Gy Total Body Irradiation Followed by Allogeneic Hematopoietic St

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ORIGINAL ARTICLE Fludarabine, amsacrine, high-dose cytarabine and 12 Gy total body irradiation followed by allogeneic hematopoietic stem cell transplantation is effective in patients with relapsed or high-risk acute lymphoblastic leukemia

F Zohren, A Czibere, I Bruns, R Fenk, T Schroeder, T Gra¨f, R Haas and G Kobbe

Department of Haematology, Oncology and Clinical Immunology, Heinrich Heine-University, Du¨sseldorf, Germany

In this prospective study, we examined the toxicity and Introduction efficacy of an intensified conditioning regimen for treatment of patients with relapsed or high-risk acute The use of intensified conventional induction chemothera- lymphoblastic leukemia who undergo allogeneic hemato- pies in the treatment of newly diagnosed ALL in adult poietic stem cell transplantation. Fifteen patients received patients has led to initial CR rates of up to 90%. But, as fludarabine 30 mg/m2, cytarabine 2000 mg/m2, amsacrine some patients are even refractory to first-line therapy, the 100 mg/m2 on days -10, -9, -8 and -7, anti-thymocyte majority of the responding patients unfortunately suffer globulin (ATG-Fresenius) 20 mg/kg body weight on days from relapse. Therefore, the probability of long-term -6, -5 and -4 and fractionated total body irradiation disease-free survival is o30%.1–5 Risk stratification based 2 Â 2 Gy on days -3, -2 and -1 (FLAMSA-ATG-TBI) on prognostic factors allows identification of high-risk before allogeneic hematopoietic stem cell transplantation. ALL patients with poor prognosis.6–12 Myeloablative At the time of hematopoietic stem cell transplantation, 10 conditioning therapy followed by allogeneic hematopoietic patients were in complete remission (8 CR1; 2 CR2), 3 stem cell transplantation (HSCT) is currently the treatment with primary refractory and 2 suffered from refractory of choice for these high-risk patients.13–15 A combination of relapse. All patients achieved a complete remission after cyclophosphamide (120 mg/kg) and total body irradiation hematopoietic stem cell transplantation; and after a (TBI, 12 Gy in six fractions) has been used as a standard median follow-up time of 1091 days (range, 334–1554 myeloablative conditioning regimen in ALL patients for the days), nine patients (60%) are alive and free from disease, last 30 years.16 Recently, a combination of TBI and including three patients with prior refractory disease. etoposide has been suggested to be superior for patients Three patients died due to treatment-related mortality. in CR2.16,17 But, despite the use of these myeloablative The most frequent and severe conditioning-related toxi- regimens followed by allogeneic HSCT, relapse has cities observed in 9 out of 15 patients were grade III/IV remained a significant cause of death in high-risk ALL infections according to common toxicity criteria. Thus, patients. The introduction of intensified conditioning regi- conditioning with the FLAMSA-ATG-TBI regimen is a mens, by additional use of VP-16, improved disease feasible and effective alternative for patients with relapsed control, but was counterbalanced by higher rates of toxicity or high-risk acute lymphoblastic leukemia. and treatment-related mortality (TRM). When looking at Bone Marrow Transplantation (2009) 44, 785–792; current conventional salvage chemotherapy regimens like doi:10.1038/bmt.2009.83; published online 11 May 2009 fludarabine-cytarabine-idarubicine (FLAG-IDA) or fludar- Keywords: high-risk acute lymphoblastic leukemia; allo- abine-cytarabine-mitoxantrone (FLAM), it is notable that geneic stem cell transplantation; high-dose cytarabine; secondary CR rates of up to 85% can be achieved in myeloablative; total body irradiation relapsed ALL patients.18–20 On the basis of these findings and the promising results of a similar regimen developed by Kolb and co-workers21,22 in patients with acute myeloid leukemia we carried out a prospective single center study to investigate the safety and efficacy of an intensified conditioning regimen consisting of fludarabine, cytarabine, amsacrine (FLAMSA) and anti-thymocyte globulin (ATG) as well as 12 Gy TBI called FLAMSA-ATG-TBI. This Correspondence: Dr F Zohren, Department of Haematology, Oncology report describes our experience with the first 15 patients and Clinical Immunology, Heinrich Heine-University, Moorenstr. 