Intensified conditioning regimen in bone marrow transplantation for Philadelphia chromosome-positive acute lymphoblastic leukemia

Bone Marrow Transplantation, (1998) 22, 1029 1033 1998 Stockton Press All rights reserved 0268 3369/98 $12.00 http://www.stockton-press.co.uk/bmt Intensified conditioning regimen in bone marrow transplantation for Philadelphia chromosome-positive acute lymphoblastic leukemia N Kröger 1, W Krüger 1, G Wacker-Backhaus 1, S Hegewisch-Becker 1, M Stockschläder 1, N Fuchs 1, BRüssmann 1, H Renges 1,MDürken 1, S Bielack 1, M de Wit 1, G Schuch 1, H Bartels 4, D Braumann 3, R Kuse 2, H Kabisch 1, R Erttmann 1 and AR Zander 1 1 Bone Marrow Transplantation Center and Department of Oncology/Hematology, University-Hospital Hamburg-Eppendorf; 2 Department of Hematology, Hospital St Georg, Hamburg; 3 Department of Hematology/Oncology, Hospital Altona, Hamburg; and 4 Department of Hematology, Community-Hospital, Lübeck, Germany Summary: We investigated an intensified conditioning regimen including fractionated total body irradiation (12 Gy), etoposide (30 45 mg/kg) and cyclophosphamide (120 mg/kg), followed by autologous (n = 5), allo-related (n = 13) or allo-unrelated (n = 6) bone marrow (n = 22) or peripheral stem cell (n = 2) transplantation in patients with Philadelphia chromosome-positive acute lymphoblastic leukemia. One patient received busulfan (16 mg/kg) instead of TBI. Nineteen patients were transplanted in 1CR, two in 2CR, one in 1PR and two in relapse. Major toxicity was mucositis grade II according to the Bearman scale in all patients. The treatmentrelated mortality was 25%, mainly due to infection or GVHD after allogeneic transplantation. After a median follow-up of 45 months (range 2 93), nine patients (37.5%) remain alive in CR. Nine patients (37.5%) relapsed and eight (33.3%) of these subsequently died. After autologous transplantation, four of five patients (80%) relapsed and died. Late relapse was seen after allogeneic, as well as autologous transplantation, at 33 and 59 months, respectively. The Kaplan Meier estimate of leukemia-free survival for all patients is 38% at 3 years (95% CI: 18 58%) and 35% at 5 years (95% CI: 15 55%). For allogeneic transplants in first CR (n = 15) the estimate of disease-free survival was 46% at 3 years (95% CI: 19 73%) and 34% at 5 years (95% CI: 17 51%). Patients aged below 30 years had a better estimated overall survival at 3 years (61% vs 11%, P 01). The bcr-abl fusion transcript (p210 vs p190 vs p210/190) did not affect disease-free or overall survival. In our experience, an intensified conditioning regimen seems to improve the results of bone marrow transplantation in patients with Ph acute lymphoblastic leukemia. However, the high relapse rate warrants novel approaches to enhance anti-leukemic efficacy. Keywords: bone marrow transplantation; total body irradiation; etoposide; Philadelphia chromosome-positive acute lymphoblastic leukemia Correspondence: Dr N Kröger, Bone Marrow Transplantation Center, University Hospital Hamburg-Eppendorf, Martinistrasse 52, D-20246 Hamburg, Germany Received 27 April 1998; accepted 19 July 1998 The Philadelphia chromosome is detectable in 2 to 6% of children and in approximately 25% of adults with acute lymphoblastic leukemia. 1,2 Despite the high remission rate (57 96%) seen with intensified conventional combination chemotherapy, almost all patients relapse, resulting in a dismal long-term prognosis. 3 5 Autologous and allogeneic bone marrow transplantation may cure a proportion of patients with Philadelphia chromosome-positive acute lymphoblastic leukemia. 6 11 The International Bone Marrow Transplant Registry reported a 31% leukemia-free survival after allogeneic transplantation from HLA-identical siblings at 2 years for all patients, and of 38% for patients transplanted in first remission. 8 After autologous transplantation approximately 70% of patients relapse. 