Combination of Aclarubicin and Etoposide for the Treatment of Advanced Acute Myeloid Leukemia: Results of a Prospective Multicenter Phase II Trial

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Combination of Aclarubicin and Etoposide for the Treatment of Advanced Acute Myeloid Leukemia: Results of a Prospective Multicenter Phase II Trial Leukemia (1998) 12, 1522–1526 1998 Stockton Press All rights reserved 0887-6924/98 $12.00 http://www.stockton-press.co.uk/leu Combination of aclarubicin and etoposide for the treatment of advanced acute myeloid leukemia: results of a prospective multicenter phase II trial W Kern1, J Braess1, A Grote-Metke2, H Kuse3, R Fuchs4, DK Hossfeld5, A Reichle6,BWo¨rmann1,TBu¨chner7 and W Hiddemann1 for the German AML Cooperative Group 1Department of Hematology and Oncology, Georg-August-University, Go¨ttingen; 2Department of Internal Medicine, Evangelisches Krankenhaus, Hamm; 3Krankenhaus St Georg, Hamburg; 4Department of Internal Medicine, St Antonius Hospital, Eschweiler; 5Department of Hematology and Oncology, Universita¨tsklinikum Eppendorf, Hamburg; 6Department of Hematology and Oncology, University of Regensburg; and 7Department of Hematology and Oncology, University of Mu¨nster, Germany In order to develop new strategies for the treatment of relapsed Patients and methods or refractory acute myeloid leukemia, the German AML Co- operative Group performed a prospective multicenter phase II study to evaluate the antileukemic efficacy of aclarubicin Patients 60 mg/m2/day and etoposide 100 mg/m2/day each given for 5 days. Of 37 heavily pretreated evaluable patients (median age Consecutive patients at ages 18 or older with AML refractory 42 years, range 18–81) 15 (40%) achieved a remission after one to a first salvage attempt or with second or subsequent or two courses of treatment consisting of nine complete (24%) relapses who were admitted at the participating centers and six partial remissions (16%). Fourteen (38%) cases were between August 1988 and November 1990 were eligible for non-responders and eight (22%) patients suffered from early the study. The diagnosis of AML was based on the revised deaths. Disease-free survival for patients in remission and 14 overall survival were 3.2 months each. The median duration of French–American–British (FAB) Group criteria. critical neutropenia Ͻ500/␮l was 27 days. The most frequent All patients were recruited from the first and second line non-hematologic side-effects were stomatitis (WHO III/IV, 48%), trials of the German AML Cooperative Group and the South infections (40%), nausea/vomiting (26%) and diarrhea (24%). German Hemoblastosis Group and had thus received a stan- Cardiac toxicity was mild. This study suggests a substantial dardized prior treatment. First-line therapy consisted of con- antileukemic efficacy and an acceptable toxicity of aclarubicin in combination with etoposide in heavily pretreated patients ventional induction therapy with either TAD-9 (thioguanine, with advanced acute myeloid leukemia, and warrants further cytosine arabinoside, daunorubicin) or DAV (daunorubicin, evaluations in a more favorable stage of the disease. cytosine arabinoside, etoposide), or double induction with Keywords: acute myeloid leukemia; aclarubicin; etoposide; refrac- either TAD-9/TAD-9, DAV/DAV or TAD-9/HAM (high-dose tory disease cytosine arabinoside and mitoxantrone). A second course of induction therapy was applied to patients older than 60 years only upon inadequate response to the first TAD-9 or DAV Introduction cycle. Patients of all ages who achieved a complete remission subsequently received TAD-9 or DAV for consolidation and Although long-term remissions can be achieved in approxi- monthly maintenance therapy for 3 years.15–17 Second-line mately one-third of patients with acute myeloid leukemia treatment consisted of TAD-9 or the sequential high-dose (AML), mostly by combinations of an anthracycline with stan- cytosine arabinoside and mitoxantrone regimen (S-HAM).4 dard- or high-dose cytosine arabinoside,1,2 the majority of Patients with antecedent hematologic disorders, secondary patients experience a relapse and ultimately die from resistant leukemias, and a preceding autologous or allogeneic bone and progressive disease.3–5 New treatment modalities are marrow transplantation were excluded from the study. Further therefore needed to improve the long-term perspectives for exclusion criteria comprised coronary heart disease, heart fail- adult patients with AML. Non-cross-resistant drug combi- ure, cardiomyopathy, severe arterial hypertension, abnormal nations may complement established regimens and may sup- liver function tests (aspartate aminotransferase (AST), alanine port this goal. aminotransferase (ALT) or alkaline phosphatase (AP) more Exhibiting relatively low levels of cross-resistance with than three times the upper normal limits, total bilirubin doxorubicin and daunorubicin,6,7 aclarubicin is a promising Ͼ2.0 mg/dl), impaired renal function (serum creatinine alternative to older anthracyclines and may be less hampered Ͼ2.0 mg/dl), severe infections, or pregnancy. in impairing cytotoxicity by the expression of p-glyco- protein.8,9 The topoisomerase-II inhibitor etoposide reveals substantial