Traitement des leucémies aiguës lymphoblastiques de l...
Transcript of Traitement des leucémies aiguës lymphoblastiques de l...
![Page 1: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/1.jpg)
Traitement des leucémies aiguës lymphoblastiques
de l’adulte (Ph1-)
Nicolas BoisselUnité d’Hématologie Adolescents et Jeunes Adultes
Hôpital Saint-Louis, Paris
DES Hématologie 12 avril 2019
![Page 2: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/2.jpg)
Acute Lymphoblastic Leukemia –Progress in Children. Less in Adults
Treatment of Acute Lymphoblastic Leukemia –30 Years' Experience
at St. Jude Children's Research Hospital
D. Hoelzer
G.K. Rivera
1993
![Page 3: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/3.jpg)
A question of biology ?
Moorman. 2007
![Page 4: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/4.jpg)
Age
(yr)
Pts CR
(%)
EFS
(%)
France FRALLE 93 15-20 77 94 67
LALA 94 100 83 41
Netherland DCOG 15-18 47 98 69
HOVON 44 91 34
UK ALL97 15-17 61 98 65
UKALLXII 67 94 49
Sweden NOPHO92 15-20 36 99 74
Adult ALL Group 23 90 39
USA CCG 16-20 197 90 63
CALGB 124 90 34
Boissel, JCO, 2003
De Bont,Leukemia, 2004 Ramanujachar, Pediatr Blood Cancer, 2007
Hallböök, Cancer, 2006
Stock, Blood, 2008
A question of therapy ?
![Page 5: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/5.jpg)
Biologists
C. AbbalV. AsnafiM. BakkusL. BarangerK. BeldjordMC. BénéML. BoullandH. Cavé JM. CayuelaA. ChasseventE. ClappierE. DelabesseN. GrardelM. LafageE. MacIntyreB. SchäferJ. Soulier
Clinicians
N. BoisselT. BraunA. BuzynJY. CahnY. ChalandonP. ChevallierA. DelannoyN. DhédinM. Escoffre-BarbeC. GardinC. Graux
Coordination
V. LhéritierN. IfrahH. Dombret
Biostatistics
J. LejeuneS. Chevret
… All GRAALL investigators
D. HeimU. HessF. HuguetA. HuynhM. HunaultT. LeguayS. LeprêtreJP. MarolleauS. MauryP. RousselotX. ThomasJP. VernantN. Vey
80 centers in Switzerland, Belgium, and France
![Page 6: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/6.jpg)
The GRAALL-2003/05 protocol
GRAALL, Group for Research on Adult Acute Lymphoblastic Leukemia
Huguet F, et al. J Clin Oncol 2009;27:911–8
![Page 7: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/7.jpg)
PDN (mg) 840 7,260 4,340VCR (mg) 6 22 19L-ASPA (IU.103) 9 144 180VP16 (mg) 0 450 1,200CPM (g) 12.5 6 or 7* 0Ara-C (g) 4,3 or 12** 24 0.96
LALA-94 GRAALL-2003 FRALLE 93
* single dose or repeted bolus
** without or with intensive consolidation
GRAALL-2003/05 vs LALA-94 :cumulative doses (/sqm)
![Page 8: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/8.jpg)
Historical GRAALL risk factors
• Baseline – WBC ≥30 x 109/L for B-lineage ALL
– CNS disease
– Immature CD10-negative B-lineage ALL*
– t(4;11) and/or MLL-AF4, t(1;19) and/or TCF3-PBX1
– Low hypodiploidy, near triploidy
– Complex karyotype (≥5 abnormalities)*
• Early response– No haematological CR after the first induction course
