Hypomethylating agents for treatment and prevention of
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Vol:.(1234567890)
International Journal of Hematology (2018) 107:138-150 1 3PROGRESS INHEMATOLOGY
Hypomethylating agents fortreatment andprevention ofrelapse afterallogeneic blood stem cell transplantationThomasSchroeder
1· ChristinaRautenberg
1· RainerHaas
1· UlrichGerming
1· GuidoKobbe
1 Received: 8 October 2017 / Accepted: 8 November 2017 / Published online: 15 November 2017© The Japanese Society of Hematology 2017
Abstract
Despite the curative potential of allogeneic stem cell transplantation (allo-SCT) in patients with acute myeloid leukemia
(AML) and myelodysplastic syndromes (MDS), many patients will relapse. Until recently therapeutic options mainly con-
sisted of palliative care, chemotherapy, donor lymphocyte infusions and second transplantation in selected cases. Still many
patients either do not tolerate intensive therapies or do not achieve durable remissions and will nally succumb. Given this
unmet medical need the hypomethylating agents (HMA), Azacitidine (Aza) and Decitabine (DAC) have been tested as salvage
therapy in patients with myeloid malignancies relapsing after allo-SCT. Furthermore, they have also been incorporated into
prophylactic and pre-emptive approaches to avoid haematological relapse. In this review, we summarize the evidence from
retrospective studies but also from a few prospective trials regarding the use of HMA after transplant. To aid clinicians in
their daily clinical practice, we also comment on some practical aspects such as dosing and schedule, the choice of HMA and
the use of complementary cellular therapies. Finally, this review also gives an overview on potential mechanisms mediating
the ecacy of HMA after transplant as well as ongoing preclinical research and clinical activities aiming to further improve
this treatment approach.Keywords Myelodysplastic syndromes· Acute myeloid leukemia· Allogeneic transplantation· Relapse· Maintenance·
Decitabine· Azacitidine
Introduction
Allogeneic blood stem cell transplantation (allo-SCT) is a potentially curative treatment option for many patients with acute myeloid leukemia (AML) and represents the only chance for long-term survival in patients with myelodysplas- tic syndromes (MDS) [1]. In the past, several improvements including donor selection, immunosuppression and support- ive care have been made to reduce non-relapse mortality. In addition, the introduction of reduced toxicity condition- ing has broadened the access for more, in particular older patients to this treatment option [2]. In contrast to this, relapse still represents the main cause of treatment failure and is associated with a poor progno- sis. The principles of treatment in this challenging situation are to reduce the disease burden on the one hand and to induce an allogeneic immune reaction on the other hand to achieve long-term disease control. Traditionally, treatment options were limited and have generally consisted of pal- liative care, low-dose or intensive chemotherapy as well as cellular therapies such as donor lymphocyte infusions [3] and second transplantation in selected cases. Still, the fact that many patients can either not tolerate intensive therapies or are refractory to these conventional interventions indi- cates the relevant need for novel treatment approaches [4]. Ideally, such a therapy mediates direct antileukemic eects and strengthens the graft-versus-leukemia (GvL) reaction, while on the other hand is not associated with an extensive risk for severe graft-versus-host disease (GvHD) and oers an acceptable toxicity pro le. New immunotherapy-based approach inallogeneic hematopoietic stem cell transplantation * Thomas Schroeder thomas.schroeder@med.uni-duesseldorf.de 1Department ofHematology, Oncology andClinical
Immunology, Medical Faculty, University ofDuesseldorf,Moorenstr. 5, 40225Düsseldorf, Germany
139Hypomethylating agents fortreatment andprevention ofrelapse afterallogeneic blood stem...
