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3483 Sequential Intensified Conditioning Regimen Allogeneic Transplantation in Younger Adult Patients with Adverse-Risk Acute Myeloid Leukemia: A Multi-Center Prospective Study from the Acute Leukemia French Intergroup on Behalf of the Filo, ALFA, and SFGM-TC Study Groups

Program: Oral and Poster Abstracts
Session: 721. Allogeneic Transplantation: Conditioning Regimens, Engraftment, and Acute Toxicities: Poster II
Hematology Disease Topics & Pathways:
Research, Clinical trials, Clinical Research
Sunday, December 8, 2024, 6:00 PM-8:00 PM

Regis Peffault de Latour1,2*, Edouard Forcade, MD, PhD3*, Anne Huynh, MD4*, Mathieu Leclerc, MD, PhD5*, Stéphanie Nguyen Quoc, MD, PhD6*, Patrice Ceballos, MD7*, Jean-Baptiste Méar, MD8*, Michael Loschi, MD, PhD9*, Helene Labussiere-vallet, MD10*, Jean-Henri Bourhis, MD, PhD11, Bruno Lioure12*, Ibrahim Yakoub-Agha, MD, PhD13*, Jacques-Olivier Bay, MD, PhD14*, Sylvie François, MD15*, Claude-Éric Bulabois, MD16*, Sylvain Chantepie, MD17*, Marie-Thérèse Rubio, MD, PhD18*, Patrice Chevallier, MD, PhD19,20, Anne Lise Mesnard21*, Delphine Lebon22*, Jean Valere Malfuson23*, Jérôme Cornillon24*, Etienne Daguindau, MD25*, Pascal Turlure, MD26*, Natacha Maillard, MD27*, Alban Villate, MD28*, Marie Robin, MD29*, Nicole Raus, RN30*, Jean-Yves Cahn, MD31*, Arnaud Pigneux, MD, PhD32*, Mathilde Hunault, MD33*, Christian Recher, MD, PhD34*, Hervé Dombret, MD, PhD35,36,37, Gerard Socie38, Jean François Hamel, MD39* and Raynier Devillier, MD, PhD40*

1Hematology and Transplantation Unit, Hôpital Saint Louis, AP-HP, Paris, France
2Université Paris Cité, Paris, France
3Service d'Hématologie Clinique et Thérapie Cellulaire, CHU Bordeaux, Bordeaux, France
4Hematology Department, Institut Universitaire du Cancer Toulouse - Oncopole, Toulouse, France
5Hematology Department, Henri Mondor University Hospital, AP-HP, Créteil, France
6Hematology Department, Sorbonne Université, Hôpital Pitié-Salpêtrière, APHP, Paris, France
7Clinical Hematology Department, Montpellier University Hospital, Saint Eloi Hospital, MONTPELLIER, France
8BMT unit, CHU Rennes, Rennes, France
9Hematology Department, Nice University Hospital, Nice, France
10BMT unit, CHU Lyon, Lyon, France
11BMT Service, Department of Hematology, Gustave Roussy Cancer Center, Villejuif, France
12Hematology, Department of Hematology, University Hospital of Strasbourg Institut De Canc, Strasbourg, France
13Lille University Hospital, Lille, France
14CHU ESTAING, Clermont-Ferrand, France
15Hematology Department, Angers University Hospital, Angers, France
16Hematology Department, Grenoble University Hospital, Grenoble, France
17Basse-Normandie Institute of Hematology, CHU de Caen, Caen, France
18Department of Hematology, Nancy University Hospital, Vandoeuvre Les Nancy, France
19Hematology Department, Nantes University Hospital, Nantes, France
20Hematology Clinic, Nantes University Hospital, Nantes, France
21BMT unit, CHU Rouen, Rouen, France
22Université Picardie Jules Verne, Amiens, FRA
23Centre des armées Percy, CLAMART CEDEX, FRA
24Département d'hématologie Clinique et de Thérapie Cellulaire, CHU Saint-Etienne, Saint-Etienne, France
25Department of Clinical Hematology, Hopital Jean Minjoz, Service d'Onco-hématologie, Besançon, France
26Service d'Hématologie Clinique, CHU de Limoges, Limoges, France
27Hematology Department, CHU de Poitiers, Poitiers, France
28Hematology Department, Tours University Hospital, Tours, FRA
29Hopital Saint Louis, APHP, Paris, France
30SFGM-TC coordination, Hôpital Lyon Sud, Lyon, FRA
31Hematology Department, CHU Grenoble, Grenoble, France
32Department of Clinical Hematology, Haut-Lévèque Hospital, CHU Bordeaux, Pessac, France
33HOTEL DIEU, ANGERS CEDEX 9, FRA
34ICUT oncopole, Toulouse, FRA
35Department of Clinical Hematology, Saint Louis University Hospital, Université Paris Cité-AP-HP, Paris, France
36Department of Hematology, Saint Louis University Hospital, AP-HP, Paris, France
37EA-3518, Saint Louis Research Institute, Université Paris Cité, Paris, France
38Hematology Transplantation, Paris, France
39Statistic, CHU Angers, Angers, France
40Hematology and Transplantation, Institut Paoli-Calmettes, Aix Marseille University, Marseille, France

