A randomized controlled study in patients with newly diagnosed severe aplastic.pdf

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CLINICAL TRIALS AND OBSERVATIONS

CME article

A randomized controlled study in patients with newly diagnosed severe aplasticanemia receiving antithymocyte globulin (ATG), cyclosporine, with or withoutG-CSF: a study of the SAA Working Party of the European Group for Blood andMarrow TransplantationAndré Tichelli,1 Hubert Schrezenmeier,2 Gérard Socié,3 Judith Marsh,4 Andrea Bacigalupo,5 Ulrich Dührsen,6 Anke Franzke,7

Michael Hallek,8 Eckhard Thiel,9 Martin Wilhelm,10 Britta Höchsmann,2 Alain Barrois,11 Kim Champion,12 and Jakob R. Passweg13

1Hematology, University Hospital Basel, Basel, Switzerland; 2Institute for Clinical Transfusion Medicine and Immunogenetics, University Hospital Ulm, Ulm,

Germany; 3Hospital Saint Louis, Hematology-Transplantation and University Paris VII, Paris France; 4Department of Haematological Medicine, King’s College

Hospital/King’s College London, London, United Kingdom; 5Department of Hematology II, Ospedalo San Martino, Genova, Italy; 6Department of Hematology,

University Hospital Essen, Essen, Germany; 7Hannover Medical School, Department of Hematology, Oncology, Hemostaseology and Stem C ell Transplantation,

Hannover, Germany; 8Department of Medicine, University of Cologne, Cologne, Germany; 9Medizini sche Klinik II I, Charité –Univers itätsmedizi n, Berlin,

Germany; 10Med. Kli nik 5, Kli nikum Nü rnberg, Nürnberg, Germany; 11EBMT Clinical Trials Office Leiden, Medical Statistics and Bio-informatics, Leiden

University Medical Centre, Leiden, The Netherlands; 12EBMT Clinical Trials Office London, Guy’s Hospital, London, United Kingdom; and 13Hematology,

University Hospital Geneva, Geneva, Switzerland

We evaluated the role of granulocyte

colony-stimulating factor (G-CSF) in pa-tients with severe aplastic anemia (SAA)

treated with antithymocyte globulin (ATG)

and cyclosporine (CSA). Between Janu-

ary 2002 and July 2008, 192 patients with

newly diagnosed SAA not eligible for

transplantation were entered into thismul-

ticenter, randomized study to receiveATG/

CSA with or without G-CSF. Overall sur-

vival (OS) at 6 years was 76% 4%, and

event-free survival (EFS) was 42% 4%.

No difference in OS/EFS was seen be-

tween patients randomly assigned to re-ceive or not to receive G-CSF, neither for

the entire cohort nor in subgroups strati-

fied by age and disease severity. Patients

treated with G-CSF had fewer infectious

episodes (24%) and hospitalization days

(82%) compared with patients without

G-CSF (36%;P .006; 87%; P .0003). In

a post hoc analysis of patients receiving

G-CSF, the lack of a neutrophil response

by day 30 was associated with signifi-

cantly lower response rate (56% vs 81%;

P .048) and survival (65% vs 87%;P .031). G-CSF added to standard ATG

and CSAreduces the rate of early infectious

episodes and days of hospitalization in very

SAA patients and might allow early identifi-

cation of nonresponders but has no effect

on OS, EFS, remission, relapse rates, and

mortality. This study was registered at www-

.clinicaltrials.gov as NCT01163942. (Blood .

2011;117(17):4434-4441)

Continuing Medical Education online

This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council forContinuing Medical Education through the joint sponsorship of Medscape, LLC and theAmerican Society of Hematology. Medscape, LLC is

accredited by theACCME to provide continuing medical education for physicians.

Medscape, LLC designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians

should claim only the credit commensurate with the extent of their participation in the activity.

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Disclosures

Judith Marsh was a consultant for Genzyme Therapeutics from 2008-2009, and received research funding from Genzyme in 2010.

The remaining authors; the Associate Editor Grover C. Bagby Jr; and the CME questions author Laurie Barclay, freelance writer and

reviewer, Medscape, LLC; declare no competing financial interests.

Learning objectives

Upon completion of this activity, participants will be able to:

1. Describe the effect of G-CSF on overall survival and event-free survival in patients with SAA treated with ATG and cyclosporine2. Describe the effect of G-CSF on number of infectious episodes and hospitalization days in patients with very severe aplastic

anemia treated with ATG and cyclosporine

3. Describe the predictive value of the lack of a neutrophil response to G-CSF by day 30 in terms of response rate and survival

Release date: April 28, 2011; Expiration date: April 28, 2012

Submitted August 27, 2010; accepted December 30, 2010. Prepublished online as

Blood First Edition paper, January 13, 2011; DOI 10.1182/blood-2010-08-304071.

The online version of this article contains a data supplement.

The publication costs of this article were defrayed in part by page charge

payment. Therefore, and solely to indicate this fact, this article is hereby

marked ‘‘advertisement’’ in accordance with 18 USC section 1734.

