Management of Acute Myeloid Leukemia (AML) in First Relapse: Retrospective Analysis about 101 Adults Cases Receiving Homogeneous First-Line Therapy. Impact of Prognostic Factors and Treatment.
Authors: Fohrer Cecile , Witz Brigitte , Harousseau Jean Luc , Witz Francis , Ame Shanti , Maloisel Frederic , Bilger Karin , Herbrecht Raoul , Lioure Bruno 
Published: October 2019

Abstract
We retrospectively analyzed impact of prognostic factors and salvage therapy in 101 patients (pts) with AML in 1st relapse. All pts were treated as 1st line according protocols GOELAMs 1 (87–94) or 2 (95–99). They all achieved complete remission after one (85%) or two (16%) induction with a combination of anthracycline and cytarabine. Consolidation therapy included one course of high-dose cytarabine (HiDAC) and a second consolidation (amsacrine-VP16) or, for a subset of pts, intensification with allogeneic or autologous stem cell transplantation (SCT). Data were collected in 3 of the centers participating to these trials. Main characteristics of pts at initial diagnosis were: median age : 39 y (range 17–64); sex : 55 male, 46 female; WBC count > 30 000/μl in 42 (42%) pts; 16/85 (18%) pts had unfavorable karyotype. Median duration of 1st complete remission (CR1) was 10 months (range: 1–101). Duration of CR1 was shorter than 6 months in 22 (22%) pts, between 6 and 12 months in 41 (40%) pts and longer than 12 months in 38 (38%) pts. At time of 1st relapse, median age was 40 y (range 18–66) and 10/38 (26%) unfavorable karyotype.
There were no specific recommendations in the GOELAMs protocols for the second line therapy: modalities of treatment were therefore left to investigator’s decision. First step of relapse treatment was based on intensive chemotherapy in 79 (79%) pts including 55 pts who received a regimen containing HiDAC (Group 1) and 24 pts who received a chemotherapy without HiDAC (Group 2). Eight pts received an autologous SCT (4 pts) or an allogeneic SCT (4 pts) without any previous salvage chemotherapy (Group 3). One pt received gemtuzumab ozogamicin and thirteen pts received only oral chemotherapy and/or supportive care (Group 4).
Fifty-seven pts (56%) achieved a second CR. Response rate and median survival according to initial therapy of relapse are shown in the following table. Differences are not significant.
Complete response (%) Median survival (months) Group 1 (n = 55) 39 (71%) 11.5 Group 2 (n = 24 10 (42%) 8 Group 3 (n = 8) 6 (75%) 7.5 Group 4 (n = 14) 2 (14%) 3.5
Twenty seven pts out of the 49 pts who achieved a CR2 after intensive chemotherapy (Group 1 and 2) received subsequent intensification with either an allogeneic SCT (7 pts) or an autologous SCT (20 pts). Median survival of these pts subsequently transplanted was 18 months compared to only 10 months in the 22 pts of group 1 and 2 who did not receive a subsequent transplantation. Difference is not significant (log rank test, p = 0.65). Nine (33%) of the 27 transplanted pts are alive more than 36 months after relapse (range 41–120).
Univariate analysis demonstrated that adverse prognosis factors on survival at 1st relapse were duration of RC1 shorter than 12 months (p= 0.005)and complex cytogenetic abnormalities (p= 0.0086).
Conclusion: Intensive chemotherapy including HiDAC at 1st relapse in AML in adults provided a high rate of complete response. Intensification with SCT after CR2 was obtained can provide a very long survival in a limited number of pts. At 1st relapse, adverse prognostic factors on survival were short CR1 and unfavorable karyotype. Risk-adapted of AML in first relapse may therefore be warranted.
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