Ann Hematol DOI 10.1007/s00277-014-2143-8

ORIGINAL ARTICLE

Liposomal daunorubicin, fludarabine, and cytarabine (FLAD) as bridge therapy to stem cell transplant in relapsed and refractory acute leukemia Enrico De Astis & Marino Clavio & Anna Maria Raiola & Anna Ghiso & Fabio Guolo & Paola Minetto & Federica Galaverna & Maurizio Miglino & Carmen Di Grazia & Filippo Ballerini & Carlo Marani & Giordana Pastori & Laura Mitscheunig & Fabio Cruciani & Davide Lovera & Riccardo Varaldo & Chiara Ghiggi & Roberto Massimo Lemoli & Andrea Bacigalupo & Marco Gobbi

Received: 1 December 2013 / Accepted: 16 June 2014 # Springer-Verlag Berlin Heidelberg 2014

Abstract Therapeutic options for patients with relapsed or refractory acute leukemia are still undefined and often unsatisfactory. We report the outcome of 79 patients with relapsedrefractory acute leukemia treated with fludarabine, cytarabine, and liposomal daunorubicin (FLAD regimen) followed by hematopoietic stem cell transplantation (HSCT), when clinically indicated, between May 2000 and January 2013. Fortyone patients had acute myeloid leukemia (AML), and 38 had acute lymphoblastic leukemia (ALL). Two patients with myeloid blast crises of CML and three with lymphoid blast crises were included in the AML and ALL subgroups, respectively. Median age was 48 years (range 13–77). FLAD was well tolerated with negligible, nonhematological toxicity. Six patients (7.5 %) died before response evaluation. Forty-seven patients achieved hematologic complete response (CR). Complete remission rate was 53 and 65 % among AML and ALL patients, respectively. No CR was recorded among 11 refractory AML patients. Twenty-four patients (30 %) underwent HSCT. Nine patients received stem cells from an HLA identical sibling, and 15 from an alternative donor (3 unrelated matched, 12 haploidentical sibling). Median overall survival in AML and ALL patients receiving FLAD therapy was 9 and 8 months, respectively. A 5-year projected OS for patients receiving the whole program (FLAD + HSCT) was 24 % for AML patients (median survival 43 months), 28 % for ALL E. De Astis : M. Clavio (*) : A. M. Raiola : A. Ghiso : F. Guolo : P. Minetto : F. Galaverna : M. Miglino : C. Di Grazia : F. Ballerini : C. Marani : G. Pastori : L. Mitscheunig : F. Cruciani : D. Lovera : R. Varaldo : C. Ghiggi : R. M. Lemoli : A. Bacigalupo : M. Gobbi Division of Clinical Hematology and Division of Hematology and Hematopoietic Stem Cell Transplantation, IRCCS S Martino-IST, Viale Benedetto XV, N 6, 16132 Genova, Italy e-mail: [email protected]

patients treated in relapse (median survival 15 months), and 0 % for ALL patients treated for refractory disease. In this paper, we show that FLAD seems to be an effective bridge therapy to HSCT for a part of poor prognosis acute leukemia patients. However, prospective studies are needed to confirm our results. Keywords Relapsed-refractory acute leukemias . AML . ALL . Liposomal daunorubicin . Fludarabine . Cytarabine . Stem cell transplant . HSCT

Introduction The long-term outcome of patients with relapsed or refractory acute leukemia is very poor. Conventional salvage regimens generally show low efficacy and are poorly tolerated on account of the heavy pretreatment. Due to the scanty amount of data that is available from prospective clinical trials, the best conventional treatment for these patients remains largely undefined. Patients with an available stem cell donor should be offered allogeneic hematopoietic stem cell transplantation (HSCT) after salvage treatment, but only few of them undergo transplant in complete remission (CR) [1–5]. New drugs have been tested with promising results in acute lymphoblastic leukemia (ALL) and include clofarabine for pediatric patients in the second relapse [6], nelarabine for T-cell ALL [7], and the second- and thirdgeneration tyrosine kinase inhibitors for Philadelphia chromosome (Ph)-positive ALL with ABL domain mutation resulting in imatinib resistance [8, 9].