5, who had high-risk, primary-refractory or relapsed 40225 Duesseldorf, Germany. E-mail: [email protected] ALL and received FLAMSA-ATG-TBI as a preparatory Received 11 August 2008; revised 19 January 2009; accepted 7 February regimen before allogeneic matched related or unrelated 2009; published online 11 May 2009 HSCT. FLAMSA-TBI followed by allogeneic stem cell transplantation F Zohren et al 786 Patients and methods risk is defined by immunophenotypes of an early or mature T-ALL. In addition, a complex aberrant karyotype, with Patients X3 aberrations including at least one structural aberration, All patients gave written informed consent and were treated defines high risk in both lineages. According to the prospectively within a protocol approved by our hospital GMALL criteria, risk stage at the time of diagnosis was according to the guidelines of the local ethical committee. standard risk for 1 patient, high risk for 13 patients and Between October 2004 and February 2008, a total of 15 very high risk (t(9;22) þ ) for 1 patient. As additional risk patients (male 12, female 3) were enrolled into this study factor, we included non-responders with active disease who (Table 1). were primary refractory or had experienced relapse. Seven Risk stratification was performed according to the patients had B-precursor ALL (B-ALL: two pro-B, three criteria of the German Multicenter Study Group for Adult pre-B and two common ALL) and eight had T-cell ALL (T- ALL (GMALL) in Frankfurt.23,24 Here, high-risk ALL is ALL: two thymic-T, four early-T and two mature-T). defined by late achievement of CR (4day 26 despite Diagnosis was based on cytology, immunophenotyping and consecutive treatment) or for B-lineage a white blood count cytogenetics. In total, 3 patients had one risk factor and the at diagnosis of 430 000/ml or a pro-B-ALL or detection of other 12 patients had several (median, 3; range, 2–5) risk either t(4;11) or t(9;22). In the case of T-lineage ALL, high factors. The reasons for high-risk stratification were: refractory disease during first-line induction therapy Table 1 Patient demographics (n ¼ 6), early relapse within 6 months after diagnosis Median (range) despite initial response (n ¼ 4), ALL subtype including early and mature T-ALL as well as pro-B-ALL (n ¼ 8), Age in years 26 (18–54) complex abnormal cytogenetics (43 aberrations including at least one structural aberration), but bcr-abl negative Sex No. (%) Male 12 (80) (n ¼ 5), t(9;22) positive ALL (n ¼ 1), t(4;11) positive ALL Female 3 (20) (n ¼ 1) and white blood count 430 000/ml at the time of diagnosis in the case of B-ALL (n ¼ 4, median 223 000/ml Diagnosis No. (%) (range, 38 000–629.000/ml)) (Table 2). Acute lymphoblastic leukemia 15 (100) Median patient age at the time of transplantation was 26 Subtype No. (%) years (range, 18–54 years). In all, 12 patients received T-ALL 8 (53) transplants (PBSC 10, BM 2) from matched unrelated Early-T 4 (27) donors (80%), and 3 patients were transplanted with PBSC Mature-T 2 (13) from matched sibling donors. With regard to HLA- Thymic-T 2 (13) B-ALL 7 (47) phenotype, 10 patients had an identical donor matched at Pro-B 2 (13) HLA-A, -B, -C, -Dq and -Dr alleles using high-resolution Pre-B 3 (20) DNA typing, whereas 5 patients had a donor with a single c-ALL 2 (13) allele mismatch (two HLA-C, two HLA-Dqb1, one HLA- Cause for high-risk stratification No. (%) Drb1). The median number of CD34 þ cells within the 6 Primary refractory 6 (40) allografts was 8.2 Â 10 /kg body weight (BW) (range, Cytogenetic (complex abnormal) 5 (33) 1.5 Â 106–29.3 Â 106/kg BW). t(9;22) or t(4;11) positive 2 (14) All 15 patients received primary induction therapy White blood count 430 000 ml in case of B-ALL 4 (27) according to the GMALL protocol of the German ALL ALL Subtype (early and mature T-ALL, pro-B-ALL) 8 (53) 23,25 Early relapseo6 month after diagnosis 4 (27) study group in Frankfurt. After induction therapy, nine Active disease at transplantation 5 (33) patients achieved CR, whereas six (40%) were refractory and, therefore, classified as induction failures. Of these six Disease status at transplant No. (%) patients three (50%; unique patient number, UPN 6, 7, 15) Relapse (refractory) 2 (13) Primary refractory 3 (20) achieved CR after consolidation I according to GMALL CR1 5 (33) (high-dose methotrexate and high-dose Ara-C) or salvage CR1*IF 3 (20) treatment with nelarabine (ARA-G) and were classified as CR2 2 (13) CR1 with induction failure (CR1/IF). The remaining three patients (UPN 3, 9, 10) were refractory despite GMALL Donor characteristics and stem cell source No. (%) Matched unrelated donor 12 (80) consolidation I and received conditioning therapy with Matched sibling donor 3 (20) active disease. Peripheral blood stem cells 13 (87) Four patients (27%) experienced early relapse during Bone marrow 2 (13) first- or second-consolidation therapy. Two of these (UPN HLA-typing No. (%) 4, 8) received fludarabine-cytarabine-idarubicine salvage Identical 10 (67) therapy and achieved a second CR (CR2) before trans- HLA-C mismatch 2 (13) plantation. The other two patients failed to achieve a HLA-Dqb1 mismatch 2 (13) second CR despite the use of several salvage chemotherapy HLA-Drb1 mismatch 1 (7) regimens (UPN 1: CLAEG, relapse protocol according to the Rostock study group, Germany, ARA-G; UPN 12: Abbreviations: CR1 ¼ first complete remission; CR1*IF ¼ first complete remission after salvage therapy because of induction failure; CR2 ¼ second 4 Â Vincristin/Dexamethason/Dasatinib) and were trans- complete remission. planted in refractory relapse.