antileukemic efficacy as single agent with only lim- Antileukemic therapy ited toxicity10,11 and is rarely used in first-line treatment. Stimulated by promising reports by Rowe et al12 and prelimi- Patients meeting the entry criteria were enrolled in the study nary first own results,13 the German AML Cooperative Group and were treated with aclarubicin 60 mg/m2/day and etopo- initiated a prospective multicenter phase II study to evaluate side 100 mg/m2/day as a 30-min infusion on days 1–5, the antileukemic potential of combination therapy with respectively. Patients not achieving a complete or partial aclarubicin and etoposide in patients with advanced heavily remission by the first course could receive a second course of pretreated AML. the identical regimen. Study parameters Correspondence: W Hiddemann, Georg-August-University, Depart- ment of Hematology and Oncology, Robert-Koch-Straße 40, 37075 Go¨ttingen, Germany; Fax: 49 551 39 2914 Response to therapy was assessed according to CALGB cri- Received 3 April 1998; accepted 23 June 1998 teria.18 Complete remission (CR) was defined as a normal Aclarubicin and etoposide for advanced AML W Kern et al 1523 cellular bone marrow with normal erythroid and myeloid Table 1). All patients had received prior chemotherapy for elements and less than 5% myeloblasts, and with peripheral their disease as indicated above. Twenty-seven (73%) patients blood counts of more than 100 000/␮l platelets and more than had received consolidation treatment with either TAD-9 or 1500/␮l granulocytes for at least 4 weeks. Patients with regen- DAV. Thirty-two (86%) patients had received high-dose cyto- erated peripheral blood values but more than 5% and less sine arabinoside as part of induction therapy or second-line than 25% myeloblasts were considered to be in partial treatment. Overall, 10 (27%) patients had disease refractory to remission (PR), as were patients fulfilling the bone marrow second-line therapy and 27 (73%) had second or subsequent criteria of CR but without full recovery of peripheral blood relapses. AML subtypes were predominantly M1, M2, M4 and platelet and/or white blood cell counts. Patients with per- M5. Thirty-two patients received one course of aclarubicin sisting leukemic blasts in the bone marrow or blood or with and etoposide and five patients received two courses. leukemic regrowth within 4 weeks after initial response were considered as non-responders (NR). Patients dying within 6 weeks after the start of antileukemic therapy without evidence Antileukemic activity of leukemic regrowth were classified as early deaths (ED). The duration of critical cytopenia was evaluated by the time Overall, 15 (40%) patients achieved a remission consisting of for granulocyte recovery to more than 500/␮l and platelet nine complete (24%) and six partial remissions (16%). An recovery to more than 20 000/␮l from the onset of chemo- adequate reduction of bone marrow blasts was documented therapy. The time to CR was measured from the onset of treat- in 13 of 22 (59%) patients with evaluable bone marrow exam- ment to the date of documented CR and disease-free survival inations on day 12, ie 1 week after completion therapy. Four- from the date of documented CR to relapse or death during teen (38%) cases were non-responders and eight (22%) remission. Survival and time to treatment failure were meas- patients suffered from ED (Table 2). Within the group of ured by the time from the beginning of treatment to death, patients with second or subsequent relapses, nine (30%) and documentation of persisting leukemia or relapse, respectively. two (7%) patients achieved a CR and PR, respectively, while Toxicity was evaluated according to the World Health Organization (WHO) grading system.19 In all patients, clinical examinations and ECGs were performed before and 3 weeks Table 1 Patient characteristics after each cycle of chemotherapy, supplemented by ultra- sound cardiography in some cases. n = 37 Sex Statistics male 17 female 20 The primary study end point was the rate of complete and Age (years) partial remissions achieved by one or two courses of chemo- median 42 therapy with aclarubicin and etoposide in a group of 35 evalu- range 18–81 able consecutive patients with advanced AML. A remission FAB rate of more than 35% was targeted. Secondary end points M0 1 (3%) were the duration of disease-free survival in patients achieving M1 10 (27%) a complete or partial remission, the hematologic and non- M2 6 (16%) M4 13 (35%) hematologic toxicity of the regimen, and the rate of ED and M5 5 (14%) NR. An ED rate of less than 30% was targeted. Actuarial ND 2 (5%) values for survival, disease-free survival, time to treatment fail- Prior first-line therapy ure, duration of neutropenia, and time to CR were calculated TAD-9/TAD-9 19 from Kaplan–Meier estimates. TAD-9/HAM 8 DAV/DAV 6 TAD-9 2 S-HAM 1 Study conduct unknown 1 Consolidation (TAD-9 or DAV) 27 (73%) Prior to therapy all patients gave their informed consent for Prior second-line therapy S-HAM 28 participation in the current evaluation after having been TAD-9 2 advised about the purpose and investigational nature of the HAM 2 study as well as of potential risks.
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