Phase II study of FLAGM (fludarabine + high-dose cytarabine + granulocyte colony-stimulating factor + mitoxantrone) for relapsed or refractory acute myeloid leukemia
Given the poor prognosis of patients with relapsed/refractory acute myeloid leukemia (AML), better therapy is needed. Fludarabine enhances the efficacy of Ara-C (cytarabine) by increasing intracellular Ara-C-triphosphate. The FLAG (fludarabine, high-dose Ara-C, supported with granulocyte colony-stimulating factor) regimen has been tested for use in AML patients by other investigators. In the phase II study reported here, we evaluated the efficacy and toxicity of FLAGM therapy (FLAG with mitoxantrone), further intensified by adding mitoxantrone, based on the results of a phase I study by our group. The major endpoints were complete remission (CR) rate and early death. From June 2004 to February 2008, 41 patients (median age 52 years; range 18–64 years) were enrolled. Thirty (73% 95% CI 58–84%) patients achieved CR, which met the primary endpoint; there was a single case of early death from pneumonia. Two-year overall survival was 39.4% (95% CI 25.2–55.6%). Of those who achieved CR, 27 underwent allogeneic stem cell transplantation (SCT), and 12 SCT recipients showed long-term survival. Grade 3/4 non-hematological adverse events included infection (59%), nausea/vomiting (15%), diarrhea (7%), and elevated liver enzymes (7%). In conclusion, FLAGM is an effective and safe salvage therapy for patients with relapsed/refractory AML, and facilitated SCT for a large proportion of patients.
KeywordsRelapsed/refractory AML Salvage therapy Fludarabine High-dose Ara-C
The authors would like to thank the patients for entering this study and the participating physicians from the 20 institutions who registered their patients and provided necessary data, which made this study possible. The authors would also like to thank Dr. Ryuzo Ohno for his advice and help during the entire study, as well as the preparation of the manuscript, Nihon Schering KK for providing fludarabine, and Kirin Brewery Company, Limited, for providing filgrastim. This study was supported in part by a grant from the Ministry of Health, Labor and Welfare of Japan.
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Conflict of interest
SM received personal fees from Astelas, Ohtsuka Pharmaceutical and Novartis Pharma K. K, outside the submitted work; AT received grants from Chugai Pharmaceutical Co., Ltd., grants from Teijin Pharma K.K., grants from Pfizer Japan Inc., grants from Astellas Pharma Inc., grants from Takeda Pharmaceutical Co.,Ltd., grants from Nihon Pharmaceutical Co.,Ltd., grants from Bristol-Myers Squibb Co., grants from Kyowa Hakko Kirin Co.,Ltd., grants from Daiichi Sankyo Co.,Ltd., grants from Japan Blood Product Organization, outside the submitted work; MO received personal fees from MundiPharma, personal fees from MeijiSeika Pharma, grants and personal fees from Celltrion, personal fees from Takeda, grants and personal fees from SymBio, personal fees from Cellgene, personal fees from AstraZeneka, outside the submitted work; NU received personal fees from Celgene Co.,Ltd, personal fees from CIMIC Co.,Ltd., personal fees from Otsuka Pharmaceutical Co.,Ltd., grants and personal fees from Pfizer Co.,Ltd., personal fees from Takeda Bio Development Center Ltd., personal fees from Kyowa Hakko Kirin Co.,Ltd., personal fees from Chugai Pharmaceutical Co.,Ltd, outside the submitted work; TN received grants and personal fees from Astellas Pharma Inc., grants from Amgen Astellas BioPharma K.K., grants and personal fees from Dainippon Sumitomo Pharma Co.,LTD., grants from Fujifilm Corporation, personal fees from Nippon Boehringer Ingelheim Co., Ltd., grants from Otsuka Pharmaceutical Co.,Ltd., grants from TOYAMA CHEMICAL CO.,LTD., outside the submitted work; In addition, TN has a patent Fujifilm Corporation issued, a patent Chugai Pharmaceutical Co.,LTD. issued, and a patent Kyowa-Hakko Kirin Co.,Ltd. issued. The other authors declare that they have no conflicts of interest.