– Slow PDN response at the end of pre-phase
– Slow BM blast clearance at Day 8 of chemotherapy
– Ig/TCR MRD ≥10-2 after induction†
*Introduced in GRAALL-2005 †In GRAALL-2003 only (1 single patient classified as high-risk due to MRD only)ASCT, allogeneic stem cell transplant; BM, bone marrow; CNS, central nervous system; CR, complete response; Ig, immunoglobulin; MRD, minimal residual disease; TCR, T-cell receptor; WBC, white blood cell count
Huguet F, et al. J Clin Oncol 2009;27:911–8;
Used for ASCT indication
![Page 9: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/9.jpg)
GRAALL-2003 vs LALA-94Event-free survival in Ph- ALL
EFS, event-free survival; LALA, France-Belgium Group for Lymphoblastic Acute Leukemia in Adults
N Boissel, personal communication; Huguet F, et al. J Clin Oncol 2009;27:911–8 and supplemental data
0.0
00.2
00.4
00.6
00.8
01.0
0
pro
ba
bili
ty o
f su
rviv
al
0 6 12 18 24 30 36 42 48months
trial = LALA-94
trial = GRAALL-2003
Event-free survival
![Page 10: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/10.jpg)
From GRAALL-2003/05To GRAALL-2014
![Page 11: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/11.jpg)
Post induction MRD andrisk of relapse
Best cutoff level, 10-4 Beldjord K et al., Blood. 2014;123(24):3739-3749
BCP-ALL
60% vs 20% at 5y*
HR, 3.62
T-ALL
60% vs 30% at 5y*
HR, 3.20
* Censored at SCT
![Page 12: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/12.jpg)
Survival by post-induction MRD
(GRAALL-2003/05, data on file)
5y-OS: 74.0%, MRD<10-4
48.7%, MRD≥10-4
p <0.001
![Page 13: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/13.jpg)
BCP-ALLMultivariate analysis
Beldjord K, et al. Blood 2014;123:3739–49
• Multivariate analysis
• High-risk group in GRAALL-2014-B trial :
IKZF1 deletion, or MLL+
or MRD1 ≥10-4
Events CIR (not censored) CIR (censored)
Hazard ratio P value Hazard ratio P value
WBC ≥30 x109/L 67/260 1.37 0.30 1.01 0.98
t(4;11) and/or MLL-AF4 or MLL+
29/253 1.73 0.17 3.15 0.028
DIKZF1 54/216 1.75 0.05 2.43 0.006
MRD1 ≥10-4 111/260 2.49 0.001 3.21 <0.001
![Page 14: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/14.jpg)
T-ALL 4-gene classifierNOTCH1/FBXW7 and RAS/PTEN
Trinquand A, et al. J Clin Oncol 2013;31:4333–42
NOTCH1/FBXW7
Wild type Mutated
RAS/PTEN
Normal High Risk Low Risk
Alteration High Risk High Risk
55%
![Page 15: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/15.jpg)
T-ALLFactors correlating with relapse
Beldjord K, et al. Blood 2014;123:3739–49Ben Abdelali R, et al. Blood 2011;118:5099–107Trinquand A, et al. J Clin Oncol 2013;31:4333–42
N=317 patients Number
CIR (not censored at ASCT) CIR (censored at ASCT)
Hazard ratio P value Hazard ratio P value
Age ≥45 years 55/317 0.85 0.56 0.65 0.18
WBC ≥100 x 109/L 69/317 1.87 0.005 1.95 0.009
CNS+ 33/313 1.78 0.046 2.45 0.013
Pre-T/cortical 39/288 0.63 0.07 0.67 0.17
Complex karyotype 27/266 1.39 0.33 1.24 0.62
