therapeutic approaches other than intensive chemotherapy or hematopoietic stem cell transplantation (HSCT) have been explored to modulate the immune system [1, 11, 12]. ABSTRACT Acute myeloid (AML) is a type of poor prognosis hematological malignancies characterized by heterogeneous clonal expansion of myeloid progenitors. Leukemic stem cells are thought to form the majority of a cell population in minimal residual diseases (MRDs) which are resistant to current chemotherapeutic regimens and mediate disease relapse. Current therapeutic vaccine strategies have developed to mount effective antileukemic immunity and eradicate the MRDs. Dendritic cells (DCs) are the most professional antigen-presenting cells to elicit efficient anti-leukemic immune responses. In this review article, we present the possibility of generating AML blast-targeted DCs, especially leukemia-derived DCs and their appropriate maturation protocols and particularly the synergistic effects of TLR agonists. We also discuss about the in vitro evaluation of the generated DCs, some reported outcomes of DC-based clinical trials as well as the possibility of combination therapy to improve the efficacy of DC-based vaccines in AML patients.

Ambulatory consolidation chemotherapy for acute myeloid leukemia with antibacterial prophylaxis is associated with frequent bacteremia and the emergence of fluoroquinolone resistant E. Coli

BackgroundAmbulatory consolidation chemotherapy for acute myeloid leukemia (AML) is frequently associated with bloodstream infections but the spectrum of bacterial pathogens in this setting has not been well-described.MethodsWe evaluated the emergence of bacteremias and their respective antibiotic susceptibility patterns in AML patients receiving ambulatory-based consolidation therapy. Following achievement of complete remission, 207 patients received the first cycle (C1), and 195 the second cycle (C2), of consolidation on an ambulatory basis. Antimicrobial prophylaxis consisted of ciprofloxacin, amoxicillin and fluconazole.ResultsThere were significantly more positive blood cultures for E. coli in C2 as compared to C1 (10 vs. 1, p=0.0045); all E. coli strains for which susceptibility testing was performed demonstrated resistance to ciprofloxacin. In patients under age 60 there was a significantly higher rate of Streptococccus spp. bacteremia in C2 vs. C1; despite amoxicillin prophylaxis all Streptococcus isolates in C2 were sensitive to penicillin. Patients with Staphylococcus bacteremia in C1 had significantly higher rates of Staphylococcus bacteremia in C2 (p=0.009, OR=8.6).ConclusionsFor AML patients undergoing outpatient-based intensive consolidation chemotherapy with antibiotic prophylaxis, the second cycle is associated with higher rates of ciprofloxacin resistant E. coli, penicillin-sensitive Streptococcus bacteremias and recurrent Staphylococcus infections.

AUTOLOGOUS STEM CELL TRANSPLANTATION IN ELDERLY ACUTE MYELOID LEUKEMIA

Treatment outcome in elderly Acute Myeloid Leukemia (AML) is still very disappointing. Although complete remission rate is around 50–60% the 2 years survival is only in the magnitude of 10–20%. This is mainly due to an overrepresentation of adverse prognostic factors present in elderly AML. As relapses emerge from residual disease present after chemotherapy, intensification of treatment could emerge as a rational strategy. Intensification of chemotherapy by increasing the dose of anthracyclines or addition of gemtuzumab ozogamycin (Mylotarg) to standard chemotherapy indeed has proved to be of advantage in elderly AML. In younger AML autologous peripheral blood stem cell transplantation (AuPBSCT) as post remission treatment in comparison to intensive consolidation chemotherapy has been investigated in a few randomized studies. AuPBSCT showed reduced relapse rates with low non-relapse mortality rates. In elderly AML intensification by AuPBSCT also have been performed although randomized studies are lacking. Nevertheless, in the previous years various reports have suggested the potential utility of AuHSCT in AML of the elderly with encouraging results, albeit mostly in highly selected patients. Acceptable toxicity and a relatively low rate of transplant-related mortality has been notified. However relapses occurred which, irrespective of age, still remains the major cause of treatment failure of AuHSCT in AML. In this review we summarize the experience of AuPBSCT in elderly AML.

