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The pretransplant conditioning regimen is an essential component for the long-term outcomes of allogeneic hematopoietic stem cell transplantation (allo-HSCT).1 The AML Hub previously published an article, and an expert opinion interview on conditioning treatment before allo-HSCT.
For patients with acute myeloid leukemia/myelodysplastic syndromes (AML/MDS), the pretransplant conditioning regimen typically consists of the nucleoside analog (NA) fludarabine, combined with the alkylating agent busulfan (intravenous). In human AML cell lines, the later generation NA clofarabine, was found to be more potent than fludarabine, and a combination of clofarabine and fludarabine synergizes to a much higher degree than NA alone when combined with busulfan.2 Further trials determined that a double NA regimen was efficacious and had an acceptable toxicity profile, and that higher doses of clofarabine yield greater antileukemic effects.1,3
Here, we report the key efficacy and safety results from a randomized phase III trial (NCT01471444) of fludarabine + busulfan ± clofarabine as a pretransplant conditioning regimen in high-risk patients with AML/MDS. The results were published by Andersson, et al.1 in the Bone Marrow Transplantation journal, and we provide a summary below.
This was a randomized phase III clinical trial of 250 patients with AML/MDS. Overall, 120 patients were randomized to receive fludarabine + clofarabine + busulfan (FCB) and 130 patients received fludarabine + busulfan (Flu-Bu). Patients with MDS/AML (n = 22) and myeloproliferative disorders/AML (n = 1) were classified within AML (Figure 1). The inclusion criteria were as follow:
Figure 1. Study design*
AML, acute myeloid leukemia; AUC, area under the concentration vs time curve; Bu-SE, busulfan systemic exposure; FCB, fludarabine + clofarabine + busulfan; Flu-Bu, fludarabine + busulfan; IV, intravenous; MDS, myelodysplastic syndromes; PD, progressive disease; PFS, progression-free survival.
*Adapted from Andersson, et al.1
†Busulfan was targeted to an average daily Bu-SE, represented by the AUC of 6,000 μMol-min, total course AUC of 24,000 μMol-min ± 5% for patients up to age 60. For patient ages 61–70, the targeted daily Bu-SE was 4,000 μMol-min, a total course of 16,000 μMol-min ± 5%.
250 patients with AML (n = 181), and MDS (n = 69) received allo-HSCT. The median age at transplant was 51.4 years. The patient characteristics at pretransplant are summarized in Table 1.
Table 1. Patient characteristics*
Characteristic, % |
Overall |
FCB |
Flu-Bu |
---|---|---|---|
Gender, n = 250 |
|||
Female |
43.6 |
45.8 |
41.5 |
Race, n = 243 |
|||
Asian |
2.9 |
2.6 |
3.2 |
Black |
3.3 |
2.6 |
4.0 |
Hispanic |
4.1 |
1.7 |
6.3 |
White |
87.2 |
90.6 |
84.1 |
Other |
2.5 |
2.6 |
2.4 |
Median age, years (range; SD), |
51.4 |
51.9 |
50.9 |
≤60 |
71.6 |
71.7 |
71.5 |
>60 |
28.4 |
28.3 |
28.5 |
Diagnosis, n = 250 |
|||
AML |
72.4 |
71.7 |
73.1 |
MDS |
27.6 |
28.3 |
26.9 |
Treatment-related MDS, n = 69 |
|||
No |
81.2 |
73.5 |
88.6 |
Yes |
18.8 |
26.5 |
11.4 |
Treatment-related AML, n = 181 |
|||
No |
85.6 |
89.5 |
82.1 |
Yes |
14.4 |
10.5 |
17.9 |
Cytogenetic risk category, n = 249 |
|||
Poor |
37.3 |
32.8 |
41.5 |
Intermediate/good |
62.7 |
67.2 |
58.5 |
Median number of chemotherapy regimens (SD), n = 250 |
1.47 (0.85) |
1.46 (0.80) |
1.48 (0.89) |
Prior auto-HSCT, n = 250 |
|||
0 |
98.8 |
98.3 |
99.2 |
1 |
0.8 |
0.8 |
0.8 |
2 |
0.4 |
0.8 |
0 |
CR, n = 250 |
53.2 |
53.3 |
53.1 |
Karnofsky performance, n = 243 |
|||
70 |
1.2 |
0.8 |
1.6 |
80 |
11.1 |
10.2 |
12.0 |
90 |
49.0 |
44.9 |
52.8 |
100 |
38.7 |
44.1 |
33.6 |
Bu-SE AUC, n = 250 |
|||
4,000 |
30.8 |
30.0 |
31.5 |
6,000 |
69.2 |