© 2011 by The American Society of Hematology

4434 BLOOD, 28 APRIL 2011 VOLUME 117, NUMBER 17

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Introduction

Aplastic anemia (AA) is a bone marrow failure disorder character-

ized by pancytopenia. Death occurs secondary to infection, bleed-

ing, or complications of severe anemia. Hematopoietic stem cell

transplantation (HSCT) can cure the disease, but only a minority of

patients has a histocompatible sibling donor. Immunosuppressive

therapy with antithymocyte globulin (ATG) and cyclosporine(CSA) is the treatment of choice for patients not eligible for

HSCT.1-4 Overall survival (OS) at 10 years lies between 60% and

80%. However, immunosuppression remains a suboptimal option

and usually does not result in cure. About 30% of patients fail to

respond, and, even in responding patients, blood counts often

remain subnormal, and relapse and late clonal complications such

as myelodysplastic syndromes (MDSs) are frequent. Other immu-

nosuppressive drugs or combinations thereof, as well as the use of

high-dose cyclophosphamide, have been used. However, infectious

complications remain the main cause of death, and these newer

regimens failed to improve response and survival over the ATG

plus CSA standard combination.5-7

Growth factors alone do notcorrectAAand may be harmful becauseof delay in starting definitive treatment.8 In contrast, the role of growth

factors added to standard immunosuppressive therapy with ATG and

CSA is still a matter of debate. Six previous small prospective

randomized controlled trials were inconclusive, and none of them

showed a survival advantage.9-14 Nevertheless, despite the lack of

evidence for preemptive use, many centers add granulocyte colony-

stimulating factor (G-CSF) to ATG plus CSA, particularly in pediatric

patients or in patients with low neutrophil counts.11,15

Therefore, the Severe Aplastic Anemia Working Party of the

European Group for Blood and Marrow Transplantation (EBMT)

conducted a randomized controlled study that compared ATG and

CSA with or without G-CSF. We sought to define, in a large cohort

of patients, the role of G-CSF in patients with newly diagnosedsevere AA (SAA) when used with ATG and CSA (registered at

www.clinicaltrials.gov as NCT01163942).

Methods

Design of the study

This prospective, open-label, multicenter randomized study was conducted

by the Severe Aplastic Anemia Working Party of the EBMT in patients with

newly diagnosed acquired SAA who were not eligible for HSCT. Disease

severity was assessed with the use of standard criteria, into SAA or very

SAA (VSAA), and patients were randomly assigned to receive ATG and

CSA or ATG, CSA, and G-CSF. Randomization was stratified by center and

disease severity. The study was approved by the ethical committees of all

participating institutions.

The inclusion criteria comprised patients with SAA or VSAA; with

disease duration of 6 months; who had not received prior ATG at any

time, CSA within 4 weeks, other growth factors within 4 weeks, or G-CSF

within 2 weeks of enrolment. Patients of any age were included, except in

Germany and the United Kingdom, where the ethical committees did not

accept the inclusion of children 18 years. Patients with congenital SAA,

such as Fanconi anemia, as well as patients with MDS were excluded.

Definitions

Thediagnosis of SAArequired bone marrowcellularityof 30%and 2 ofthe

3 following criteria from peripheral blood counts: platelet counts 20 109 /L,

neutrophil count 0.5 109 /L, and reticulocyte count (performed by manual

counting) 20 109 /L.16 Patients with a neutrophil count 0.2 109 /L were

classified as VSAA.17 Complete response was defined as transfusion indepen-

dence associated with a hemoglobin level of 110 g/L, neutrophil count of

1.5 109 /L, and a platelet count of 150 109 /L. Partial response was

defined as no longer meeting the criteria for SAAand no transfusion dependence

forplatelets or redblood cells. Continuous transfusion dependency wasclassified

as no response. Relapse was defined as a decrease in blood counts to

values either requiring transfusions or needing reinstitution of immuno-suppressive therapy or HSCT.

Treatment protocol

Horse ATG (Lymphoglobuline; Genzyme) was administered at a dose of

15 mg/kg body weight per day on 5 consecutive days. To prevent serum

sickness, prednisolone 1 mg/kg/d was started from the first day of ATG and

maintained over 14 days. Thereafter, the dose was tapered off over the

subsequent 14 days. CSA, given orally at a dose of 5 mg/kg/d, was started

on day 1 and administered for a minimum of 6 months and then tapered

according to institution guidelines. In patients randomly assigned to receive

G-CSF, glycosylated recombinant human G-CSF at a dose of 150 g/m2 /d

was administered daily from day 8 as a subcutaneous injection. Treatment

with G-CSF was continued through day 240 except for subjects who

achieved a complete remission before.Patients were also randomly assigned to receive or not to receive an

early second course of immunosuppression after day 120 if a response was

not achieved. Data on this second randomization are not sufficiently mature

at this time, and the patient groups are small. Therefore, only a limited

report is included here.