Feasibility of outpatient consolidation chemotherapy in older versus younger patients with acute myeloid leukemia

Intensive consolidation chemotherapy for acute myeloid leukemia (AML) patients in complete remission is being increasingly administered on an outpatient basis. Although this approach has been found to be safe and feasible in younger patients, its safety in older patients remains unknown. We therefore undertook an evaluation of outpatient-based consolidation chemotherapy in older AML patients, and compared results to younger patients treated at the same institution over the same time period. The overall rate of readmission was ~50%, mostly for infections, with mean admission duration of 2 weeks. The overall mortality rate was 2.2%. Readmission rates and duration of readmission were somewhat higher in older patients, but infection rate, intensive care (ICU) admissions, and mortality rates were comparable to those in the younger patient cohort. However, we also observed that rates of febrile neutropenia, bacteremia, ICU admission, and death were significantly higher during the second consolidation, as compared with the first, in both younger and older patients. We conclude that outpatient-based consolidation therapy can be safely undertaken in a substantial proportion of fit older patients with AML.

HOW I TREAT NEWLY DIAGNOSED ACUTE PROMYELOCYTIC LEUKEMIA

Acute promyelocytic leukemia (APL) represents a medical emergency with a high rate of early mortality. As a consequence, as soon as the diagnosis is suspected based upon cytologic criteria, it is necessary to start all- trans retinoic acid (ATRA) treatment without delay. For patients with newly diagnosed APL, induction therapy with ATRA plus anthracycline based chemotherapy is recommended. At present the combination of arsenic trioxide plus ATRA should be considered for patients who are not candidates for anthracycline-based therapy. For pediatric and adult patients with APL aged < 60 years who achieve a CR with induction, I recommend 3 intensive courses of consolidation chemotherapy associated to ATRA, targeted on the basis of the risk group at diagnosis. In patients treated with a very intensive consolidation chemotherapy maintenance treatment can be omitted. However If a maintenance treatment has to be adopted I suggest the use of intermittent ATRA for 15 days every 3 months for a period of 2 years, rather than ATRA associated to chemotherapy. Moreover, taking into account the medical literature, a reduced dosage of ATRA ( 25 mg/m2) in pediatric patients and a consolidation chemotherapy of reduced intensity in elderly patients is recommended. Furthermore, in order to maximize survival, careful attention should be reserved to the coagulopathy and to the appearance of the differentiation syndrome. Finally, PCR for the PML/RARA fusion gene on a bone marrow specimen every three months for two years, and then every six months for additional three years are needed during the follow-up.

Autologous peripheral blood stem cell transplantation for acute myeloid leukemia

AbstractWe report the results of a prospective, randomized phase 3 trial evaluating autologous peripheral blood stem cell transplantation (ASCT) versus intensive consolidation chemotherapy in newly diagnosed AML patients in complete remission (CR1). Patients with AML (16-60 years) in CR1 after 2 cycles of intensive chemotherapy and not eligible for allogeneic SCT were randomized between intensive chemotherapy with etoposide and mitoxantrone or ASCT ater high-dose cyclophosphamide and busulfan. Of patients randomized (chemotherapy, n = 259; ASCT, n = 258), more than 90% received their assigned treatment. The 2 groups were comparable with regard to prognostic factors. The ASCT group showed a markedly reduced relapse rate (58% vs 70%, P = .02) and better relapse-free survival at 5 years (38% vs 29%, P = .065, hazard ratio = 0.82; 95% confidence interval, 0.66-1.1) with nonrelapse mortality of 4% versus 1% in the chemotherapy arm (P = .02). Overall survival was similar (44% vs 41% at 5 years, P = .86) because of more opportunities for salvage with second-line chemotherapy and stem cell transplantation in patients relapsing on the chemotherapy arm. This large study shows a relapse advantage for ASCT as postremission therapy but similar survival because more relapsing patients on the chemotherapy arm were salvaged with a late transplantation for relapse. This trial is registered at www.trialregister.nl as #NTR230 and #NTR291.