12,13 Therefore, new approaches to reduce the relapse rate are needed. We investigated an intensified conditioning regimen with total body irradiation (12 Gy) or busulfan (16 mg/kg), etoposide (30 45 mg/kg) and cyclophosphamide (120 mg/kg) in 24 patients with Philadelphia chromosome-positive acute lymphoblastic leukemia. After promising results from an interim analysis of the first 14 patients, 11 we now report the results of 24 patients, with a median follow-up of 45 months. Patients and methods Between August 1990 and November 1997, 24 patients with a median age of 28.5 years (range: 2 60) and cytogenetically proven Philadelphia chromosome-positive acute lymphoblastic leukemia were treated with an intensified conditioning regimen followed by allogeneic or autologous bone marrow transplantation. Twenty-three patients received TBI, etoposide and cyclophosphamide and one patient received busulfan (16 mg/kg), etoposide and cyclophosphamide. The conditioning regimen is given in Table 1. Table 1 Intensified conditioning regimen Total body irradiation 2 2 Gy day 7, 6, 5 Etoposide 30 45 mg/kg day 4 Cyclophosphamide 60 mg/kg day 3, 2 Bone marrow/pbsc day 0

1030 Table 2 Patient characteristics Patient Age Disease Stem cell source bcr-abl VP16-dose Acute GVHD Relapse Survival Cause of death (sex) (years) status transcript (mg/kg) grade (months) (months) 1 (F) 43 1CR autobm p210 30 Y (18) 2 relapse 2 (F) 48 1CR autobm NA 45 Y (4) 6.8 relapse 3 (M) 6 1CR autobm p210 45 N 47.5 4 (M) 23 1CR autobm p190 45 Y (4) 21.8 relapse 5 (F) 24 2CR autobm p190 45 Y (59) 65.9 relapse 6 (M) 18 1CR allobm p210 45 2 N 38.9 7 (M) 60 1CR allopbsc NA 30 0 N 5.4 graft-failure/sepsis 8 (M) 21 1CR allobm NA 45 0 N 7.3 9 (F) 30 1CR allobm p210 30 0 Y (3) 19.4 relapse 10 (M) 36 1CR allobm p190 45 2 N 8.9 interst pneumonia 11 (M) 32 1CR allobm p190 45 2 Y (33) 49.9 relapse 12 (M) 39 1 Relapse allobm NA 45 3 N 0.7 sepsis 13 (F) 4 1CR allobm p190 30 0 Y (6) 1 14 (M) 22 1CR allobm p190 45 0 N 66.6 15 (F) 31 1CR allopbsc p190 45 2 N 17.8 TTP/CMV 16 (F) 28 1CR allobm p190 30 2 N 56.4 17 (F) 29 2 Relapse allobm p210 45 3 N 8.1 cerebral bleeding/gvhd 18 (M) 45 2CR allobm p210 30 2 Y (5) 21.6 relapse 19 (F) 2 1CR allobm (MUD) p210/190 45 2 N 51.6 20 (F) 18 1CR allobm (MUD) p190 30 0 N 12.1 21 (M) 38 1CR allobm (MUD) p210/190 30 0 N 3.0 CMV 22 (M) 7 1CR allobm (MUD) p210 45 0 Y (9) 25.2 relapse 23 (M) 45 1PR allobm (MUD) NA 45 1 N 2.3 24 (M) 14 1CR allobm (MUD) p190 30 0 N 20.5 CR = complete remission; PR = partial remission; Y = yes; N = no; NA = not applicable. Thirteen patients were transplanted with HLA-identical (including two minor mismatches) bone marrow (n = 11) or peripheral blood progenitor cells (n = 2); six patients were transplanted with HLA-identical bone marrow from an unrelated donor and five patients received autologous bone marrow which was purged in two patients (one by mafosfamide; one by immunological means). One of these patients experienced delayed engraftment after mafosfamide purged bone marrow transplantation and received additional unpurged back-up marrow. For allogeneic bone marrow transplantation, graft-versus-host (GVHD) prophylaxis consisted of cyclosporin A and methotrexate in all patients and anti-thymocyte globulin (ATG) in 10 patients. Acute and chronic GVHD were diagnosed and graded according to the standard criteria. 14 Acute GVHD was treated with methylprednisolone and/or anti-thymocyte globulin. Nineteen patients were studied for both p210 bcr-abl and p190 bcr-abl fusion transcript in marrow before induction chemotherapy as described elsewhere. 11 Nineteen patients were transplanted in first complete remission, two in second complete remission, one in first partial remission and two in relapse. Treatment-related toxicities were classified according to the Bearman scale. 15 The median time from diagnosis to BMT was 5.5 months (range 3 14). Two relapsed patients who received a second transplant (cord blood and allogeneic PBSC) died of treatment-related complications (infections/gvhd). Patient characteristics are listed in Table 2. Statistic analysis was performed using WinSTAT software (Kalmia, Cambridge, MA, USA). Disease-free (DFS) and overall survival (OS) were calculated by the methods of Kaplan and Meier. 16 The log rank test was used for comparison. A P value of 5 was considered significant. Results Engraftment and toxicity The median time to reach leukocytes /nl was 18 days (range 12 25). One patient died of early infection (day 21) and one patient did not engraft sufficiently after mafosfamide purged autologous marrow and received a marrow boost of unpurged back-up marrow. One allogeneic patient did not engraft and died of infection. The median time for platelets 20/nl was 28 days (range 16 39) for 19 evaluable patients. Mean toxicity of the intensified conditioning regimen was mucositis grade II in all patients requiring intravenous morphine. Hepatic and skin toxicities were slightly higher in the 45 mg/kg than in the 30 mg/kg group (Table 3). Nine of 19 (47%) patients in the allogeneic group developed grade II/III acute GVHD. Chronic GVHD developed in three patients (15%). Overall, six patients (25%) died of causes other than leukemia after allogeneic Table 3 Toxicity of TBI, cyclophosphamide and etoposide regimen related to etoposide (VP16) dose Toxicity VP16 30 mg/kg VP16 45 mg/kg (n = 9) (n = 15) Mucositis a II 100% 100% Liver a I 44% 46% II 13% GI tract a I 22% Renal a I 22% 26% Skin: erythema 11% 46% a According to the Bearman score. 15