Ann Hematol

In acute myeloblastic leukemia (AML) patients, gemtuzumab ozogamicin and clofarabine have shown promising results [10–12]. Anthracyclines remain the mainstay of salvage treatment, although their use is limited by their significant cardiotoxicity. In this view, liposomal encapsulation of the anthracyclines offers the opportunity to deliver the drugs with equal or improved clinical efficacy and reduced toxicity. Daunoxome (DNX) alone or in association with cytarabine ± fludarabine showed activity in patients with poor risk AML and ALL [13–18]. In vitro studies have shown that Daunoxome is more active against multidrug resistant (MDR)-positive leukemic cells compared to free DNR [19] and is able to pass through the blood–brain barrier [20]. We previously showed that the association of fludarabine, cytarabine, and Daunoxome (FLAD) is well tolerated and might offer a feasible and effective salvage treatment for poor risk leukemia patients. Complete response rate ranged from 59 % (ALL patients) to 69 % (AML patients), but leukemiafree and overall survival were poor due to a very high relapse rate and a low percentage of patients proceeding to HSCT [14]. In the last few years, new transplant procedures have been developed to allow the use of alternative donors, so that nowadays, far more patients are potentially eligible for HSCT [20, 21]. In this study, we retrospectively review our experience with FLAD salvage therapy focusing on the association with a recently introduced transplants procedure. The most innovative result of our study is the observation that FLAD and early HSCT from haploidentical familial donors can rescue a significantly higher proportion of relapsed acute leukemia patients.

Patients and methods

In the ALL group, median age was 50 years (range 18–77), 13 patients were refractory, and 25 had relapsed disease (four of whom after HSCT). In the AML group, median age was 60 years (range 16–76), 11 patients were refractory, and 30 had relapsed disease (six of whom following HSCT). Poor prognosis karyotype was detected in 18 (47 %) and 9 (23 %) ALL and AML patients, respectively. ALL patients had received a median of two prior regimens (range 1–5) including vincristine-, daunorubicin-, and cyclophosphamide-based regimens, Hyper-CVAD, or the pediatric AIEOP protocol in younger patients. AML patients had previously been treated with fludarabine, cytarabine, and idarubicin (FLAI) as induction therapy and mitoxantrone, etoposide, and cytarabine (MEC) at relapse or for refractory disease (median of two prior regimens; range 1–6). ALL and AML patients had received a median of 50 and 70 % of the maximum cumulative anthracycline dosage, respectively. Treatment plan The FLAD regimen consisted of 3 days of treatment with a 30-min infusion of fludarabine 30 mg/m2 followed 4 h later by a 4-h infusion of cytarabine 2 g/m2 and a 60-min infusion of DNX 100 mg/m2. G-CSF (300 μg/day) was administered subcutaneously until complete neutrophil recovery only if clinically required [14]. All patients in hematologic CR after the FLAD regimen were scheduled to receive a further identical consolidation course. Patients aged 60 or less with no significant comorbidities and who were in hematological CR proceeded to HSCT if an HLA identical sibling or matched unrelated donor (MUD) or haploidentical donor was available. Definition of hematological recovery, response, and statistical analysis

Patient selection and patient features Between March 2000 and January 2013, 79 patients with relapsed or refractory acute leukemia (41 AML and 38 ALL) were treated with the FLAD regimen. Two patients with myeloid blast crises of CML and three with lymphoid blast crises were included in the AML and ALL subgroups, respectively. Only patients who failed to achieve CR after at least two previous lines of different chemotherapy were considered refractory. Patients who had previously achieved CR were considered relapsed. Written informed consent was obtained from all patients. Absence of heart, liver, or kidney dysfunction, as well as no active infection were requisites for treatment. Adequate heart function was assessed by echocardiography (left ventricular ejection fraction ≥50 %) and electrocardiogram.