70.0 |
68.5 |
Allotype/relation, n = 250 |
|||
HLA-identical sibling |
38.0 |
38.3 |
37.7 |
Unrelated |
62.0 |
61.7 |
62.3 |
Match 10/10 |
60.4 |
58.3 |
62.3 |
Match 9/10 |
1.6 |
3.3 |
0 |
HCT-CI score, n = 250 |
|||
0–2 |
42.8 |
42.5 |
43.1 |
≥3–10 |
57.2 |
57.5 |
56.9 |
AML, acute myeloid leukemia; AUC, area under the concentration vs time curve; auto-HSCT, autologous hematopoietic stem cell transplantation; Bu-SE, busulfan systemic exposure; CR, complete remission; FCB, fludarabine + clofarabine + busulfan; Flu-Bu, fludarabine + busulfan; HCT-CI, hematopoietic cell transplantation-specific comorbidity index; HLA, human leukocyte antigens; MDS, myelodysplastic syndromes. |
Overall, 248 patients who underwent allo-HSCT were evaluated. Full donor chimerism was achieved in 92.4% and 86.2% of patients in the FCB group and Flu-Bu group, respectively. Overall, 97.6% of patients remained in, or achieved, CR following the transplant. The median follow-up time for all patients was 66 months. Outcomes were as follows:
The median graft-versus-host disease (GvHD)-free, relapse-free survival (GRFS) for FCB was 9.7 months and for Flu-Bu was 9.1 months (p = 0.896). 26 patients died due to non-relapse causes in the FCB group, and 13 patients died in the Flu-Bu group, most commonly from infection and GvHD. Serious adverse events are summarized in Table 2.
Table 2. Serious adverse events by grade and treatment group*
Serious adverse event, n |
FCB (n = 120) |
Flu-Bu (n = 130) |
||||||
---|---|---|---|---|---|---|---|---|
Grade 3 |
Grade 4 |
Grade 5 |
All |
Grade 3 |
Grade 4 |
Grade 5 |
All |
|
Mucositis |
19 |
0 |
0 |
115 |
25 |
0 |
0 |
119 |
VOD/SOS |
2 |
0 |
1 |
3 |
0 |
0 |
0 |
0 |
Elevated bilirubin |
6 |
1 |
0 |
49 |
7 |
0 |
0 |
42 |
PRES |
3 |
0 |
0 |
3 |
1 |
0 |
0 |
1 |
DAH |
0 |
1 |
1 |
2 |
0 |
0 |
2 |
2 |
Pneumonitis |
3 |
1 |
1 |
5 |
5 |
0 |
1 |
6 |
Hand/foot syndrome |
1 |
0 |
0 |
11 |
0 |
0 |
0 |
11 |
Infection |
||||||||
Bacterial |
21 |
3 |
6 |
37 |
11 |
3 |
1 |
33 |
Viral |
9 |
0 |
3 |
55 |
4 |
1 |
2 |
71 |
Fungal |
4 |
2 |
3 |
9 |
2 |
2 |
2 |
6 |
DAH, diffuse alveolar hemorrhage; FCB, fludarabine + clofarabine + busulfan; Flu-Bu, fludarabine + busulfan; PRES, posterior reversible encephalopathy syndrome; SOS, sinusoidal obstruction syndrome; VOD, hepatic veno-occlusive disease. |
Non-relapse mortality estimates are displayed in Figure 2.
When RI was evaluated according to disease status at transplant, the benefits of FCB were larger for not in complete remission (NCR) patients; this benefit was offset by the higher non-relapse mortality rates, and only the NCR patients >60 years maintained the PFS and OS benefits. Patients with lower HCT-CI score (0–2) benefitted the most from FCB for both PFS and OS.
Figure 2. Cumulative non-relapse mortality*
FCB, fludarabine + clofarabine + busulfan; Flu-Bu, fludarabine + busulfan; NRM, non-relapse mortality.
*Adapted from Andersson, et al.1
Conditioning with FCB did not improve PFS overall; nevertheless, it showed better outcomes in NCR patients, or patients >60 years. In patients with active AML and low HCT-CI (0–2), FCB performed better than Flu-Bu; however, HCT-CI was not considered during the design of this study, and therefore, the results regarding HCT-CI should be considered non-confirmatory and require further investigation. Andersson, et al. recommended that the FCB treatment should be personalized based on CR/NCR status, and by including a risk assessment for treatment-related complications based on the HCT-CI and performance scores. Overall, the FCB treatment has shown to be a promising option for older patients (aged <70) with AML/MDS, and may yield improved disease control.
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