Introduction: The French Backbone Intergroup (BIG-1) trial (NCT02416388) is a large open label, multicenter phase II/III study, with several therapeutic interventions in patients (pts) aged 18-60 years (yrs) with AML. HSCT is the only curative strategy for pts with adverse risk acute myeloid leukemia (adv AML) but the prognosis remains dismal (long-term survival ranging from 10% to 25%). Sequential-based conditioning regimens (Seq) with prophylactic donor lymphocyte infusions (pDLIs) have been successful in AML pts with refractory disease (Schmid C et al, JCO 2005). We hypothesized this strategy might improve the outcome in adv AML pts in first complete remission (CR).

Study design and methods: Pts were classified as adv AML based on the cytogenetics and molecular biology at diagnosis. In case of CR, the HSCT protocol strategy recommended a Seq FLAMSA (Fludarabine 30 mg/m2, high-dose cytarabine 2 g/m2, and amsacrine 100 mg/m2) followed by a RIC regimen (Busulfan 6.4 mg/kg and cyclophosphamide 100 mg/kg) from matched sibling donor (MSD), 10/10 (MUD) or 9/10 (MMUD) unrelated donors. GvHD prophylaxis consisted in rabbit ATG 5 mg/kg with CsA plus MMF. CsA was quickly tapered from day 60 and discontinued at day 120 with pDLIs administered if no GvHD. Other graft sources and conditioning regimens were nevertheless authorized. The primary endpoint was overall survival (OS) based on a unique Cox model with predefined covariates: age (median), delay between diagnosis to HSCT (+/- 6 months), Seq strategy versus other conditioning regimen, donor type (MSD or MUD versus others), cytogenetic (monosomal karyotype [MK] versus others) and complete remission (CR) at time of HSCT. A selection of significant interactions between these covariates was planned based on likelihood-ratio tests between nested models. Non-relapse mortality (NRM) and relapse-free survival (RFS) were studied (secondary endpoints).