Bone Marrow Transplantation FLAMSA-TBI followed by allogeneic stem cell transplantation F Zohren et al 787 Table 2 Risk stratiﬁcation

Risk stratiﬁcation according to the GMALL Additional risk factors

UPN ALL - subtype* Complex Achievement of WBC 4 30 000/ml t(9;22) or Induction failure Relapse Active disease abnormal CR 4 day 26* in case of B-ALL t(4;11) at transplant karyotype*

1 À + ÀÀÀÀ++ 2+ÀÀÀÀÀÀÀ 3 À ++ÀÀ+ À + 4 ÀÀÀÀÀÀ+ À 5+ÀÀ+ ÀÀÀÀ 6+À + ÀÀ+ ÀÀ 7+À + ÀÀ+ ÀÀ 8 ÀÀÀ+ ÀÀ+ À 9 ÀÀ+ ÀÀ+ À + 10 + + + ÀÀ+ À + 11 + ÀÀ+ t(4;11) ÀÀÀ 12 ÀÀÀ+ t(9;22) À ++ 13 À + ÀÀÀÀÀÀ 14 + + ÀÀÀÀÀÀ 15 + À + ÀÀ+ ÀÀ

UPN ¼ unique patient number; ALL subtype ¼ includes pro-B, early and mature T; complex aberrant karyotype ¼ X3 aberrations including at least one structural aberration; achievement of CR 4d26¼ late achievement of complete remission despite consecutive therapy 4day 26; WBC ¼ white blood count.