Hematologic response to therapy was evaluated as complete (CR) if there was no morphological evidence of leukemic cells, with complete or incomplete recovery of blood count, absence of extramedullary disease or central nervous system (CNS) involvement; patients were considered nonresponders (NR) in all other cases. Death before day 28 with hypocellular marrow was considered induction-related. The duration of neutropenia and thrombocytopenia was evaluated from the end of chemotherapy only in patients achieving CR. Univariate comparison of the CR rates according to karyotype, gender, age. and disease status was assessed by chi square test or by Fisher’s exact test when necessary; a logistic regression model was used for multivariate CR analysis. Disease-free survival (DFS) was only calculated in patients achieving CR and was defined as the time from complete response to relapse or last follow-up. Overall survival

Ann Hematol

AML group Twenty-two of 30 patients treated for relapsed disease achieved CR (73 %), whereas none of the 11 subjects treated for refractory disease responded. As reported in Table 1, the CR rate was significantly affected only by disease status and karyotype. In multivariate logistic regression analysis, only disease status retained statistical significance.

2.5 months from the start of FLAD (range 2–3), 12 patients after one course of FLAD, 11 after two, and 1 after three courses. The reasons for not performing HSCT in 16 eligible patients included early disease relapse (n=8), infections (n=2), and lack of donor (n=6). The choice of the donor was based on the availability of an HLA matched related or unrelated donor; the second choice was a HAPLO mismatched family donor. All patients received myeloablative conditioning based on chemotherapy including thiotepa (THIO), busulfan (BU), fludarabine (FLU); THIO plus cyclophosphamide (CY); and total body irradiation (TBI) 9.9–12 Gy TBI in fractionated doses with fludarabine (FLU-TBI) or CY [22, 23]. HLA identical siblings received cyclosporin (CyA) with short course methotrexate (MTX) as GvHD prophylaxis; patients grafted from an UD received CyA plus MTX and antithymocyte globulin (ATG 3.75 mg/kg) on days 3 and 2 pretransplant; patients receiving a HAPLO transplant were given CyA from day 0, MMF from day +1, and CY 50 mg/kg on days +3 and +5 from transplant [21]. Nine patients received a transplant from an HLA identical sibling, three from an unrelated matched donor, and 12 from a haploidentical sibling. The number of patients undergoing HSCT has steadily increased over time due to the development of new transplant procedures. Between January 2000 and December 2009, nine transplants were performed among the 20 patients who were considered eligible for stem cell transplant (45 %). We began performing transplants from HAPLO donors in 2009, and over the last 3 years, 15 patients were transplanted out of the 20 patients who were considered eligible (75 %). Eleven patients relapsed after HSCT, 6/9 after a transplant from an HLA identical sibling, 1/3 after a transplant from an unrelated donor, and 4/12 after a transplant from a haploidentical donor. Three patients died due to transplant-related complications (one patient undergoing matched unrelated transplant, two patients who underwent HSCT from a sibling matched donor). None of the patients undergoing HSCT from haploidentical donors died of transplant-related complications. Twelve patients (50 % of transplanted patients) are alive and 10 (41 %) are disease-free at the time of analysis after a median follow-up of 35 months (range 2–128). Details and outcome of patients undergoing HSCT are reported in Table 2

Hematopoietic stem cell transplant

DFS and OS

Forty patients in CR, aged 60 or less, with no significant comorbidities were considered eligible for HSCT. Twentyfour patients underwent HSCT: 14 out of 23 patients in the ALL group (61 %) and 10 out of 17 patients (58 %) in the AML group. Patients underwent transplant after a median of

Median DFS for AML and ALL patients is 9 and 7 months, respectively. A detailed analysis of variables possibly affecting OS is reported in Table 3. In multivariate Cox regression analysis, both response to FLAD and receiving HSCT retained

(OS) was calculated from the beginning of treatment to death due to any cause, or to the last follow-up visit. Survival analysis was performed using the Kaplan–Meier method; log-rank test was used for univariate analysis; a Cox regression model with forward/backward model selection was built for multivariate survival analysis. We considered a two-tailed p value of 0.05 or less as statistically significant.