TLX1 hyper-expression 63/294 0.62 0.10 0.65 0.15
TLX3 hyper-expression 28/294 1.24 0.52 0.79 0.60
ERG-BAALC overexpression 106/187 1.16 0.53 0.59 0.26
NOTCH1/FBXW7 mutation 164/236 0.43 <0.001 0.46 0.004
N/K-RAS mutation 23/218 2.45 0.004 2.13 0.032
PTEN alteration 25/196 1.78 0.08 2.50 0.01
Slow prednisone response 118/316 1.28 0.24 1.54 0.08
Slow BM blast clearance 129/311 1.36 0.14 1.65 0.04
MRD1 ≥10-4 47/163 2.50 0.001 2.93 0.002
![Page 16: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/16.jpg)
• Multivariate analysis
• High-risk group in GRAALL-2014-T: high risk NOTCH1/FBXW7/RAS/PTEN classifier
or MRD1 ≥10-4
T-ALLMultivariate analysis
Beldjord K, et al. Blood 2014;123:3739–49
Events CIR (not censored) CIR (censored)
Hazard ratio P value Hazard ratio P value
WBC ≥100 x109/L 37/163 1.51 0.29 1.34 0.53
CNS+ 18/162 1.38 0.53 2.49 0.29
Phenotype: Pro-T/mature 22/151 1.22 0.63 1.01 0.98
NOTCH1/FBXW7/RAS/PTEN 60/125 4.39 0.002 5.59 0.003
MRD1 ≥10-4 47/163 3.13 0.002 2.50 0.036
![Page 17: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/17.jpg)
Benefit from ASCTAccording to post-induction MRD
Dhédin N, et al. Blood 2015;125:2486–96
![Page 18: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/18.jpg)
GRAALL-2014 Risk-stratification
0.00
0.20
0.40
0.60
0.80
1.00
Ove
rall
Su
rviv
al (p
roba
bili
ty)
173 140 103 95 70 50 36 9 2HR124 112 100 94 78 57 29 11 5SR
Number at risk
0 1 2 3 4 5 6 7 8Time(years)
0.00
0.20
0.40
0.60
0.80
1.00
Ove
rall
Su
rviv
al (p
roba
bili
ty)
137 114 87 73 61 50 24 11 3HR78 76 68 64 54 38 26 12 4SR
Number at risk
0 1 2 3 4 5 6 7 8Time(years)
High-RiskIKZF1 deletion,
or KMT2A(MLL)+,or MRD1 ≥10-4
≈ 60%
HR, 5y: 45.9%
SR, 5y: 74.7%
Beldjord K et al., Blood. 2014;123(24):3739-3749
High-RiskNOTCH1/FBXW7/RAS/PTEN
unfavorable,or MRD1 ≥10-4
Ph- BCP-ALL T-ALL
≈ 65%Very High-RiskMRD1 ≥10-3
or MRD2 ≥10-4
ASCT
HR, 5y: 52.9%
SR, 5y: 84.9%
≈ 25-30%
![Page 19: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/19.jpg)
Signaling pathways in Ph-like ALL
Iacobucci et Mullighan, J Clin Oncol. 2017 Mar 20;35(9):975-983Hunger S & Mullighan C, Blood. 2015 Jun 25; 125(26): 3977–3987
![Page 20: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/20.jpg)
Ph-like ALL outcome in adults
1. Herold T, et al. Haematologica 2017;102:130–8;2. Jain N, et al. Blood 2017;129:572–81.
DFS
OS
MDACC: HyperCVAD/A-BFM2GMALL: 06/99 & 07/031
EFS
OS
![Page 21: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/21.jpg)
Kinase rearrangements in Ph-like ALL
Roberts KG, et al. Cancer Cell 2012;22:153–66;Pui CH, et al. Clin Lymphoma Myeloma Leuk 2017;17:464–70.
Selected kinase-activating gene fusions Kinases with re-arrangements in Ph-like ALL
![Page 22: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/22.jpg)
GRAALL-2014Ph-like ALL with targetable ABL-family gene
Slide courtesy of E. Clappier and P. Rousselot.
