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2054 International Collaborative Study to Compare the Prognosis for Acute Leukemia Patients Transplanted with Intensified Myeloablative Regimens

Program: Oral and Poster Abstracts
Session: 721. Allogeneic Transplantation: Conditioning Regimens, Engraftment and Acute Toxicities: Poster I
Hematology Disease Topics & Pathways:
Research, Therapies, Adverse Events
Saturday, December 10, 2022, 5:30 PM-7:30 PM

Yasuyuki Arai, MD, PhD, FACP1, Yoshiko Atsuta2*, Ruta Brazauskas, PhD3,4*, Naya He, MPH4*, Shahrukh Hashmi, MD, MPH5,6*, Leslie E. Lehmann, MD7, William A. Wood, MD, MPH8, Hemalatha G. Rangarajan, MD9, Shingo Yano, MD, PhD10, Shinichi Kako11, Masamitsu Yanada, MD12*, Yukiyasu Ozawa13*, Noriko Doki14*, Yoshinobu Kanda, MD, PhD15, Takahiro Fukuda16*, Yuta Katayama, MD, PhD17, Tatsuo Ichinohe18, Junji Tanaka, MD, PhD19, Junya Kanda, MD, PhD20, Takanori Teshima, M.D., Ph.D.21, Shinichiro Okamoto, MD, PhD22 and Wael Saber, MD, MS4

1Department of Hematology and Oncology, Kyoto University Hospital, Kyoto, Japan
2The Japanese Data Center for Hematopoietic Cell Transplantation, Nagoya, Japan
3Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, WI
4CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
5Department of Internal Medicine, Mayo Clinic, Rochester, MN
6Department of Medicine, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
7Dana Farber Cancer Institute/Boston Children's Hospital, Boston, MA
8Division of Hematology/Oncology, Department of Medicine, University of North Carolina, Chapel Hill, NC
9Division of Hematology, Oncology, Blood and Marrow Transplant, Nationwide Childrens Hospital, Columbus, OH
10Division of Clinical Oncology and Hematology, Jikei University School of Medicine, Tokyo, Japan
11Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
12Department of Hematology and Cell Therapy, Aichi Cancer Center, Nagoya, Japan
13Department of Hematology, Japanese Red Cross Nagoya First Hospital, Nagoya, Japan
14Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
15Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama City, Japan
16Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
17Department of Hematology, Hiroshima Red Cross Hospital and Atomic-bomb Survivors Hospital, Hiroshima, Japan
18Department of Hematology and Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
19Department of Hematology, Tokyo Women's Medical University, Tokyo, Japan
20Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
21Department of Hematology, Hokkaido University Faculty of Medicine, Sapporo, Japan
22Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan


In allogeneic hematopoietic stem cell transplantation (HSCT) for acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL), intensified myeloablative conditioning regimens have been studied to reduce the frequency of post-HSCT relapse. Our group previously analyzed leukemia cases using the Japanese registry database, and found that addition of high-dose cytarabine (AraC) showed superior overall survival (OS) compared with the conventional myeloablative regimen (cyclophosphamide plus total-body irradiation [CY/TBI]) with decreased post-HSCT relapse and the same level of TRM in cord blood transplantation (CBT). Moreover, the addition of etoposide (VP16) to CY/TBI improved the outcome in bone marrow (BM) or peripheral blood stem cell (PBSC) transplants in patients with high-risk ALL.

These results had certain limitations, due to heterogenous donor sources, variable conditioning regimens and time-frame bias (older vs. more recent years of HSCT). These limitations led us to validate the previous results using a large international cohort from the Center for International Blood and Marrow Transplant Research (CIBMTR) in the United States (U.S.) and the Japanese Society for Transplantation and Cellular Therapy (JSTCT) to compare the merit/demerit of these regimens between different cohorts.


We included adult patients (18 years or older at transplantation) who underwent first myeloablative allogeneic HSCT (BM or PBSC) for acute leukemia in remission (CR1 or 2) between 2010 and 2018, either in Japan or the U.S. using conditioning regimens of CY/TBI, CY/TBI+AraC, or CY/TBI+VP16 without any ex vivo T-cell depletion or post-transplant CY. Two datasets from the U.S. and Japan were merged for analysis.

The primary endpoint was the overall survival (OS), and the secondary endpoints included disease-free survival (DFS), therapy-related mortality (TRM), disease relapse/progression, acute and chronic graft-versus-host disease (GVHD), cumulative incidence of infections (bacterial and viral) and veno-occlusive disease/ sinusoidal obstruction syndrome (VOD/SOS) by day 100 post-HSCT.


In total, 6381 patients were included in this study (3469 from the U.S., and 2912 from Japan) (Table 1). CY/TBI was most commonly used (N = 5374, 84.2%), while CY/TBI+AraC was used in 389 patients and CY/TBI+VP16 in 618 patients. Median age of the patients was 40, 36, and 35 years in CY/TBI, CY/TBI+AraC, and CY/TBI+VP16, respectively. The majority of the patients (N = 5007, 78.4%) were transplanted at CR1. The most frequently used donor sources included HLA-matched unrelated donor (N = 2546, 39.8%), followed by HLA-matched sibling (N = 2522, 39.5%).