Results Morbidity, mortality, and hematological recovery Six patients died before response evaluation (7.5 %) due to infection (n=4), cardiogenic shock related to acute myocardial infarction (n=1), and cerebral hemorrhage (n=1). Thirty-four infectious complications were recorded; sepsis in 17 patients, pneumonia in 4 (2 probable pulmonary aspergillosis), herpes virus infection in 5 cases (meningoencephalitis in one), and fever of unknown origin (FUO) in 8 cases. Neutrophil (ANC >0.5×109/L) and platelet (Plt >20×109/L) recovery occurred a median of 18 days (range 12–31) and 18 days (range 13–31) after the end of therapy, respectively. Patients received a median of five packed erythrocyte units (range 0–31) and five platelet units (range 1–27). As expected, nonhematological toxicity was minimal, including six cases of diarrhea. Neither severe (grades 3–4) mucositis nor therapyrelated cardiac, renal or hepatic toxicity were observed. Side effects, hematological recovery, and supportive therapy were similar for AML and ALL patients. Response to FLAD ALL group Seventeen of 25 relapsed patients (68 %) and 8 of 13 refractory (62 %) patients achieved CR, respectively. None of the analyzed variables reported in Table 1 affected the probability of achieving CR.

Ann Hematol Table 1 Variables affecting CR probability Acute myeloid leukemia patients Sex Male Female Disease Status Relapsed disease Refractory disease Karyotype Good/Intermediate Poor Risk Age 65 Acute lymphoblastic leukemia patients Sex Disease Status Karyotype Age

Male Female Relapsed disease Refractory disease Good/intermediate Poor risk 65

statistical significance. Figure 1 shows OS of AML patients receiving FLAD + HSCT (all were treated for disease relapse). Figure 2 shows OS of ALL patients receiving FLAD + HSCT according to disease status before FLAD (relapsed or refractory disease). Figure 3 shows that OS was not affected by type of donor (HLA-matched or haploidentical) in either AML or ALL patients. Patients who were not transplanted relapsed early and died within the first year after therapy (median survival was 5 months in ALL patients and 5 months in AML).

Discussion Our long-term experience confirms that the combination of liposomal daunorubicin, fludarabine, and cytarabine is an

CR (%)

p (univariate)

p (multivariate)

22/41 (53) 13/24 (54) 9/17 (52) 22/30 (73) 0/11 (0) 21/32 (65) 1/9 (11) 20/34 (58) 2/7 (29) 25/38 (65)

– 0.822

– 0.931

0.000

0.000

0.025

0.756

0.211

0.249

–

–

1.000

0.746

0.908

0.955

0.589

0.580

0.313

0.352

16/25 (64) 9/13 (69) 17/25 (68) 8/13 (62) 15/20 (75) 10/18 (56) 23/34 (67) 2/4 (50)

effective and well-tolerated salvage regimen for acute leukemia patients [13, 14]. The therapeutic strategy combining FLAD and HSCT is increasingly used and may result in long-term control of disease in about 30 % of patients treated for relapsed acute leukemia. The reported low incidence of both therapy-related deaths (7.5 %) and severe side effects in a cohort of heavily pretreated patients, including prior stem cell transplant, clearly indicates the safety of this regimen. Due to the quick hematological recovery and the good toxicity profile, this treatment is feasible in fit, elderly patients as well. The percentage of infectious complications and deaths during induction were similar to those observed in other studies with liposomal daunorubicin in similar cohorts of patients [13–19, 24, 25]. Furthermore, the FLAD regimen did not lead to an increase in transplant-related mortality (TRM) and transplant complications.