Pre-phase & induction
HDAC HD-MTX CPM
PDN PDN-VCR-DNR-CPM-ASPA
PDN-VCR-DNR-CPM-ASPA/ERW
MRD1
HDAC HD-MTX CPM
HDAC HD-MTX CPM
Consolidation n°1
Delayed intensification
Consolidation n°3
Consolidation n°2
2-year maintenance
MRD2
MRD3
Ph-likewith
targetable ABL gene
IM600
IM600
VHR (HSCT)MRD1≥10-3
or MRD2≥10-4
IM600
IM600
IM600
CPM, cyclophosphamide; IM600, imatinib 600 mg/day; MTX, methotrexate; VCR, vincristine; VHR, very high-risk.
![Page 23: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/23.jpg)
COG ALL0434, Phase 3 nelarabine in T-ALL/LBLTreatment scheme
• Nelarabine is a soluble pro-drug of Ara-G• AraG is intracellularly converted to AraG triphosphate (AraGTP)• AraGTP accumulates in T-lymphoblasts and inhibits DNA synthesis
• Aim : To determine the relative safety and efficacy of the addition of Nelarabine to COG-modified ABFM therapy.
• Treatment scheme :• 4-Drug Induction• Consolidation: Augmented BFM (Similar to Ib) +/- NELA (x2)• Interim Maintenance: MTX Randomization : Capizzi MTX/ASNase vs HD MTX• Delayed Intensification: (similar to II A+B) +/- NELA (x1)• Maintenance Cycles: 7 (girls) or 11 (boys) : +/- NELA (x3)• CNS1 or CNS2: 1,200 cGy; CNS3: 1,800 cGy
• Nelarabine arms : 6 courses of nelarabine monotherapy (650 mg/m2/day, D1–5)Winter SS, et al. Pediatr Blood Cancer 2015;62:1176–83.
![Page 24: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/24.jpg)
COG ALL0434, Ph 3 nelarabine in T-ALL/LLPatient outcome
0 2 4 6 8 10
0.0
0.2
0.4
0.6
0.8
1.0
Years
Pro
bab
ilit
y
Nelarabine (n=323)
No Nelarabine (n=336) One-sided P = 0.0450
4yr DFS + Nel 88%4yr DFS – Nel 83%
Outcome of Randomized Patients
• Patients receiving nelarabine had fewer CNS relapses• No difference in peripheral neurotoxicities between arms
0 1 2 3 4 5 6 7
0.0
0.2
0.4
0.6
0.8
1.0
Years
Pro
bab
ilit
y
Nelarabine (n=60)
No Nelarabine (n=58) One-sided P = 0.2127
No benefit to nelarabine for T-LLy
DFS 4yr 85%
T-LBL arm not powered to evaluate efficacy
Dunsmore KP, et al. ASCO 2018; Abstract 10500.
![Page 25: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/25.jpg)
GRAALL phase 2 study, HR-T-ALLATRIALL trial
Prephase & induction
HDAC HD-MTX CPM
PDN PDN-VCR-DNR-CPM-ASPA
PDN-VCR-DNR-CPM-ASPA/ERW
PDN-VCR-6MP-MTX
* MRD1
* MRD2
HDAC HD-MTX CPM HDAC HD-MTXCPM/NEL
HDAC HD-MTXCPM/NEL
PDN-VCR-DNR-CPM-ASPA/ERW
SRHR
Def. 4-gene classifieror MRD1≥10-4
VHR (ASCT)MRD1≥10-3
or MRD2≥10-4
HDAC HD-MTX CPM
PDN-VCR-6MP-MTX- NEL
Consolidation n°1
Delayed intensification
Consolidation n°3
Consolidation n°2
2-year maintenance
* MRD3
![Page 26: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/26.jpg)
Benefits and limits ofpediatric-like therapyin adults
![Page 27: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/27.jpg)
Age and increasing risk of failurein children (>1y) and AYAs with Ph- ALL
Hough R, Br J Haematol. 2016 Feb;172(3):439-51.
Toft N, Leukemia. 2018 Mar;32(3):606-615.