The AML cohort (N = 2480, 38.8%) indicated that OS was poorer in CY/TBI+AraC (hazard ratio [HR] 1.46, p < 0.001) and CY/TBI+VP16 (HR 1.39, p = 0.059) compared to CY/TBI. DFS was significantly inferior in these intensified regimens (HR 1.32 and 1.39, p = 0.008 and 0.049, respectively). Relapse was not suppressed (HR 0.98 and 1.16, p = 0.913 and 0.528), while TRM was significantly higher (HR 1.78 and 1.74, p < 0.001 and 0.018, respectively) (Table 2). Incidence of GVHD and infections were comparable among the regimens. Interactions regarding the country were not observed.

In the ALL cohort (N = 3901, 61.2%), OS was comparable among the regimens (HR 1.02, p = 0.880 in CY/TBI+AraC and HR 1.02, p = 0.841 in CY/TBI+VP16, compared to CY/TBI). DFS was also comparable. The merit of intensified regimen was observed in relapse; relapse was significantly suppressed in CY/TBI+VP16 (HR 0.74, p = 0.005), while TRM was higher with borderline significance (HR 1.21, p = 0.077) (Table 2). Other outcomes including GVHD and infections showed no clear differences, according to the conditioning regimens. No interactions were observed regarding the country.


Our analyses using international datasets provided new insights regarding intensified myeloablative conditioning regimens. In AML, adding AraC to CY/TBI resulted in increased TRM without reducing relapse; thus, it had an adverse effect on OS. Conversely, in ALL adding VP16 or AraC to CY/TBI did not affect survival, but addition of VP16 resulted in lowering the risk of relapse. These trends were comparable between the Japan and U.S. cohorts. Therefore, intensified myeloablative regimens are not recommended in BM or PBSC HSCT, except for CY/TBI+VP16 in ALL.

Disclosures: Atsuta: Meiji Seika Pharma Co, Ltd.: Honoraria; Mochida Pharmaceutical Co., Ltd.: Honoraria; Astellas Pharma Inc.: Honoraria; AbbVie GK: Honoraria; Kyowa Kirin Co., Ltd: Honoraria; Novartis Pharma KK: Honoraria. Wood: Genentech: Research Funding; Pfizer: Research Funding; Teladoc: Consultancy; Koneksa Health: Current equity holder in private company, Membership on an entity's Board of Directors or advisory committees; Quantum Health: Consultancy. Kanda: Mundipharma Pharmaceuticals: Research Funding. Kanda: asclepia: Honoraria; ASAHI KASEI PHARMA CORPORATION: Honoraria; Janssen Pharmaceutical K.K.: Honoraria, Membership on an entity's Board of Directors or advisory committees; Bristol-Myers Squibb Co: Honoraria; Novartis Pharma K.K.: Honoraria, Membership on an entity's Board of Directors or advisory committees; TEIJIN PHARMA LIMITED.: Honoraria; CHUGAI PHARMACEUTICAL Co., Ltd.: Honoraria; Takeda Pharmaceutical Company Limited: Honoraria; Sumitomo Dainippon Pharma Co., Ltd.: Honoraria; DAIICHI SANKYO Co., Ltd.: Honoraria, Membership on an entity's Board of Directors or advisory committees; SymBio Pharmaceuticals, Ltd.: Membership on an entity's Board of Directors or advisory committees; Sanofi K.K.: Honoraria; Kyowa Kirin Co., Ltd.: Honoraria; Megakaryon Co: Honoraria, Membership on an entity's Board of Directors or advisory committees; Janssen Pharmaceutical K.K.: Honoraria; Ono Pharma Inc.: Honoraria; Otsuka Pharmaceutical Co., Ltd.: Honoraria; Amgen Pharma Inc.: Honoraria; AbbVie Inc.: Honoraria, Membership on an entity's Board of Directors or advisory committees; Astellas Pharma Inc.: Consultancy, Honoraria; MSD K.K.: Honoraria; CSL Behring K.K.: Honoraria; Otsuka Pharmaceutical Co., Ltd.: Honoraria; NIPPON KAYAKU CO.,LTD.: Honoraria; Nippon Shinyaku Co., Ltd.: Honoraria; Eisai: Research Funding. Teshima: Bristol-Myers Squibb: Honoraria; Asahi Kasei Pharma: Research Funding; Takeda: Membership on an entity's Board of Directors or advisory committees; Chugai: Research Funding; Astellas: Research Funding; Eisai: Research Funding; Fuji Pharma: Research Funding; NIPPON SHINYAKU: Research Funding; Janssen: Other: Manuscript preparation; Kyowa Kirin: Honoraria, Research Funding; Sanofi: Research Funding; Merck Sharp & Dohme: Honoraria, Membership on an entity's Board of Directors or advisory committees; Novartis: Membership on an entity's Board of Directors or advisory committees, Other: Manuscript preparation; Luca Science Inc.: Research Funding; Sumitomo Pharma: Research Funding; ONO: Research Funding; SHIONOGI: Research Funding; Priothera SAS: Research Funding; Otsuka: Research Funding; AbbVie: Honoraria; Celgene: Honoraria; Meiji Seika Pharma: Other: non-financial support; DAIICHI SANKYO: Other: non-financial support ; AstraZeneca: Other: non-financial support ; Roche Diagnostics: Other: non-financial support .

*signifies non-member of ASH