transplantation (graft-failure/sepsis, n = 1; CMV pneumonia, n = 1; cerebral bleeding/gvhd, n = 1; TTP, n = 1; interstitial pneumonia, n = 1; Candida crusei sepsis, n = 1), whereas no deaths occurred after autologous transplantation. Survival and relapse After a median follow-up of 45 months (range 2 93), nine patients (37.5%) remain alive in CR. Nine patients (37.5%) relapsed and eight (33.3%) of these subsequently died. The Kaplan Meier estimate of leukemia-free survival for all patients is 38% at 3 years (95% CI: 18 58%) and 35% at 5 years (95% CI: 15 55%) (Figure 1). Four of five patients (80%) relapsed after autologous transplantation and subsequently died. For all patients neither hematologic status (1CR vs 1CR) at BMT, type of transplant (autologous vs allogeneic), nor etoposide dose (30 mg vs 45 mg/kg) affected outcome. Six of nine relapses occurred within the first year after transplantation. However, late relapse was seen in three patients at 18, 33 and 59 months after autologous or allogeneic transplantation. The bcr-abl fusion transcript (p210 vs p190 vs p210/190) did not affect disease-free or overall survival (P = 0.74). For allogeneic transplants in first CR (n = 15) the estimate of disease-free and overall survival was 46% (95% CI: 19 73%) and 50% at 3 years and 34% (95% CI: 17 51%) and 38% at 5 years. In this subgroup, transplantation in first CR resulted in a better disease-free and overall survival compared to transplantation beyond first remission (P = 5 and P = 38) (Figure 2). Age at time of bone marrow transplantation significantly affected outcome. The estimated overall survival at 3 years was 62% for patients less than 30 years and only 11% for patients 30 years (P 01) (Figure 3). Discussion In the largest series of 67 bone marrow transplants from HLA-identical siblings for Philadelphia chromosome-posi- n = 24 DFS (months) Figure 1 Disease-free survival after autologous or allogeneic bone marrow transplantation in 24 patients with Philadelphia chromosome-positive acute lymphoblastic leukemia. n = 4 n = 15 Remission 1CR >1CR P = 4 Overall survival (months) Figure 2 Overall survival after allogeneic bone marrow transplantation in 1CR (n = 15) or beyond first remission status (n = 4) in patients with Philadelphia chromosome-positive acute lymphoblastic leukemia. n = 14 n = 10 P < 01 Age <30 >30 Overall survival (months) Figure 3 Overall survival according to age at time of autologous or allogeneic bone marrow transplantation in 24 patients with Philadelphia chromosome-positive acute lymphoblastic leukemia. tive acute lymphoblastic leukemia, the International Bone Marrow Transplant Registry reported a 31% leukemia-free survival at 2 years for all patients and 38% for patients transplanted in first remission. 8 Less extensive studies with a short follow-up have reported similar results. Forman et al 6 reported that six of 10 patients were alive after allogeneic bone marrow transplantation and a median followup of 19 months. Miryamura et al 7 reported seven of 15 patients who were transplanted for Ph acute lymphoblastic leukemia and who were disease-free after a median follow-up of 21 months. However, the results of studies with a longer follow-up are significantly worse. Arnold et al 10 reported 19 patients with Ph acute lymphoblastic leukemia undergoing autologous or allogeneic bone marrow transplantation who had a 22% probability of being diseasefree at 5 years. The results from Dunlop et al 17 are even worse. The estimated overall survival for 19 patients is 37.5% at 3 years and only 12.5% at 5 years, with no differences in outcome between autologous and allogeneic transplantation. The high probability of relapse is the major fac- 1031