1 3 Given their balance between ecacy and moderate tox icity, the two hypomethylating agents (HMA) Azacitidine (Aza) and Decitabine (DAC) might meet many of these demands. Both are licensed and usually employed for the treatment of older patients with AML and MDS not eligible for intensive therapies [5-8]. Taking this into account, these two substances have also been tested in the post-transplant period. In this review, we aim to summarize the current literature reporting on the use of Aza and DAC to prevent or to treat relapse of myeloid malignancies after allo-SCT. Besides an overview about ongoing research and clinical studies in this eld, we also address practical issues regarding the use of these two HMA after transplant.Treatment ofrelapse withHMA
Azacitidine for the treatment of relapse
In the absence of realistic treatment alternatives, we treated the rst patient with early relapse of an AML evolved fromMDS after allo-SCT with Aza and DLI in 2007 [
9]. Fol-
lowing this combined pharmacological and cell-based approach, this woman achieved a complete remission (CR) and our observation presented the starting point for several retrospective studies reporting on the use of Aza as salvage therapy for relapse of myeloid malignancies after allo-SCT in a limited number of patients [ 10 -12]. These data built the rationale for the rst prospective multicenter trial (AZA-RELA, Eudra-CT 2007-004860-37) [
13 ], where Aza was administered as rst intervention for relapse and DLI were scheduled after every second Aza cycle. All 30 patients included in this trial had hematologic relapse of AML ( n=28, 92%) or MDS and MDS-MPS (n=2, 8%) in median 175days after transplantation. They received a median of 3 courses of Aza (range 1-8) and 22 patients (73%) nally received at least one DLI. This treat ment resulted in an overall response rate of 30% including7 patients (23%) achieving CR and 2 patients (7%) partial
remission (PR). These remissions were durable in 5 of 7 patients lasting for a median of 777days (range 461-890). One of these patients remains in ongoing remission with out any further antileukemic treatment for 56months until now. The nding that this therapy was in particular eec tive in patients with high-risk cytogenetics such as complex karyotype is in accordance with its primary indication in the non-transplant setting and gave already an early hint, which patients might benet from this approach. This ecacy was not counterbalanced by an excess of toxicity and compared well if not better with other treatment options. Indeed, the rate and severity of GvHD as well as toxicities followingthe treatment with Aza and DLI were rather low and mild. Altogether, this prospective study conrmed the observation from the retrospective reports that the combination of Aza and DLI could by a safe and eective treatment alternative for patients with myeloid malignancies who relapse after allo-SCT.
Table1 summarizes the publications regarding the use of Aza as salvage treatment for relapse after allo-SCT: until now a total of 601 patients with AML, MDS and other related myeloid malignancies have been published with varying schedules and dosages of Aza. These included 3 pro spective, non-randomized trials and the majority of patients reported retrospectively [9-25]. Furthermore, Aza was the
rst treatment of relapse and combined with DLI in some of these patients, while other patients had previously received other salvage therapies or did not receive DLI. This hetero geneity of treatment strategies explains CR rates and overall survival (OS, not given in details in a relevant number of many studies) ranging from 14 to 75% and from 12 to 80% after treatment with Aza. Furthermore, as a consequence of this heterogeneity and limited number of patients in most of these analyses, the reproducible identication of factors predictive for response and long-term survival was not possible. For this purpose, two larger retrospective surveys were performed. In the rst one, we analysed the outcome of 154 patients with hematologic (88%) or molecular (12%) relapse of AML or MDS after allo-HSCT. All were treated with Aza (median 4 courses; range 4-14) and DLI (administered to 105 patients,68%) either as rst (93%) or later (7%) salvage approach at
12 transplant centres participating in the german cooperative
transplant study group [ 22]. The size of this patient group and the quality of data provided by the participating cen tres enabled us to identify patients who may benet most from the combination of Aza and DLI. Multivariate analy- ses carved out that the diagnosis of MDS and detection of relapse at a molecular stage were signicantly predictive for the likelihood to achieve CR. In congruency with this, a low disease burden (molecular relapse or bone marrow blast count<13%) at the time of relapse and the diagnosis of MDS were also signicant predictors for a longer overall survival [ 22
These issues were also addressed in another retrospective analysis of a similar-sized patient group ( n=181) by Crad- dock etal. within the EBMT [
16]. They also identied the
diagnosis of MDS instead of AML and in addition transplan- tation in remission as predictors for response. Conrming our results with regard to overall survival disease burden dened by the bone marrow blast count (cut-o 20%) at the time of relapse turned out to be predictive in multivariate analysis. Furthermore, a longer interval between allo-SCT and relapse (cut-os 6 and 12months) was also associated with a better outcome. These variables were included into a so-called AZA Relapse Prognostic Score (ARPS), which140 T.Schroeder et al.
1 3 Table 1Retrospective and prospective studies investigating Aza and DAC as treatment of relapseAuthorYearType of studyDrugScheduleDLIPatients (n)DiagnosisOverall
response (CR,