UKALL-2003 NOPHO-2008
![Page 28: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/28.jpg)
• Even if TRM progressively increased with advanced age, patients aged 55 years or more displayed a significantly lower EFS, mostly due to higher TRM during induction and post-remission therapy, even if not transplanted.
Patients by age range N CR rate
Inductiondeath rate
5-yearCIF
5-year CITRM
5-yearEFS
w/o SCT censoring
with SCT censoring
18-24y 200 98.5% 0.5% 32.7% 7.6% 1.8% 60%
25-34y 172 95.3% 1.7% 29.4% 12.7% 6.4% 58%
35-44y 171 87.7% 7.6% 31.0% 15.0% 11.3% 54%
45-54y 151 89.4% 6.6% 26.7% 22.4% 16.7% 50%
55y+ 93 79.6% 18.3% 33.0% 39.7% 38.4% 26%
All 787 92% 5.5% 30.5% 17% 12% 52%
Huguet F. ASH 2016, #762
Age and increasing risk of TRMin adults (18-59y) with Ph- ALL
![Page 29: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/29.jpg)
EFS event incidences, by age subgroups
18-24y 25-34y 35-45y 46-54y 55-59y
Cumulative incidence of failure(primary resistance, relapse)
Cumulative incidence of TRM(induction death, death in CR1)
Leukemia-related events Treatment-related events
Huguet F. ASH 2016, #762
![Page 30: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/30.jpg)
Children Adults Elderly
Cu
mu
lati
ve in
cid
ence
of
TRM
/Fai
lure
Adult and pediatric strategies in ALLTRM and CI of Failure according to age & treatment intensity
Children Adults Elderly
Cu
mu
lati
ve in
cid
ence
of
TRM
/Fai
lure
Treatment Intensity : Low/Medium/HighTRMFailure
Treatment Intensity : Low/Medium/HighTRMFailure
AYA
![Page 31: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/31.jpg)
Impact of age-based care organizationon the outcome of AYA 18-39y with ALL
Siegel SE, JAMA Oncol. 2018 Feb 15.
Five-Year Relative Survival Rate by Single Year of Age at Diagnosis, 2000 to 2007 (SEER)
![Page 32: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/32.jpg)
Relapsed Ph-negative ALLin adults
![Page 33: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/33.jpg)
Post-relapse survival
LALA 94
• Median OS: 6.3 mois
• 2y OS : 11%
• 5y OS : 9%
GRAALL 2003 & 2005
• Median OS : 6.7 mois
• 2y OS : 19.3%
• 5y OS : 13.3%
Tavernier E. et al. Leukemia. 2007 Sep;21(9):1907-14.Desjonquères A. et al. Blood Cancer J. 2016 Dec 9;6(12):e504
![Page 34: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/34.jpg)
Prognostic factors at relapseGRAALL study
Desjonquères A. et al. Blood Cancer J. 2016 Dec 9;6(12):e504
CR2
No CR2
SCT
No SCT
![Page 35: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/35.jpg)
Standard chemotherapy in late relapse
GMALL n CR, n (%)
Total 224 95 (42%)
< 18 months 160 58 (36%)
SCT in relapse 18 10 (56%)
≥ 18 months 64 37 (58%)
Standard induction 30 27 (90%)
FLAG-IDA 15 4 (27%)
GRAALL n CR, n(%)
Total 229 121 (53%)
< 18 months 179 87 (49%)*
≥ 18 months 50 34 (68%)
*p=.02
GRAALL, data out of fileAdapted from Gökbuget N et al., Blood. 2012 Sep 6;120(10):2032-41.