Table 2 Stem cell transplantation aGVHD (grades 3–4) cGVHD (grades 3–4) TRM Relapse Alive Median OS (months) pa Haploidentical donor

AML ALL All patients HLA-matched unrelated donor AML ALL

0/5 1/7 1/12 1/2 0/1

1/5 1/7 2/12 0/2 0/1

0/5 0/7 0/12 1/2 0/1

0/5 4/7 4/12 1/2 0/1

5/5 3/7 8/12 0/2 1/1

NR 14 19 11 NR

All patients AML ALL All patients

1/3 1/2 0/7 1/9 3/24

0/3 0/2 1/7 1/9 3/24

1/3 0/2 2/7 2/9 3/24

1/3 2/2 4/7 6/9 11/24

1/3 0/2 2/7 3/9 12/24

11 13 15 15 43

HLA identical sibling

All HSCT a

Comparing different HSCT impact on OS duration in all patients

0.351

Relapsed disease Refractory disease Karyotype Good/intermediate Poor risk Age 65 Response to FLAD Complete response No response HSCT Received HSCT No HSCT Acute lymphoblastic leukemia Sex Male Female Disease status Relapsed disease Refractory disease Karyotype Good/intermediate Poor risk Age 65 Response to FLAD Complete response No response HSCT Received HSCT No HSCT

Disease status

Acute myeloid leukemia Sex Male Female

Table 3 Variables affecting OS duration

10/22 (45) – 10/21 (47) 0/1 (0) 10/20 (50) 1/2 (50) 10/22 (45) – 5/10 (50) 5/11 (45) 15/25 (67) 10/16 (62) 5/9 (55) 13/17 (76) 2/8 (25) 8/15 (53) 7/10 (70) 13/23 (56) 2/2 (100) 15/25 (67) – 9/14 (62) 6/11 (32)

10/22 (45) 7/13 (53) 3/9 (33)

Relapsed/CR (%)

9 – 9 4 8 9 9 – NR 6 7 7 7 7 14 8 7 8 3 7 – 11 5

9 9 8

Median DFS (months)

p (multivariate) – 0.609 – 0.565 0.913 – 0.005 – 0.337 0.168 0.464 0.217 – 0.044

p (univariate) – 0.892 – 0.171 0.538 – 0.001 – 0.929 0.194 0.248 0.091 – 0.030

10/30 (33) 1/11 (9) 10/32 (31) 1/9 (9) 11/34 (32) 0/7 (0) 9/22 (40) 2/19 (10) 6/10 (60) 5/31 (13) 6/38 (16) 3/25 (12) 3/13 (23) 5/25 (20) 1/13 (8) 3/20 (15) 3/18 (17) 6/34 (18) 0/4 (0) 6/25 (24) 0/13 (0) 5/14 (31) 1/24 (8)

11/41 (27) 7/24 (29) 4/17 (23)

Alive (%)

12 3 12 4 11 7 12 3 43 5 8 6 14 8 8 8 8 11 3 14 4 15 5

9 10 9

Median OS (months)

0.021

0.000

0.026

0.907

0.683

– 0.904

0.001

0.000

0.524

0.012

0.010

– 0.651

p (univariate)

0.026

0.000

0.034

0.743

0.741

– 0.920

0.041

0.024

0.268

0.396

0.453

– 0.946

p (multivariate)

Ann Hematol

Ann Hematol

Fig. 1 OS in transplanted AML patients

FLAD proved to be effective both in ALL and relapsed AML patients, but was completely ineffective in AML patients who were refractory to conventional induction regimens. On the contrary, Camera et al. reported that 44 % of refractory AML patients achieved CR after FLAD [25]. This discrepancy may derive from differences in the previous

Fig. 2 OS in transplanted ALL patients. A patients treated for relapsed disease, B patients treated for refractory disease