The remaining five patients (UPN 2, 5, 11, 13, 14) were on appearance of GvHD. In patients without any scheduled for allogeneic PBSCT after the first consolidation symptoms of GvHD, tacrolimus was tapered beginning cycle because of accumulated risk factors like: extramedul- on day þ 70 till day þ 100. lary disease manifestation (UPN 2), ALL subtype (UPN 2, All patients received prophylactic ciprofloxacin and 5, 11, 14), cytogenetics (UPN 11, 13, 14), white blood count metronidazol for selective intestinal decontamination from at diagnosis of 430 000/ml (UPN 5, 11) and increasing the beginning of conditioning therapy until hematological minimal residual disease burden in a quantitative assess- reconstitution. Furthermore, prophylactic fluconazole ment of minimal residual disease (UPN 13, 14). 200 mg/day was administered from the day of stem cell Overall, a median of three earlier chemotherapy courses infusion until discontinuation of immunosuppression. (range, 3–10 courses) were administered before allogeneic Antiviral prophylaxis adjusted on the results of surveillance HSCT. At the time of allogeneic transplantation, 3 patients cultures and CMV serologic status was also administered to (20%; UPN 3, 9, 10) were primary refractory, 2 patients all patients. Trimethoprim-sulphamethoxazole was used as (13%; UPN 1, 12) suffered from refractory relapse and 10 prophylaxis against Pneumocystis jiroveci and given until patients (67%) received their allografts in CR (8 CR1 reconstitution of T4-helper lymphocyte 4200 cells/ml (UPN 13 þ 14 were minimal residual disease positive), 2 after HSCT. CR2). In January 2009, surviving patients had a median Quantitative chimerism analyzes were performed using follow-up of 1091 days (range, 334–1554 days). short-tandem-repeat-based polymerase chain reaction tech- niques at regular intervals for every 4 weeks after allografting in peripheral blood and at day þ 28, þ 100 Transplantation procedure, immunosupression, supportive and þ 365 after transplantation in bone marrow. care and chimerism All patients underwent the same conditioning regimen that GvHD grading and treatment included FLAMSA chemotherapy (fludarabine 30 mg/m2– Diagnosis and clinical grading of acute and chronic GvHD cytarabine 2000 mg/m2–amsacrine 100 mg/m2 on days -10, were performed according to established criteria.26,27 Initial -9, -8 and -7 (total dose: fludarabine 120 mg/m2, cytarabine treatment consisted of prednisone (1–2 mg/kg BW/day, 8 g/m2, amsacrine 400 mg/m2)), ATG-Fresenius ( 20 mg/kg taper started after 14 d) and the administration of BW on days -6, -5 and -4 (total-dose: 60 mg/kg BW)) and tacrolimus was resumed at full dosage. Mycophenolate fractionated TBI (2 2 Gy on days -3, -2 and -1 (total-dose: Â mofetil has only been resumed to full dose in cases of acute 12 Gy)). After TBI, unmodified granulocyte-colony stimu- GvHD within the first 50 days after HSCT. Steroid- lating factor mobilized PBSC (n 13) or unmodified ¼ refractory acute GvHD was treated with additional T-cell bone marrow (n 2) was infused. Immunosuppression ¼ and TNF-a directed monoclonal antibodies such as was started on day -1 with tacrolimus (trough levels: basiliximab and infliximab. 10–15 ng/ml) twice daily. One hour after HSCT, mycophenolatmofetil (15 mg/kg BW) was administered three times a day. Statistical methods In the absence of GvHD, mycophenolatmofetil admin- Treatment response, GvHD-onset and overall survival were istration was tapered beginning at day þ 28 till day þ 50. calculated from the day of transplantation to respective Tacrolimus administration was individualized depending event. Death of what cause ever was counted as an event in

Bone Marrow Transplantation FLAMSA-TBI followed by allogeneic stem cell transplantation F Zohren et al 788 case of overall survival. All time-to-event curves were showed a decrease of donor chimerism as a consequence of estimated according to the method of Kaplan and Meier. the expanding malignant cells. The statistical analyzes were performed using SPSS statistical software. Survival and disease response All 15 patients achieved a complete hematological and cytogenetic remission after myeloablative conditioning and Results allogeneic HSCT. At a median follow-up time of 1091 days (range, 334–1554 days), nine patients (60%) are alive Engraftment and chimerism (Table 3; Figure 1). Leukocyte engraftment was defined as the first of three All surviving patients were in CR without evidence of consecutive days of peripheral white blood count 41000/ disease. Among these were three patients (UPN 1, 3, 10) ml. Platelet engraftment was defined as the first of seven who suffered from refractory disease and failed to attain a consecutive days with platelet counts of 450 000/ml. All cytological remission and another patient (UPN 14) who patients were successfully engrafted and there was no case did not achieve a molecular remission before transplant- of late graft failure within our study. The time needed for ation. One patient suffering from bcr-abl positive common white blood cell engraftment varied between 13 and 34 days ALL (UPN 12) became minimal residual disease positive (median 18 days), whereas platelet counts 420 000/ml were after transplantation and received a donor lymphocyte observed between 12 and 26 days (median 17 days) and infusion and Dasatinib reinducing a complete molecular 450 000/ml between 16 and 47 days (median 23 days). As remission. the FLAMSA-ATG-TBI regimen requires 10 days of Still, six patients (40%) died after transplantation, three consecutive treatment, we were particularly interested in from relapse (UPN 4, 8, 11) and three from treatment- the duration of aplasia, defined as white blood count related complications (UPN 9, 12, 13). The relapsed (o1000/ml), in comparison to engraftment. The median patients died on days þ 121, þ 340 and þ 449 after duration of aplasia was 20 days (range, 13–36 days). transplantation. Out of these, only one (UPN 4) developed A complete donor chimerism was observed in all patients mild GvHD symptoms. All three patients who died from at day þ 28 after HSCT. Three patients with relapse treatment-related complications suffered from grade III

