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.

This is a preview of subscription content, log in to check access.

Fig. 1
Fig. 2
Fig. 3


  1. 1.

    Burnett A, Wetzler M, Löwenberg B. Therapeutic advances in acute myeloid leukemia. J Clin Oncol. 2011;29:487–94.

    Article  PubMed  Google Scholar 

  2. 2.

    Döhner H, Estey EH, Amadori S, Appelbaum FR, Büchner T, Burnett AK, et al. Diagnosis and management of acute myeloid leukemia in adults: recommendations from an international expert panel, on behalf of the European LeukemiaNet. Blood. 2010;115:453–74.

    Article  CAS  PubMed  Google Scholar 

  3. 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.

    Article  CAS  PubMed  Google Scholar 

  4. 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.

    Article  CAS  PubMed  Google Scholar 

  5. 5.

    Estey EH. Treatment of relapsed and refractory acute myelogenous leukemia. Leukemia. 2000;14:476–9.

    Article  CAS  PubMed  Google Scholar 

  6. 6.

    Gandhi V, Plunkett W. Modulation of arabinosylnucleoside metabolism by arabinosylnucleotides in human leukemia cells. Cancer Res. 1988;48:329–34.

    CAS  PubMed  Google Scholar 

  7. 7.

    Gandhi V, Estey E, Keating MJ, Plunkett W. Fludarabine potentiates metabolism of cytarabine in patients with acute myelogenous leukemia during therapy. J Clin Oncol. 1993;11:116–24.

    Article  CAS  PubMed  Google Scholar 

  8. 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. 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.

    Article  CAS  PubMed  Google Scholar 

  10. 10.

    Estey E, Plunkett W, Gandhi V, Rios MB, Kantarjian H, Keating MJ. Fludarabine and arabinosylcytosine therapy of refractory and relapsed acute myelogenous leukemia. Leuk lymphoma. 1993;9:343–50.

    Article  CAS  PubMed  Google Scholar 

  11. 11.

    NCCN Practice Guidelines in Oncology AML. (Version 2.2011). Accessed 24 Nov 2011.

  12. 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.

    CAS  PubMed  Google Scholar 

  13. 13.

    Nokes TJC, Johnson S, Harvey D, Goldstone AH. FLAG is a useful regimen for poor prognosis adult myeloid leukemia and myelodysplastic syndrome. Leuk Lymphoma. 1997;27:93–101.

    Article  CAS  PubMed  Google Scholar 

  14. 14.

    Parker JE, Pagliuca A, Mijovic A, Cullis JO, Czepulkowski B, Rassam SM,et al. Fludarabine, cytarabine, G-CSF and idarubicin (FLAG-IDA) for the treatment of poor-risk myelodysplastic syndromes and acute myeloid leukaemia. Br J Haematol. 1997;99:939–44.

    Article  CAS  PubMed  Google Scholar 

  15. 15.

    Montillo M, Mirto S, Petti MC, Latagliata R, Magrin S, Pinto A,et al. Fludarabine, cytarabine, and G-CSF (FLAG) for the treatment of poor risk acute myeloid leukemia. Am J Hematol. 1998;58:105–9.

    Article  CAS  PubMed  Google Scholar 

  16. 16.

    Steinmetz HT, Schulz A, Staib P, Scheid C, Glasmacher A, Neufang A, et al. Phase-II trial of idarubicin, fludarabine, cytosine arabinoside, and filgrastim (Ida-FLAG) for treatment of refractory, relapsed, and secondary AML. Ann Hematol. 1999;78:418–25.

    Article  CAS  PubMed  Google Scholar 

  17. 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.

    CAS  PubMed  Google Scholar 

  18. 18.

    Miyawaki S, Kawai Y, Takeshita A, Komatsu N, Usui N, Arai Y, et al. Phase I trial of FLAGM with high doses of cytosine arabinoside for relapsed, refractory acute myeloid leukemia: study of the Japan Adult Leukemia Study Group (JALSG). Int J Hematol. 2007;86:343–7.

    Article  CAS  PubMed  Google Scholar 

  19. 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.

    CAS  PubMed  Google Scholar 

  20. 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.

    Article  Google Scholar 

  21. 21.

    Simon R. Optimal two-stage designs for phase II clinical trials. Control Clin Trials. 1989;10:1–10.

    Article  CAS  PubMed  Google Scholar 

  22. 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. 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.

    PubMed  Google Scholar 

  24. 24.

    Byrne JL, Dasgupta E, Pallis M, Turzanski J, Forman K, Mitchell D, et al. Early allogeneic transplantation for refractory or relapsed acute leukaemia following remission induction with FLAG. Leukemia. 1999;13:786–91.

    Article  CAS  PubMed  Google Scholar 

  25. 25.

    Perl AE, Altman J, Cortes J, Smith C, Litzow M, Baer MR, et al. Selective inhibition of FLT3 by gilteritinib in relapsed or refractory acute myeloid leukaemia: a multicenter, first-in-human, open-label, phase 1–2 study. Lancet Oncol. 2017;18:1061–75.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

Download references


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.

Author information




Corresponding author

Correspondence to Shuichi Miyawaki.

Ethics declarations

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.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

All author are members of JALSG and All institusions join to JALSG.

About this article

Verify currency and authenticity via CrossMark

Cite this article

Hatsumi, N., Miyawaki, S., Yamauchi, T. et al. Phase II study of FLAGM (fludarabine + high-dose cytarabine + granulocyte colony-stimulating factor + mitoxantrone) for relapsed or refractory acute myeloid leukemia. Int J Hematol 109, 418–425 (2019).

Download citation


  • Relapsed/refractory AML
  • Salvage therapy
  • Fludarabine
  • High-dose Ara-C