Fig. 3 OS according to source of stem cells. A matched-related donor, B alternative donor

treatment history since all patients in our series had received a combination of fludarabine, cytarabine, and anthracycline as induction regimen, whereas in Camera’s series, 57 out of 61 patients had received a standard three-drug combination as front-line treatment. Furthermore, Camera et al. delivered cytarabine as continuous infusion and this schedule might be more effective in refractory AML patients. In the ALL subgroup the FLAD regimen showed a relevant antileukemic activity both in relapsed (68 %, n=17/25) and refractory patients (62 %, n=8/13). The elevated sensitivity of lymphoid blasts to liposomal daunorubicin allowed FLAD to overcome the negative impact of poor prognosis karyotype. It has already been reported that Daunoxome can overcome the blood–brain barrier [20]. Our results are better than what was reported by Kantarjian et al. [2] who showed that 31 % of ALL patients who were treated in the first relapse or for refractory disease achieved CR, with a CR rate of 48 % in the subgroup of patients receiving the Hyper-CVAD regimen. It should be noted that 14 patients in our cohort were refractory to Hyper-CVAD given as the first-line treatment. Candoni et al. [15] reported that the association of Daunoxome + cytarabine was able to induce CR in 80 % of relapsed patients, despite the expression of MDR-related proteins. Our CR rate among relapsed patients was lower (69 %), but four patients had been previously transplanted. The most relevant observation of our study is the increase in transplant rate, especially in the last 3 years, due to the use of haploidentical donors. Unlike Kantarjian et al. [2] who reported that less than 3 % of patients could receive an

Ann Hematol

allogeneic transplant, we were able to offer an HSCT to 57 % of the eligible patients. Sixty-five percent of transplants were performed after 2010, with haploidentical transplants now accounting for more than 50 % of performed transplants. Our study cannot evaluate the impact of HSCT in the context of the salvage strategy. However, we do want to highlight that a significant proportion of ALL and AML patients receiving transplant actually achieve long-term control of their disease. Although, we were only able to carry out a historical comparison on a limited and heterogeneous cohort of patients, TRM, incidence, and grading of GvHD and OS are similar in all transplant procedures. In particular, no transplant-related deaths were observed in the 12 patients who received stem cells from familial haploidentical donors. The positive impact of HSCT seems to be limited to patients with relapsed disease. We must acknowledge that FLAD-induced complete remissions are of short duration and that this regimen alone cannot modify the poor clinical course in these high risk patients. However, the use of haploidentical donors allows to perform transplant within 2–3 months from the end of salvage chemotherapy, so that the majority of patients can be transplanted in CR. TRM does not increase since the administration of post transplant cyclophosfamide allows us to control GvHD, and the relapse rate is comparable to what is observed in HSCT from matched HLA identical siblings or from MUD. However, the posttransplant relapse rate remains very high and leukemia recurrence represents the main cause of death. The association of liposomal daunorubicin and cytarabine with other drugs, such as clofarabine, tyrosine kinase inhibitors might be tested in order to increase CR rate, reduce minimal residual disease, and improve the efficacy of HSCT. The promising results of haploidentical HSCT and the consequent possibility to easily find a donor might progressively increase the number of patients that can be rescued, especially if the salvage strategy is performed earlier in the course of the disease.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13. Conflicts of interest The authors declare that they have no conflict of interest. 14.

References 15. 1. Fielding AK, Richards SM, Chopra R et al (2007) Medical Research Council of the United Kingdom Adult ALL Working Party. Outcome of 609 adults after relapse of acute lymphoblastic leukaemia (ALL): an MRC UKALL12/ECOG 2993 study. Blood 109:944–950 2. Kantarjian HM, Thomas D, Ravandi F, Faderl S, Garcia-Manero G, Shan J, Pierce S, Cortes J, O'Brien S (2010) Outcome of adults with

16.