Table 3 Outcome of treated patients

UPN Diagnosis Status at transplant Donor (mismatch) Engraftment Acute GvHD Chronic GvDH Best response Current status

1 T-ALL Refractory MUD Yes II Limited CR(a) Alive CR +1554 Thymic Relapse (—) 12 B-ALL Refractory MUD Yes — Extensive CR(a) Dead TRD At +410 Common Relapse (—) after DLI Bcr-abl+ 3 B-ALL Primary MUD Yes I — CR(a) Alive CR +1091 Pre B Refractory (—) 9 B-ALL Primary MUD Yes II–III — CR(a) Dead TRD At +87 Pre B Refractory (—) 10 T-ALL Primary MSD Yes — — CR(a) Alive CR +819 Mature Refractory (—) 4 B-ALL CR2 MSD Yes II Limited CR(m) Dead PD At +449 Common (—) 8 B-ALL CR2 MUD Yes — — CR(m) Dead PD At +121 Pre B (HLA-Dqb1) 6 T-ALL CR1*/IF MUD Yes — — CR(m) Alive CR +1140 Early (HLA-c) 7 T-ALL CR1*/IF MUD Yes III Extensive CR(m) Alive CR +1161 Early (HLA-c) 15 T-ALL CR1*/IF MUD Yes — — CR(a) Alive CR +334 Early (HLA-Drb1) 13 T-ALL CR1/ MSD Yes II–III Extensive CR(a) Dead TRD At +207 Thymic MRD pos (—) 14 T-ALL CR1/ MUD Yes III Extensive CR(a) Alive CR +411 Early MRD pos (HLA-Dqb1) 2 T-ALL CR1 MUD Yes — Limited CR(m) Alive CR +1175 Mature (—) 5 B-ALL CR1 MUD Yes — — CR(m) Alive CR +1062 Pro-B (—) 11 B-ALL CR1 MUD Yes — — CR(m) Dead PD At +340 Pro-B (—)

Abbreviations: (a) ¼ achieved; ALL ¼ acute lymphoblastic leukemia; CR 1*/IF ¼ ﬁrst CR achieved after salvage chemotherapy because of induction failure; CR ¼ complete remission; DLI ¼ donor lymphocyte infusion; (m) ¼ maintained; MRD pos ¼ minimal residual disease positive; MRD ¼ minimal residual disease; MSD ¼ matched sibling donor; MUD ¼ matched unrelated donor; PD ¼ progressive disease; TRD ¼ treatment-related death; UPN ¼ unique patient number.

Bone Marrow Transplantation FLAMSA-TBI followed by allogeneic stem cell transplantation F Zohren et al 789 Overall survival relapsed after decay of GvHD symptoms and died at day 1.0 þ 449 after transplantation (Table 3).