Outpatient Management of Acute Myeloid Leukemia after Intensive Consolidation Chemotherapy Is Feasible and Reduces Hospital Treatment Costs

Background: This study assessed the feasibility and safety of outofhospital management of acute myeloid leukemia (AML) patients during consolidation therapy. Methods: 103 consolidation cycles were analyzed retrospectively. All patients received treatment as inpatients; they were discharged provided they were in a good clinical condition and then either electively readmitted or managed as outpatients during the aplastic phase. Results: In 95/103 cycles (92%), discharge was feasible after a median of 7 (6–16) days. In 45 cycles, patients were electively readmitted at the onset of chemotherapyinduced cytopenia after a median time of 12 (9–16) days. In 50 cycles, patients were managed as outpatients. In 23/50 outpatient cycles (46%), patients required rehospitalization, the main cause being neutropenic fever. There was 1 treatmentrelated death due to sepsis in a patient in the outpatient group, accounting for an overall mortality of 2%. Transfusion requirements, occurrence of grade 3–4 toxicity, and diseasefree and overall survival after a median followup of 20 months did not differ between the treatment strategies. Comparison of diagnosisrelated group (DRG) proceeds revealed a 40% reduction with the outpatient strategy. Conclusion: Outpatient management of consolidation therapy in selected AML patients appears to be feasible and safe and may reduce hospital treatment costs.

Imatinib and Interferon-Alpha Maintenance Therapy for Patients with Philadelphia-Positive Acute Lymphoblastic Leukemia (Ph+ALL) Ineligible for Allogeneic Stem Cell Transplantation (SCT).

Abstract 2042Poster Board II-19 Introduction:The tyrosine kinase inhibitor imatinib (IM), alone or in combination with chemotherapy, has become the mainstay of front-line treatment for Ph+ ALL. We recently demonstrated that IM in combination with intensive consolidation chemotherapy of approximately one year duration is feasible in elderly patients with de novo Ph+ ALL, but is associated with a high relapse rate. Allogeneic SCT (alloSCT) is potentially curative but may not be feasible in most elderly or comorbid patients. Maintenance therapy (MT) in such patients is conceptually attractive, but data on whether any type of MT facilitates long-term leukemia-free survival of patients with Ph+ALL in first CR is lacking. Based on data suggesting that interferon-alpha (IFN-a) possesses anti-leukemic activity in patients with Ph+ALL, we conducted a phase II study to determine the feasibility and efficacy of MT consisting of imatinib in combination with low-dose (LD) IFN-a in elderly patients with Ph+ALL who were not eligible for SCT. In addition, we examined whether bcr-abl transcript levels and mutation status were predictive of relapse and remission duration. Methods:Nineteen elderly patients (median age 66 yrs; [60-75 yrs.]) who had received IM-based remission induction and consolidation therapy as reported previously (Ottmann et al., Cancer 109:2068-76, 2007) were enrolled in a clinical trial of IM 400 mg daily in combination with LD-IFNa with a target dose of 3 Mio IU/week. At the time of enrollment, the majority of patients (n=12) had received five (n=3) or six (n=9) consolidation cycles, the remaining patients had discontinued intensive front-line therapy after four (n=2), three (n=1), two (n=1), and one (n=1) consolidation cycles, 2 patients were switched to MT after induction. The median number of cycles of consolidation chemotherapy given concurrently with IM was six. Minimal residual disease (MRD) was serially assessed by quantitative RT-PCR, mutational analyses was performed by D-HPLC and direct sequencing. Results:The median overall duration of MT is 26 mos. (range 3-92 mos.). Seven of 19 pts. (37 %) are in ongoing CR, with a median remission duration from start of maintenance of 76.7 mos. (54-91 mos.). Median overall survival of all pts. is 61 mos. (range: 20-99 mos.). Eleven of 18 evaluable pts. experienced side effects which lead to a dose reduction of IFN. 9 pts. suffered from moderate depressions or fatigue. Hematologic toxicity was mild: only 2 pts. developed grade 3 cytopenia during MT. Remission duration was independent of the number of previous cycles of intensive chemotherapy, of the MRD response during the first 6 mos. of intensive front-line therapy (16 mos. vs. 26 mos.) and of achievement of PCR negativity at any time during intial therapy. Surprisingly, the bcr-abl transcript level at the start of MT likewise had no impact on time to disease recurrence. Conclusions:In elderly Ph+ALL pts. ineligible for allogeneic SCT, maintenance with imatinib in combination with low-dose IFN-a results in long-term sustained remissions in a substantial proportion of patients, with acceptable side effects. Surprisingly, the MRD response and mutation status prior to MT were not significantly predictive of remission duration. Likewise, greater intensity of prior chemotherapy as determined by the number of administered consolidation cycles had no significant benefit with respect to remission duration during MT. More extensive evaluation of tyrosine kinase inhibitors in combination with LD IFNa as MT for Ph+ALL is warrented. Disclosures:Ottmann:Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees; BMS: Honoraria.