- 3.Ohtake S, Miyawaki S, Fujita H, Kiyoi H, Shinagawa K, Usui N, et al. Randomized study of induction therapy comparing standard-dose idarubicin with high-dose daunorubicin in adult patients with previously untreated acute myeloid leukemia: the JALSG AML201 Study. Blood. 2011;117:2358–65.CrossRefGoogle Scholar
- 4.Miyawaki S, Ohtake S, Fujisawa S, Kiyoi H, Shinagawa K, Usui N, et al. A randomized comparison of 4 courses of standard-dose multiagent chemotherapy versus 3 courses of high-dose cytarabine alone in postremission therapy for acute myeloid leukemia in adults: the JALSG AML201 Study. Blood. 2011;117:2366–72.CrossRefGoogle Scholar
- 6.Gandhi V, Plunkett W. Modulation of arabinosylnucleoside metabolism by arabinosylnucleotides in human leukemia cells. Cancer Res. 1988;48:329–34.Google Scholar
- 8.Gandhi V, Estey E, Du M, Keating MJ, Plunkett W. Minimum dose of fludarabine for the maximal modulation of 1-beta-d-arabinofuranosylcytosine triphosphate in human leukemia blasts during therapy. Clin Cancer Res. 1997;9:1539–45.Google Scholar
- 9.Estey E, Thall P, Andreeff M, Beran M, Kantarjian H, O’Brien S, et al. Use of granulocyte colony-stimulating factor before, during, and after fludarabine plus cytarabine induction therapy of newly diagnosed acute myelogenous leukemia or myelodysplastic syndromes: comparison with fludarabine plus cytarabine without granulocyte colony-stimulating factor. J Clin Oncol. 1994;12:671–8.CrossRefGoogle Scholar
- 11.NCCN Practice Guidelines in Oncology AML. (Version 2.2011). http://www.nccn.org/professionals/physician_gls/pdf/aml.pdf. Accessed 24 Nov 2011.
- 12.Clavio M, Carrara P, Miglino M, Pierri I, Canepa L, Balleari E, et al. High efficacy of fludarabine-containing therapy (FLAG-FLANG) in poor risk acute myeloid leukemia. Haematologica. 1996;81:513–20.Google Scholar
- 17.Pastore D, Specchia G, Carluccio P, Liso A, Mestice A, Rizzi R, et al. FLAG-IDA in the treatment of refractory/relapsed acute myeloid leukemia: single-center experience. Ann Hematol. 2003;82:231–5.Google Scholar
- 19.Grimwade D, Walker H, Oliver F, Wheatley K, Harrison C, Harrison G, et al. The importance of diagnostic cytogenetics on outcome in AML: analysis of 1,612 patients entered into the MRC AML 10 trial. Blood. 1998;92:2322–33.Google Scholar
- 20.Cheson BD, Bennett JM, Kopecky KJ, Büchner T, Willman CL, Estey EH, et al. Revised recommendations of the International Working Group for Diagnosis, Standardization of Response Criteria, Treatment Outcomes, and Reporting Standards for Therapeutic Trials in Acute Myeloid Leukemia. J Clin Oncol. 2003;21:4642–9.CrossRefGoogle Scholar
- 22.Feldman E, Gandhi V, Plunkett W, Nowak B, Estey E, Kantarjian H, et al. Sequential administration of fludarabine, ara-C, and MIT enhances topoisomerase II-DNA complex formation and has efficacy in acute leukemia. Blood. 1992;80:208 a.Google Scholar
- 23.Hänel M, Friedrichsen K, Hänel A, Herbst R, Morgner A, Neser S, et al. Mito-FLAG as salvage therapy for relapsed and refractory acute myeloid leukemia. Onkologie. 2001;24:356–60.Google Scholar