0.9 Chronic GvHD 0.8 Thirteen patients were evaluable for chronic GvHD (cGvHD). Seven patients (54%) had cGvHD (three limited, 0.7 four extensive). Five patients (UPN 1, 4, 7, 13, 14) had earlier episodes of acute GvHD, one patient (UPN 2) 0.6 developed a de novo cGvHD limited disease and another patient (UPN 12) developed an extensive cGvHD after 0.5 infusion of donor lymphocytes (5 Â 106 kg/BW). Another patient (UPN 7) suffering from extensive disease had lung 0.4 involvement and developed bronchiolitis obliterans, which 0.3 resolved after steroid therapy. Four of seven patients suffering from cGvHD are 0.2 currently alive and free of disease. In all patients with limited disease, GvHD symptoms resolved. In these 0.1 patients, immunosuppressive therapy was stopped on days þ 175, þ 227 and þ 371. UPN 7, who suffered from 0.0 extensive disease with lung involvement, is also currently 0 400 800 1200 1600 free of GvHD symptoms and immunosupressive therapy Days after transplantation was stopped on day þ 680. Patient UPN 14 still requires Figure 1 Overall survival. immunosuppressive therapy on day þ 411 due to extensive cGvHD (Table 3). acute and/or extensive chronic GvHD. UPN 9 and 13 had Early toxicity acute GvHD grades II–III with involvement of the skin, Early toxicities, appearing from day –10 up to þ 50 after liver and gut and received escalated GvHD treatment. UPN transplantation, were graded using the National Cancer 9 developed transplantation-associated thrombotic micro- Institute—Common Toxicity Criteria 2.0. With 9 out of 15 angiopathy and the patient died at day þ 87 post patients developing grade III/IV infections during cytope- transplantation from multiorgan failure. UPN 13 died nia, infectious complications were of capital importance. In from septicemia at day 207 after transplantation. Patient þ detail, these were: gram-negative septicemia (n ¼ 2; UPN 3, UPN 12, suffering from bcr-abl positive common ALL 5), aspergillus pneumonia (n ¼ 4; UPN 1, 5, 8, 14), bacterial became minimal residual disease positive after transplant- pneumonia (n ¼ 1; UPN 9), hemorrhagic BK virus cystitis ation and received donor lymphocytes and Dasatinib (n ¼ 2; UPN 7, 11) and external otitis (n ¼ 1; UPN 4). Two causing an extensive cGvHD with liver involvement and patients, UPN 5 and 9, required intensive care treatment he died due to liver failure on day þ 410 after transplant- due to therapy-related complications. Remarkably, both ation (Table 3). cases of hemorrhagic BK virus cystitis were successfully treated with palifermin, a human recombinant keratinocyte growth factor.28 Acute GvHD The remaining non-hematological complications within Acute GvHD grades I–III occurred in seven patients (47%) this group of patients were almost exclusively limited to and grades II–III in six patients (40%). There was no case gastrointestinal toxicities. Grade I mucositis was seen in of grade IV acute GvHD (Table 3). The onset of acute four patients, grade II in four, grade III in five and grade IV GvHD was observed at days þ 20, þ 23, þ 28, þ 36, þ 39, in two. All patients required parenteral nutrition during þ 40 and þ 80 after transplantation (median day þ 36). At hospitalization. Five patients (33%) had grade III/IV this time, all but one patient received full-dose tacrolimus nausea and another five patients (33%) showed grade III/ and additional mycophenolate mofetil. Organs involved IV diarrhea in the absence of intestinal GvHD. were skin (n ¼ 5), gut (n ¼ 4) and liver (n ¼ 3). Two patients One patient had severe acute peripheral neuropathy that with isolated grade II involvement of the skin received was attributable to tacrolimus treatment. Slight and topical corticosteroids, whereas the other five patients, who transient renal and hepatic toxicity was common, but had grades I–III involvement of gut and liver or skin, almost limited to grades I and II. Reversible grade III/IV received systemic corticosteroids. One of these (UPN 7) nephrotoxicity was seen in one patient with gram-negative required further treatment with basiliximab because of septicemia during intensive care treatment (UPN 5). Two refractory acute GvHD. Four out of seven patients with patients showed grade III/IV hepatic toxicity, both suffer- acute GvHD are currently alive and free of disease. Three ing from acute GvHD with liver involvement. of them developed chronic GvHD (1 limited, 2 extensive). There was no case of venous occlusive disease. One Two patients (UPN 9, 13) suffering from acute GvHD patient suffering from aGvHD grades II–III developed grades II–III died due to treatment-related complications. transplantation-associated thrombotic microangiopathy as UPN 4 who suffered from acute and chronic GvHD mentioned above (Table 4).