1032 tor for poor outcome. Our approach to reducing relapse rate after transplantation was to use an intensified conditioning regimen prior to bone marrow transplantation. The results of this intensified conditioning regimen including total body irradiation, etoposide and cyclophosphamide appear to be more effective, with 38% probability of leukemiafree survival at 3 years and 35% at 5 years for all patients. The best results were seen after allogeneic transplantation in first CR, with an estimated disease-free survival of 46% at 3 years and 34% at 5 years. However, even after a median follow-up of 45 months, patients with long-term disease-free survival cannot be considered as cured, since late relapses occurred in our study up to 33 months after allogeneic and up to 59 months after autologous transplantation. Similar results for allogeneic transplantation with genotypically identical sibling donors in first CR have been recently reported by Chao et al. 9 After conditioning with fractionated TBI either with cyclophosphamide and/or etoposide, a 46% probability of disease-free state at 4 years for this group of patients was reported. The effectiveness of an intensified conditioning regimen including etoposide and TBI in advanced leukemia has been reported earlier. 18,19 The main toxicity of the conditioning regimen has been mucositis in all patients, requiring intravenous analgesics. Hepatic toxicity was slightly higher in the 45 mg/kg group and skin toxicity was usually mild and reversible. Treatment-related mortality was 25% and occurred only in allogeneic transplants mainly due to infections and GVHD. Age has had a significant impact on outcome in our study. 62% of patients transplanted at under 30 years of age and only 11% of the patients transplanted after the age of 30 years are projected to be alive at 3 years (P 01). Patients bearing the p210 bcr-abl may have a better outcome after conventional chemotherapy than patients bearing the p190 transcript, and type of bcr-abl chimeric mrna post-transplant correlates with relapse. 4,20,21 We found no correlation between the type of bcr-abl transcript and outcome after BMT. Four of five patients transplanted with purged or unpurged autologous marrow relapsed and subsequently died. Because of the small number of patients and lack of treatment-related deaths after autologous transplantation, there was no difference between the type of transplant (autologous vs allogeneic). Unrelated donor marrow transplantation seems to be an alternative treatment for young patients who lack a family donor. In 18 patients who underwent unrelated bone marrow transplantation, a 49% probability of leukemia-free survival at 2 years has been reported. 22 Our study confirmed the feasibility of unrelated donor transplantation in six patients with no difference in outcome compared with 13 patients transplanted from family donors. A graft-versus-leukemia effect might decrease relapse rates in allograft patients. Because of small numbers and the low incidence of severe GVHD, the impact of GVHD/GVL on outcome cannot be determined. Attempts to reduce hematological relapse have been made successfully by donor leukocyte infusion. 23 Our results suggest that intensified conditioning therapy with TBI, etoposide and cyclophosphamide may improve the results of bone marrow transplantation in Philadelphia chromosome-positive acute lymphoblastic leukemia, with acceptable toxicity. Allogeneic transplantation in first complete remission is likely to result in the best outcome. In young patients who lack a family donor an unrelated donor search should be performed early. However, because of the high relapse rate post-transplant investigational approaches are warranted to reduce relapse rate and improve results after allogeneic bone marrow transplantation. Acknowledgements We thank the staff of the BMT unit for providing excellent care for our patients and the medical technicians for their excellent work in the BMT laboratory. References 1 Hoelzer D. Treatment of acute lymphoblastic leukemia. Semin Hematol 1994; 31: 1 22. 2 Lestingi T, Hooberman A. Philadelphia chromosome-positive acute lymphoblastic leukemia. Hematol Oncol Clin N Am 1993; 7: 161 175. 3 Bloomfield CD, Goldman AI, Alimena G et al. Chromosomal abnormalities identify high-risk and low-risk patients with acute lymphoblastic leukemia. Blood 1986; 67: 415 420. 4 Kantarjian HM, Talpaz M, Dhingra K et al. 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