![Page 36: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/36.jpg)
New immunostrategies
![Page 37: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/37.jpg)
Immunostrategies in BCP-ALL
Batlevi et al., Nat Rev Clin Oncol. 2015
![Page 38: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/38.jpg)
Inotuzumab Ozogamicin
![Page 39: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/39.jpg)
Inotuzumab phase III (INO-VATE)BCP-ALL, R/R
Kantarjian, N Engl J Med. 2016 Aug 25;375(8):740-53
MRD < 0.01% in patients with CRInotozumab: 78.4% vs. SOC: 28.1%, P<0.001
![Page 40: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/40.jpg)
Inotuzumab phase III (INO-VATE)BCP-ALL, R/R
Duration of remission
Progression-free Survival
Kantarjian, N Engl J Med. 2016 Aug 25;375(8):740-53
Overall Survival
2-year survival rate: InO 23% (95% CI 16–30) vs SOC 10% (95% CI 5–16)
![Page 41: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/41.jpg)
Inotuzumab phase III (INO-VATE) Liver toxicity
Kantarjian, Lancet Haematol. 2017 Aug;4(8):e387-e398
Inotuzumab and HSCT• SOS in 17/77 (22%)• 5 deaths
![Page 42: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/42.jpg)
Inotuzumab frontlineEWALL-INO Phase 2 study
Followed by six INO-free consolidation cycles and maintenance.
• N= 130 patients aged 56y+ with Ph-negative BCP-ALL
• Sequential INO for first 2 courses :• 0.8/0.5/0.5 mg/m2 for cycle 1; 0.5/0.5 mg/m2 for cycle 2
![Page 43: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/43.jpg)
BlinatumomabMechanism of action
1. Baeuerle PA, Reinhardt C. Cancer Res 2009;69:4941–4; 2. Bargou R, et al. Science 2008;321:974–7; 3. Klinger M, et al. Blood 2012;119:6226–33; 4. Hoffmann P, et al. Int J Cancer 2005;115:98–104.
![Page 44: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/44.jpg)
Blinatumomab phase III (TOWER)BCP-ALL, R/R, complete remission
Katarjian H, N Engl J Med. 2017 Mar 2;376(9):836-847.
MRD < 0.01% in patients with CR/CRh/CRiBlinatumomab: 76% vs. SOC: 48%, P<0.001
![Page 45: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/45.jpg)
Blinatumomab phase III (TOWER)BCP-ALL, R/R, OS according to salvage status
Dombret H, et al. EHA 2017; Abstract S478
KM median, months (95% CI) P-value*
S1: Blinatumomab 11.1 (8.2–NR)0.016
S1: SOC 5.5 (3.7–9.0)S2+: Blinatumomab 5.1 (3.2–7.1)
0.055S2+: SOC 3.0 (2.1–4.0)
00
20
40
100
Time (years)
Overa
ll surv
ival (%
)
1.0
60
0.5 1.5
80
2.0
104 2680 1463 1139 5
167 1996 13
S1: blinatumomabS1: SOCS2+: blinatumomab
Patients at risk:592665
391840
71 632 2S2+: SOC 15 9
5341
1031
0
00
0
Censored
![Page 46: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/46.jpg)
Blinatumomab, LAL-Ph1-, MRD+BLAST Study, OS by CMR
48
Landmark analysis from day 45;
Complete MRD response was defined as no target amplification, with a minimum sensitivity of 10–4.