Bone Marrow Transplantation FLAMSA-TBI followed by allogeneic stem cell transplantation F Zohren et al 790 Table 4 Non-hematological toxicity addition, pharmacological studies in patients with chronic and ALL have shown a synergistic effect of ﬂudarabine and CTC 2.0 grade 0 I/II III/IV cytarabine, when administered consecutively. This effect Infection n (%) 6 (40) 0 (0) 9 (60) relates to the increase of intracellular concentration of Nausea/vomiting n (%) 0 (0) 10 (67) 5 (33) active metabolites such as AraCTP.35,36 Moreover, Arlin Mucositis n (%) — 8 (53) 7 (46) et al.37 showed that the combination of high-dose Bilirubin n (%) 1 (7) 12 (80) 2 (13) Creatinine n (%) 3 (20) 11 (73) 1 (7) cytarabine and amsacrine (4’-(9-acridinylamino) methan- Central nervous system n (%) 15 (100) — — sulfon-m-anisidine) also leads to increased CR rates up to Cardiac-arrhythmia n (%) 15 (100) — — 75% in relapsed or refractory ALL patients. Diarrhea n (%)a — 10 (67) 5 (33) Then, after this initial phase of FLAMSA chemotherapy,

a patients received consecutive ATG infusions for 3 days. Not associated with GvHD. Finally, a myeloablative dosage of 12 Gy fractionated TBI was administered 7 days after the beginning of chemo- Discussion therapy. It was intended to achieve a remission before TBI to improve outcome, as the prognosis of ALL It is well known that especially among patients suffering patients who fail to achieve CR before allogeneic HSCT from high-risk ALL both in CR1 and in CR2 myeloablative is very poor.38 allogeneic HSCT is able to improve disease-free survi- After a median follow-up of 1091 days, 60% of our val.29,30 But the results of the LALA-94 trial also showed patients are alive and free from disease. The rate of TRM in that relapse of the underlying disease remains the major our study was 20% and no patient died before engraftment. cause of death for patients with ALL even after myeloa- Time to leukocyte engraftment was 18 days (median, range, blative conditioning with cyclophosphamide/TBI and 13–34 days) and thereby comparable with other intensified allogeneic HSCT. In comparison with a 3-year TRM rate conditioning regimens such as cyclophosphamide/TBI/ of 18% in this trial, the 3-year relapse and disease-free Ara-C32 and cyclophosphamide/TBI/VP-16.32,39,40 survival rates were only 34 and 47%, respectively, With 60% patients suffering from grade III/IV (6 III, 3 indicating high rates of disease recurrence in adult ALL IV) infectious complications during aplasia, infections were patients even after allogeneic transplantation.31 These the main risks for our patients within the early post survival rates are even worse when taking into account transplant phase. But, there was no case of TRM due to that patients within the LALA-94 trial were in first CR infectious complications. Gastrointestinal toxicities like before allogeneic HSCT. Intensified conditioning regimens nausea/vomiting, mucositis and diarrhea evoked by this have already been used in high-risk adult ALL patients and regimen were the most common side effects. Grades III–IV resulted in higher rates of disease control, but this success nausea/vomiting was seen in 33%, grades III–IV mucositis was counterbalanced by an increased rate of toxicity and in 46% and grades III–IV diarrhea in 33%, which was transplant-related mortality. However, intensification of higher than in earlier studies with cyclophosphamide/TBI/ conditioning therapy before allogeneic HSCT could still be Ara-C or cyclophosphamide/TBI/VP-16.32,39,40 However, a viable approach to improve outcome, especially in young no patient required preventive intubation or experienced adults suffering from high-risk ALL. The composition of aspiration pneumonia. Life-threatening toxicities other the intensified conditioning regimens has been rather than infections did not accumulate. It is noteworthy that conservative in the past, adhering basically to the standard despite the use of high-dose Ara-C in combination with of cyclophosphamide/TBI with the additional use of VP-16 TBI, there were no cases of respiratory complications. or Ara-C.17,31–34 These results indicate that the FLAMSA-ATG-TBI regi- Here, we report on the first 15 patients with high-risk or men is sufficiently practicable and, therefore, comparable refractory ALL who received allogeneic matched unrelated with other myeloablative conditioning regimens with donor or matched sibling donor HSCT after myeloablative regards to TRM, although higher rates of gastrointestinal conditioning using a novel and more intensive conditioning toxicity occurred. As only two patients were older than 40 regimen called FLAMSA-ATG-TBI. Our primary purpose years, the regimen-related toxicity in older patients remains was to evaluate practicability, safety and complication unevaluated. profile of this regimen as a myeloablative conditioning It is worth mentioning that, although 5 patients failed to therapy. Our secondary goal was to evaluate the long-term reach a cytological remission and 2 failed to reach a anti-leukemic effect of this treatment. The keynote of this molecular remission before allogeneic transplantation, all regimen was the combination of a novel salvage therapy 15 patients achieved a CR after conditioning therapy. based on high-dose cytarabine, fludarabine and amsacrine Moreover, four out of these refractory patients are alive with full-dose TBI. and free from disease including three long-term survivors Conditioning was started using FLAMSA chemotherapy (UPN 1 þ 1554, UPN 3 þ 1091, UPN 10 þ 819). These to achieve clearance of malignant cells before the myeloa- data suggest that allogeneic transplantation after condi- blative component of this conditioning regimen. In this tioning with FLAMSA-ATG-TBI is able to induce long- context, it is worth noting that current conventional salvage term remission in otherwise refractory patients. Three chemotherapy regimens in the treatment of relapsed ALL patients transplanted in our study relapsed (20%) and died. are based on the combined administration of high-dose This result compares well with other conditioning regimens cytarabine and fludarabine and have proven strong potency that have been used in the past,31,41 especially considering resulting in secondary CR rates of up to 80%.18–20 In the unfavorable state of disease in our patients.