Risk-Stratified Therapy and the Intensive Use of Cytarabine Improves the Outcome in Childhood Acute Myeloid Leukemia: The AML99 Trial From the Japanese Childhood AML Cooperative Study Group

To improve the prognosis in children with newly diagnosed acute myeloid leukemia (AML) by introducing a dose-dense intensive chemotherapy regimen and an appropriate risk stratification system. Two hundred forty children with de novo AML were treated with continuous cytarabine-based induction therapy and stratified to three risk groups based on the initial treatment response, age, and WBC at diagnosis and cytogenetics. All of the patients were treated with intensive consolidation chemotherapy including three or four courses of high-dose cytarabine. Allogeneic hematopoietic stem-cell transplantation (HSCT) was indicated for only the intermediate-risk patients with matched related donors and for all the high-risk subsets. Two hundred twenty-seven children (94.6%) achieved a complete remission (CR). Four children demonstrated induction death. The median follow-up of the live patients was 55 months (range, 37 to 73 months). The 5-year overall survival of all 240 children was 75.6% (95% CI, 70.3% to 81.4%) and event-free survival was 61.6% (95% CI, 55.8% to 68.1%). The 5-year disease-free survival in each risk group were 71.3% (95% CI, 63.4% to 80.2%) in the low-risk group (n = 112), 59.8% (95% CI, 50.6% to 70.7%) in the intermediate-risk group (n = 92), and 56.5% (95% CI, 39.5% to 80.9%) in the high-risk group (n = 23). Eight children died during the first CR, including four after HSCT. A high survival rate, 75.6% at 5 years, was achieved for childhood with de novo AML in the AML99 trial. The treatment strategy was well tolerated with only 1.7% induction death rate and 3.5% remission death rate. Low-risk children were successfully treated with chemotherapy alone.

A High Long-Term Survival Were Produced by Early Sequential Intensive Consolidation Chemotherapy Followed by Autologous Stem Cell Transplantation in First Complete Remission in Patients with Adult Acute Lymphoblastic Leukemia.