Median follow-up for survival was 53.1 months (approximately 4.5 years)
Gökbuget N, et al. ASH 2018, abstract 554
![Page 47: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/47.jpg)
Blinatumomab, LAL-Ph1-, MRD+BLAST Study, Outcome by HSCT in CCR
49Gökbuget N, et al. ASH 2018, abstract 554
![Page 48: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/48.jpg)
Early response after blinatumomabImpact of tumor burden
0
10
20
30
40
50
60
70
80
90
>50% blasts<50% blasts≥10-3
& <10-2
≥10-2
& <10-1
≥10-1
& <1
R/R (TOWER)MRD (BLAST)
45%53%
CR rate67%
84%78%
CR/CRh/CRi
CMR
Extrapolated CMR* Res
po
nse
rate
Katarjian H, N Engl J Med. 2017 Mar 2;376(9):836-847Gokbuget et al., ASH2015, #680
Tumor burden
* Considering a 76% CMR rate in CR/CRh/Cri patients
![Page 49: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/49.jpg)
GRAALL-QUEST phase 2 studyfor Ph- HR BCP-ALL
Prephase & induction
HDAC HD-MTX CPM
PDN PDN-VCR-DNR-CPM-ASPA
PDN-VCR-DNR-CPM-ASPA/ERW
PDN-VCR-6MP-MTX
* MRD1
* MRD2
HDAC HD-MTX CPM
HDAC HD-MTXBLIN
HDAC HD-MTX
PDN-VCR-DNR-CPM-ASPA/ERW
SR HRIKZF1del, or KMT2A+
or MRD1≥10-4
VHR (ASCT)MRD1≥10-3
or MRD2≥10-4
HDAC HD-MTX CPM
PDN-VCR-6MP-MTX- BLIN
Consolidation n°1
Delayed intensification
Consolidation n°3
Consolidation n°2
2-year maintenance
BLIN
BLIN
* MRD3
![Page 50: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/50.jpg)
GRAALL-2014Toward pediatric-inspired age-adapted trial
• Next step of pediatric-inspired approach• Increased HD-methotrexate doses in patients <45y• No CNS irradiation in CNS-1 patients• MRD-based indication for allogeneic SCT• Asparaginase switch in immunized patients• Rituximab in CD20+ patients
• Decreased toxicity in older patients• Desescalated doses in patients >45y• RIC in patients >45y
• New drugs in high-risk patients• Blinatumomab in HR BCP-ALL (QUEST study)• Nelarabine in HR T-ALL (ATRIALL Study)• Targeted therapy in Ph-like ALL
![Page 51: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/51.jpg)
Chimeric antigen receptor generations
Heczey A, Louis CU. Discov Med 2013;16:287–94.
• T-cell activation is improved by costimulation domains:
- CD28, 4-1BB
- CD27, OX-40, CD244, ICOS
• Consequences:
- ↑ cytokine release
- ↑ cytotoxicity
- ↑ proliferation
- ↑ in vivo expansion & persistence
![Page 52: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/52.jpg)
Autologous CD19 CAR-T in R/R B-ALL Phase 1/2 studies
1. Maude SL, et al. N Engl J Med 2014;371:1507–17;2. Lee DW, et al. Lancet 2015;385:517–28;
3. Gardner RA, et al. Blood 2017;129:3322–31;4. Maude SL, et al. N Engl J Med 2018;378:439–48;
5. Park JH, et al. N Engl J Med 2018;378:449–59;6. Hay KA, et al. Blood 2019; doi: 10.1182/blood-2018-11-883710 [Epub].
Study Population CD19-CAR V N Cond. T-cells ORR
Maude, 20131
Ped+adult 4-1BB LV 30 CyF unselected 90%
Lee, 20152
Ped+YA CD28 gRV 21 Cy unselected 68%
Gardner, 20173 Ped+YA 4-1BB LV 45 CyF 1:1 CD4/8 93%
Maude, 20184
Ped+YA 4-1BB LV 75 CyF unselected 81%
Park, 20185
Adult CD28 gRV 53 Cy/CyF unselected 83%
Hay, 20196
Adult 4-1BB LV 53 Cy/CyF 1:1 CD4/8 85%
Cy, cyclophosphamide; CyF, cyclophosphamide + fludarabine; Ped, paediatric; YA, young adults;LV, lentivirus; gRV, gamma-retrovirus; Auto, autologous.
![Page 53: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/53.jpg)
Impact of conditioning regimen
Hay KA, et al. Blood 2019; doi: 10.1182/blood-2018-11-883710 [Epub].
Fludarabine associated with higher AUC (D28–D90) and better EFS
FHCRC>18 years
CD19/4-1BB/CD3z
![Page 54: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/54.jpg)
CAR-T cells cross the blood-brain barrier
Jacoby E, et al. Am J Hematol 2018;93:1485–92.Lee DW, et al. Lancet 2015;385:517–28.