acute lymphocytic leukemia in second or subsequent complete remission. Leuk Lymphoma 51(3):475–480 Tavernier E, Boiron JM, Huguet F, GET-LALA Group; Swiss Group for Clinical Cancer Research SAKK; Australasian Leukaemia and Lymphoma Group et al (2007) Outcome of treatment after first relapse in adults with acute lymphoblastic leukemia initially treated by the LALA-94 trial. Leukemia 21:1907–1914 O'Brien S, Thomas D, Ravandi F, Faderl S, Cortes J, Borthakur G, Pierce S, Garcia-Manero G, Kantarjian HM (2008) Outcome of adults with acute lymphocytic leukemia after second salvage therapy. Cancer 113(11):3186–3191 Litzow MR, Othus M, Cripe LD, Gore SD, Lazarus HM, Lee SJ, Bennett JM, Paietta EM, Dewald GW, Rowe JM, Tallman MS, Eastern Cooperative Oncology Group LeukemiaCommittee (2010) Failure of three novel regimens to improve outcome for patients with relapsed or refractory acute myeloid leukaemia: a report from the Eastern Cooperative Oncology Group. Br J Haematol 148(2):217–225 Jeha S, Gandhi V, Chan KW et al (2004) Clofarabine, a novel nucleoside analog, is active in pediatric patients with advanced leukemia. Blood 103:784–789 DeAngelo DJ, Yu D, Johnson JL et al (2007) Nelarabine induces complete remissions in adults with relapsed or refractory T lineage acute lymphoblastic leukemia or lymphoblastic lymphoma: Cancer and Leukemia Group B study 19801. Blood 109:5136–5142 Ottmann OG, Druker BJ, Sawyers CL et al (2002) A phase 2 study of imatinib in patients with relapsed or refractory Philadelphia chromosome-positive acute lymphoid leukemias. Blood 100:1965–1971 Ottmann O, Dombret H, Martinelli G et al (2007) Dasatinib induces rapid hematologic and cytogenetic responses in adult patients with Philadelphia chromosome positive acute lymphoblastic leukemia with resistance or intolerance to imatinib: interim results of a phase 2 study. Blood 110:2309–2315 Tischer J, Stemmler HJ, Engel N, Hubmann M, Fritsch S, Prevalsek D, Schulz C, Zoellner AK, Bücklein V, Hill W, Ledderose G, Hausmann A (2013) Feasibility of clofarabine cytoreduction followed by haploidentical hematopoietic stem cell transplantation in patients with relapsed or refractory advanced acute leukemia. Ann Hematol 92(10):1379–1388 Pilorge S, Rigaudeau S, Rabian F, Sarkozy C, Taksin AL, Farhat H, Merabet F, Ghez S, Raggueneau V, Terré C, Garcia I, Renneville A, Preudhomme C, Castaigne S, Rousselot P (2014) Fractionated gemtuzumab ozogamicin and standard dose cytarabine produced prolonged second remissions in patients over the age of 55 years with acute myeloid leukemia in late first relapse. Am J Hematol 89(4):399–403 Tsunemine H, Akasaka H, Sakane EI, Ito K, Kodaka T, Takahashi T (2014) Successful repeated treatment of acute myeloid leukemia in early relapse with gemtuzumab ozogamicin alone. Int J Hematol 99(2):193–197 Pierri I, Miglino M, Gatto S, Venturino C, Quintino S, Beltrami G, Lanino E, Clavio M, Canepa L, Gobbi M (2000) Combination of liposomal daunorubicin (Daunoxome), fludarabine and cytarabine as salvage therapy in relapsed and refractory acute leukemia. Blood 96(suppl 2):215b Clavio M, Venturino C, Pierri I, Garrone A, Miglino M, Canepa L, Balleari E, Balocco M, Michelis GL, Ballerini F, Gobbi M (2004) Combination of liposomal daunorubicin (DaunoXome), fludarabine, and cytarabine (FLAD) in patients with poor-risk acute leukemia. Ann Hematol 83(11):696–703 Candoni A, Michelutti A, Simeone E, Damiani D, Baccarani M, Fanin R (2006) Efficacy of liposomal daunorubicin and cytarabine as reinduction chemotherapy in relapsed acute lymphoblastic leukaemia despite expression of multidrug resistance-related proteins. Eur J Haematol 77(4):293–299 Cortes J, Estey E, O'Brien S, Giles F, Shen Y, Koller C, Beran M, Thomas D, Keating M, Kantarjian H (2001) High-dose liposomal

Ann Hematol

17.