Objective: To investigate the efficiency of our designed protocol with early sequential intensive consolidation chemotherapy followed by autologous stem cell transplantation (ASCT) in first complete remission (CR1)on adult acute lymphoblastic leukemia (ALL) patients who lack of matched sibling donors.Methods: The ALL patients were given a median 4 intensive/ consolidation therapy courses including high-dose of methotrexate, cytarabine and/or cyclophosphamide in CR1, followed by ASCT with total body irradiation (TBI)-based conditioning regimen. A 1 to 1.5 year maintenance chemotherapy with 6-mercaptopurine, methotrexate and vincristine-prednisone in combination with interleukin-2/IFN-α immunotherapy were administered after adequate hematological recovery.Results: A total of 83 patients were enrolled in this study. 78 patients reconstituted hematopoiesis except 5 patients died of early toxicity. By a median 47(3– 218) months follow-up after ASCT, the 5-year probabilities of leukemia free survival (LFS) and overall survival (OS) were 53.2%±5.9% and 54.4%±5.8%, respectively. The 5-year cumulative relapse rate (RR) was 35.7%±6.1%, and no patients relapsed more than 3 years after transplantation. According to the adverse features, age ≥35 years, WBC >30×109/L for B-cell ALL or >100×109/L for T-ALL, Pro-B and early T immunotyping, more than 4 weeks to attain remission, and high-risk karyotypes including t(9;22)/BCRABL, t(4;11)/ALL1-AF4 or t(1;19)/E2A-PBX1, the patients were identified in 3 prognostic risk groups of standard (24, 29.0%), intermediate(32, 38.5%), and high(27, 32.5%) with 0, 1, 2 or high-risk karyotypes adverse features, respectively. The 5-year probabilities of DFS were 80.36%±9.0%, 59.39%±9.2% and 24.78%±8.9% in these 3 group s, respectively. While, the 5-year cumulative incidences of relapse was 16.7%,37.5% and 70.4%, respectively.. The standard and intermediate -risk groups had significantly better OS and LFS than the high-risk group.Conclusion: Theses results indicated our designed protocol with early sequential intensive consolidation chemotherapy followed by autologous stem cell transplantation (ASCT) in first complete remission (CR1) could produced a relatively high log-term survival in standard and intermediate-risk group of adult ALL patients.

Treatment Outcome with Imatinib-Based Maintenance Therapy in Elderly Patients with Philadelphia-Positive Acute Lymphoblastic Leukaemia (Ph+ALL) Ineligible for Allogeneic Stem Cell Transplantation (SCT).

Background: The tyrosine kinase inhibitor imatinib (IM), alone or in combination with induction and post-remission chemotherapy, has become the mainstay of front-line treatment for Ph+ ALL, followed by allogeneic SCT as a potentially curative treatment option. However, alloSCT is not feasible in many elderly or comorbid patients. In a prospective, randomized clinical trial of elderly patients with de novo Ph+ ALL, we recently demonstrated that IM induction followed by IM in combination with intensive consolidation chemotherapy of approximately one year duration was feasible in the majority of pts. but associated with a high relapse rate. To assess the impact of IM-based maintenance, we here provide an analysis of maintenance therapy with IM either alone, in combination with low dose interferon-α (LD-IFNα), or with zoledronic acid. In addition, we examined whether determination of minimal residual disease (MRD) and/or BCR-ABL mutation status prior to and during pre-maintenance therapy were predictive of freedom from relapse and remission duration.Patients and Methods: Remission induction and consolidation therapy have been reported previously (Ottmann et al., Cancer 109:2068–76, 2007). As the present analysis focuses entirely on the maintenance phase, patients who failed to achieve a CR, relapsed or died during the consolidation cycles are not included. Following a median of 6 cycles of remission induction and consolidation chemotherapy given concurrently with IM, 33 CR pts. (n=33; median age 69.5 yrs; [58–75 yrs.]) were enrolled either in a clinical trial of IM in combination with low-dose IFN (n=19), or with zoledronic acid (n=4), or received Glivec as a single agent (n=8). Minimal residual disease was serially assessed by quantitative RT-PCR and mutational analyses was performed by D-HPLC and direct sequencing.Results: With a median duration of maintenance of 17 months (range 6–72 mos.), 14 of 33 patients (42%) are in ongoing CR, with a median maintenance duration of 46 mos. (20–72 mos.). Median overall survival of all patients is 28 mos. (range: 9–81 mos.). Detection of a BCR-ABL mutation at or within 4 weeks of initial diagnosis was associated with inferior remission duration, 18 mos. versus 27 mos. (p=0.06). Remission was independent of the MRD response during induction and consolidation: 24 mos. and 26 mos. in pts. who did or did not achieve MRD negativity at any time; similarly, detection of MRD at the start of maintenance had no impact on time to progression.Conclusions: Among elderly Ph+ALL pts. who did not undergo SCT, treatment outcome with IM-based maintenance therapy is encouraging, but remissions are not sustained in the majority of patients. Surprisingly, persistent MRD positivity during consolidation or at the start of maintenance were not associated with an inferior outcome; conversely, relapses occurred even in patients who had achieved prolonged MRD negativity.