![Page 55: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/55.jpg)
CRS and neurotoxicity in CD19 CAR-T ALL studies
1. Maude SL, et al. N Engl J Med 2014;371:1507–17;2. Lee DW, et al. Lancet 2015;385:517–28;
3. Gardner RA, et al. Blood 2017;129:3322–31;4. Maude SL, et al. N Engl J Med 2018;378:439–48;
5. Park JH, et al. N Engl J Med 2018;378:449–59;6. Hay KA, et al. Blood 2019; doi: 10.1182/blood-2018-11-883710 [Epub].
Study CD19-CAR N Population CR CRS Neurotoxicity/CRES
Maude, 20131
4-1BB 30 Ped+Adult 90%100%
27% severe43% encephalopathy, seizure,
aphasia
Lee, 20152
CD28 21 Ped+YA 68%76%
28% severe29% encephalopathy,
hallucination
Gardner, 20173 4-1BB 45 Ped+YA 93%93%
23% severe49%
21% severe
Maude, 20184
4-1BB 75 Ped+YA 81%77%
46% severe40%
13% severe
Park, 20185
CD28 53 Adult 83%85%
26% severe43%
42% severe
Hay, 20196
4-1BB 53 Adult 85%75%
19% severe23% severe
![Page 56: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/56.jpg)
Escape mechanisms to CD19-targeted therapy
Kohnke T, et al. J Hematol Oncol 2015;8:111;Sotillo E, et al. Cancer Discov 2015;5:1238–40;
Rayes A, et al. Pediatr Blood Cancer 2016;63:1113–5;Ruella M, et al. Nat Med 2018;24:1499–503.
• Mutation/deletion of CD19 gene
oGene deletion
o Exon 2 mutations → alternative splicing
• Lineage switch
oALL → AML (MLL+ disease)
• Loss of CD81 and disruption of CD19 trafficking
• Transduction of ALL blasts and antigen masking
![Page 57: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/57.jpg)
CD19-positive vs CD19-negative relapse
1. Park JH, et al. N Engl J Med 2018;378:449–59;2. Gardner RA, et al. Blood 2017;129:3322–31;
3. Maude SL, et al. N Engl J Med 2018;378:439–48.
MSKCC1
CD19/CD28/CD3z
SEATTLE2
CD19/4-1BB/CD3
ELIANA3
CD19/4-1BB/CD3
Median CAR-T persistance
14 days (7–138) 90 days 168 days (20–617)
Relapse rate 25/41 (61%) 18/40 (45%) 22/61 (36%)
% of CD19- relapse 4/25 (16%) 7/18 (40%) 15/16* (94%)
The rate of CD19-negative relapseincreases with CAR-T persistence
Hay KA, et al. Blood 2019; doi: 10.1182/blood-2018-11-883710 [Epub].
* Patients with known CD19 status at relapse among 22 relapses
![Page 58: Traitement des leucémies aiguës lymphoblastiques de l ...aihemato.cluster013.ovh.net/AIH/documents/Cours DES... · Traitement des leucémies aiguës lymphoblastiques de l’adulte(Ph1-)](https://reader030.fdocuments.in/reader030/viewer/2022041008/5eafef95f245fc0b900d9ddf/html5/thumbnails/58.jpg)
Conclusion
• Avant l’ère des immunothérapies, 2 progrès thérapeutiques en 20 ans :• L’intensification “pediatric-like” des chimiothérapies
• La combinaison de la chimiothérapie aux ITK (Ph+)
• Deux outils majeurs dans la stratification : • Génétique de la tumeur
• MRD
• Intensification des chimiothérapies limitée par l’âge
• L’avenir :• Identification de nouveaux oncogènes cibles (ITK)
• Combinaison des approches conventionnelles avec les immunostratégies(comment et pour quelle toxicité ?)