Bone Marrow Transplantation FLAMSA-TBI followed by allogeneic stem cell transplantation F Zohren et al 791 With 7 out of 15 patients developing an aGvHD (46%) acute lymphoblastic leukemia: results of Southwest Oncology and 7 out of 13 evaluable patients showing cGvHD (53%), Group 9400 study. Blood 2008; 111: 2563–2572. the incidences of acute and chronic GvHD are comparable 8 Thomas X, Le QH. Prognostic factors in adult acute with other studies.14,42 Considering the GvHD rates of our lymphoblastic leukemia. Hematology 2003; 8: 233–242. patients transplanted with matched unrelated donors, it is 9 Andreeff M, Gaynor J, Chapman D, Little C, Gee T, Clarkson noteworthy that only 5 out of 12 patients developed an BD. Prognostic factors in acute lymphoblastic leukemia in adults: the Memorial Hospital experience. Haematol Blood aGvHD (41%) and 4 out of 10 evaluable patients Transfus 1987; 30: 111–124. developed a cGvHD (40%), indicating that allogeneic 10 Gaynor J, Chapman D, Little C, McKenzie S, Miller W, matched unrelated donor transplantation might also be a Andreeff M et al. A cause-specific hazard rate analysis of feasible treatment for patients with high-risk ALL even in prognostic factors among 199 adults with acute lymphoblastic first remission missing a sibling donor. Although patients leukemia: the Memorial Hospital experience since 1969. J Clin with GvHD in our study had a better outcome than those Oncol 1988; 6: 1014–1030. without GvHD, undermining the presence of a graft- 11 Gulati SC, Gaynor J, Esseesse I, Gee T, Little C, Andreeff M versus-leukemia effect, eradication of residual disease by et al. Use of prognostic factors in deciding therapy for adult the conditioning regimen is the basic requirement for acute lymphoblastic leukemia: new approaches at Memorial Bone Marrow disease control in this group of patients. Although there Sloan-Kettering Cancer Center (MSKCC). Transplant 1989; 4(Suppl 1): 86–89. has been evidence for a graft-versus-leukemia effect in 12 Hoelzer D, Thiel E, Loffler H, Buchner T, Ganser A, Heil G 13–15,29 ALL, the potency of this graft-versus-tumor effect et al. Prognostic factors in a multicenter study for treatment may be less powerful than in myeloid malignancies. of acute lymphoblastic leukemia in adults. Blood 1988; 71: Therefore, a conditioning regimen has to be sufficiently 123–131. intense to facilitate engraftment and to provide an interval 13 Goldstone AH, Richards SM, Lazarus HM, Tallman MS, of remission to establish immunological control of the Buck G, Fielding AK et al. 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