Results: Between 01/2015 and 07/2021, 2023 AML pts were included (469 adv AML). Overall, 357 pts were transplanted (58.8% male) with 200 pts receiving the protocol Seq strategy (161 pts in CR; 69 MSD, 98 MUD, 29 MMUD and 4 haploidentical HSCT). The others 157 pts received mainly a RIC regimen (n=81; 52%) (113 pts in CR; 25 MSD, 40 MUD, 17 MMUD and 75 haploidentical HSCT). Median age was 50 yrs. Median follow-up was 5 yrs. In the 112 pts who were not transplanted, OS was estimated at 42.8% (95% CI, 31.3%-53.8%) and 0% (95% CI not evaluable) at 1 and 5 yrs, respectively. In the 357 transplanted pts, OS estimates were 66.9% (95% CI, 59.1%-72.5%) and 41.2% (95% CI, 35.3%-47.1%) at 1 and 5 yrs, respectively. OS for transplanted pts with Seq in CR at time of HSCT (n=161) was 52.3% (95% CI, 44.3%-59.7%) at 5 yrs versus 45.5% (95% CI, 34.9%-55.5%) in the 115 non Seq pts. For pts not in CR, OS was 18.8% (95% CI, 7.4%-34.2%) at 5 yrs for Seq pts (n=31) versus 23.6% (95% CI, 12.1%-37.2%) for non Seq pts (n=42). While no benefit of the protocol Seq strategy was found (HR: 0.81 [0.59-1.28], p=0.214), CR at time of HSCT was associated with better OS (HR: 0.44 [0.32-0.62], p=0.0001). Two interactions were identified impacting OS: the first between age (less than 50 versus 50 yrs or more) and MK (p=0.018) and the second between the delay from diagnosis to HSCT and donor type (MSD or MUD) (p=0.084). The impact of MK was significantly worse in older pts (HRs of 1.47 [0.93-2.33], p=0.099 and 3.05 [2.05-4.54], p=0.0001 for MK in pts under 50 yrs and those aged 50 yrs or more, respectively). A non-MSD, non-MUD donor was associated with a worse OS for pts transplanted after 6 months (HR: 2.33 [1.06 – 5.10], p=0.034) but not for those receiving HSCT within less than 6 months (HR: 1.08 [0.75-1.55], p=0.68). At 5 yrs, the cumulative incidence of non-relapse mortality was 19.1% (95% CI, 15.1%-23.4%) with CR at time of HSCT as the only factor associated with less NRM (adjusted HR, 0.53 [0.32-0.90]; p=0.017). The cumulative incidence of relapse was 25.8% (95% CI, 21.0%-30.8%) at 5 yrs. The 5 yrs RFS of 39.2% (95% CI, 33.8%-44.5%) with worse RFS for pts aged 50 yrs or more with MK (HR of 2.63 [1.80-3.85]), p=0.0001, while CR at HSCT was protective (HR of 0.53 [0.38-0.73], p=0.0001).

Conclusion: The 5-yrs OS of 41.2% compares favorably with published results. While a Seq regimen did not improve HSCT outcomes, best results were obtained in younger pts with adv risk AML in CR at time of HSCT irrespective of graft source for those transplanted less than 6 months after AML diagnosis.

Disclosures: Peffault de Latour: pfizer: Consultancy, Honoraria, Research Funding; soby: Consultancy, Honoraria, Research Funding; novartis: Consultancy, Honoraria, Research Funding; alexion: Consultancy, Honoraria, Research Funding. Forcade: Gilead: Other: Travel support, Speakers Bureau; GSK: Speakers Bureau; Astellas: Research Funding; Sobi: Speakers Bureau; Sanofi: Other: Travel support, Speakers Bureau; Novartis: Other: Travel support, Speakers Bureau; Jazz: Speakers Bureau; Alexion: Other: Travel support, Speakers Bureau; Maat Pharma: Consultancy; Novartis: Consultancy. Yakoub-Agha: Kite, a Gilead Company: Honoraria, Other: Travel Support; Janssen: Honoraria; Bristol Myers Squibb: Honoraria; Novartis: Honoraria. Robin: Abbvie: Other: research support; Novartis: Other: research support; Medac: Other: research support; Neovii: Other: research support. Recher: Abbvie, Astellas, BMS, Daiichi-Sankyo, Iqvia and Jazz Pharmaceuticals: Other: Research Funding to my institution. Dombret: Servier: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Daiich Sankyo: Honoraria, Membership on an entity's Board of Directors or advisory committees; Amgen: Honoraria, Research Funding, Speakers Bureau; BMS-Celgene: Research Funding; Pfizer: Research Funding; Jazz Pharma: Honoraria, Membership on an entity's Board of Directors or advisory committees; Astellas: Research Funding; Incyte: Research Funding.

*signifies non-member of ASH