18.

19.

20.

21.

daunorubicin and high-dose cytarabine combination in patients with refractory or relapsed acute myelogenous leukemia. Cancer 92:7–14 Russo D, Piccaluga PP, Michieli M, Michelutti T, Visani G, Gugliotta L, Bonini A, Pierri I, Gobbi M, Tiribelli M, Fanin R, Piccolrovazzi S, Baccarani M (2002) Liposomal daunorubicin (DaunoXome) for treatment of poor-risk acute leukemia. Ann Haematol 81:462–466 Baccarani M, Russo D, Fanin R, Michieli M (2000) Liposomal daunorubicin (Daunoxome) in the treatment of acute lymphocytic leukemia (ALL). Blood 96(suppl 1):720a, abtr. 3110 Ermacora A, Michieli M, Pea F, Visani G, Bucalossi A, Russo D (2000) Liposome encapsulated daunorubicin (Daunoxome) for acute leukemia. Haematologica 85:324–325 Piccaluga PP, Visani G, Martinelli G, Isidori A, Malagola M, Rondoni M, Baccarani M, Tura S (2010) Liposomal daunorubicin (DaunoXome) for treatment of relapsed meningeal acute myeloid leukemia. Leukemia 16(9):1880–1881 Raiola AM, Dominietto A, Ghiso A, Di Grazia C, Lamparelli T, Gualandi F, Bregante S, Van Lint MT, Geroldi S, Luchetti S, Ballerini F, Miglino M, Bacigalupo A, Varaldo R (2013) Unmanipulated haploidentical bone marrow transplantation and posttransplantation cyclophosphamide for hematologic malignancies aftermyeloablative conditioning. Biol Blood Marrow Transplant 19(1):117–122

22. Frassoni F, Gualandi F, Podestà M, Raiola AM, Ibatici A, Piaggio G, Sessarego M, Sessarego N, Gobbi M, Sacchi N, Labopin M, Bacigalupo A (2008) Direct intrabone transplant of unrelated cordblood cells in acute leukaemia: a phase I/II study. Lancet Oncol 9(9): 831–839. doi:10.1016/S1470-2045(08)70180-3 23. Sanz J, Boluda JC, Martín C, González M, Ferrá C, Serrano D, de Heredia CD, Barrenetxea C, Martinez AM, Solano C, Sanz MA, Sanz GF, Grupo Español de Trasplante Hematopoyético y Terapia Celular (2012) Single-unit umbilical cord blood transplantation from unrelated donors in patients with haematological malignancy using busulfan, thiotepa, fludarabine and ATG as myeloablative conditioning regimen. Bone Marrow Transplant 47(10):1287–1293 24. Michieli M, Damiani D, Ermacora A, Masolini P, Michielutti A, Michelutti T, Russo D, Pea F, Baccarani M (1999) Liposomalencapsulated daunorubicin for Pgp-related multidrug resistance. Br J Haematol 106:92–99 25. Camera A, Rinaldi CR, Palmieri S, Cantore N, Mele G, Mettivier V, Miraglia E, Mastrullo L, Grimaldi F, Luciano L, Guerriero A, Rotoli B, Ferrara F (2009) Sequentialcontinuous infusion of fludarabine and cytarabine associated with liposomal daunorubicin (DaunoXome) (FLAD) in primary refractory or relapsed adult acute. myeloid leukemia patients. Ann Hematol 88(2):151–158