Statistical analysis

The study was powered to detect a 15% difference in event-free survival

(EFS), with a baseline estimate at 5 years of 40%. Assuming a type II error

of 20% and a type I error of 5%, 340 patients were to be enrolled,

170 patients into each study arm.18 Time to event analyses (OS and EFS)

start on the day of randomization. For OS, patients were censored either at

time of last follow-up or at time of transplantation, used as salvage therapy.

For EFS analysis, events were defined as relapse of the disease, a newlydiagnosed clonal complication (MDS, paroxysmal nocturnal hemoglobin-

uria [PNH]), nonresponse at day 120, allogeneic transplantation, and death,

whichever came first. In 2008 the horse preparation of ATG (Lymphoglobu-

line, Genzyme GmbH) was no longer available in Europe, and as a

consequence the patient accrual declined rapidly. It was therefore decided to

close the study prematurely as of August 1, 2008, after enrolling

205 patients.

Primary outcome parameters analyzed were EFS and mortality. Second-

ary endpoints of the study were causes of death, responseto immunosuppres-

sion (assessed at day 30, 60, 90, 120, 180, 270, 365), relapse in responders,

late complications, number of infectious complications, and days of

hospitalization, both by follow-up periods (from 0 to 30 days, from 30 to

60 days, and from 60 to 90 days after randomization). Causes of death were

classified as related to aplastic anemia (infection, bleeding), secondary

neoplasm (MDS, leukemia, solid tumor), transplantation related in patientswho received HSCT fortreatment failure, unrelatedto aplastic anemia, or of

unknown cause.

Group differences were analyzed with the use of the Mann-Whitney U

test for continuous variables and the 2 test for categorical variables.

Survival probabilities were calculated with the use of the Kaplan-Meier

estimator. Time at risk started at the date of randomization and ended at the

date of death for OS, an event for EFS, or the date of last known assessment,

whichever came first. The 95% confidence interval (CI) was calculated

according to Rothman and Boice. To calculate the cumulative incidence of

relapse in responding patients, and of secondary clonal complications,

death from other causes was considered as a competing risk. Variables

significantly associated with the risk of death were assessed by univariate

and multivariate analyses. The log-rank test with 2-sided significance levels

was used for comparisons in Kaplan-Meier estimates. Proportional hazards

regression analysis was used to assess the effect of risk factors for the

ATG AND CYCLOSPORINE WITH OR WITHOUTG-CSF IN SAA 4435BLOOD, 28 APRIL 2011 VOLUME 117, NUMBER 17




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outcome. Variables considered were sex, age, disease severity, and treat-

ment group (with or without G-CSF). A backward stepwise procedure was

used to eliminate nonsignificant variables.

Results

From January 2002 to July 2008, 205 patients were randomly

assigned to treatment; 13 were excluded from analysis (1 patient

for incorrect diagnosis and 12 patients without follow-up informa-

tion). In total, 192 patients were included in the analysis (95 with

G-CSF, 97 without G-CSF). The median age of the patients was

46 years (range, 2-81 years), 94 (49%) were males and 70 (36%)

had VSAA. There was no difference between treatment groups

with respect to age, sex, severity of the AA, the presence of a PNH

clone, number of platelet and red blood cell transfusions before

treatment, or prior exposure to hepatitis A, B, or C virus infection

(Table 1).

General results of the study

At a median follow-up of 41 months (range, 1-96 months) for

surviving patients, 148 patients (77%) were alive. The OS and

the EFS at 6 years of all patients were 76% 4% (Figure 1A)and 42% 4%, respectively. The overall response rate was 70%

(134 of 192 patients). Complete response was observed in 21 (11%)

and partial response in 113 (59%) patients. Fifty-eight patients

(30%) showed no response. Nineteen patients (10%) who did not

respond subsequently underwent allogeneic HSCT from an unre-

lated donor (Table 2). During the study period, 44 patients died.

The median time from randomization to death was 135 days

(range, 15-2378 days). Bacterial and fungal infections were by far

the most common causes of death, accounting for 55% of all deaths

(24 of 44 deaths). Other causes of death were noninfectious

SAA-related deaths (bleeding, disease progression) in 8, secondary

MDS or acute myeloid leukemia (AML) in 2, solid tumor in 1,

cardiovascular complications in 4, transplantation-related death in

4, and unknown in 1 patient. Fourteen of 44 deaths (32%) occurred

within the first 30 days from randomization, 12 of them because of

infectious complications.

During the first 30 days, 53% of the patients had an infection

(91 patients with infection of 171 reported patients) (Table 2).

Between 30 and 60 days 23% (34 of 148) and between 60 and

90 days 8% (12 of 143) presented with an infectious complica-

tion. Thirty-eight of responding patients (20%) relapsed at a

median of 12 months (range, 1-70 months) after randomization.

The cumulative incidence of relapse at 6 years from randomiza-

tion was 33% (95% CI, 24%-46%). Seven patients (3.6%)developed a secondary malignant neoplasm, 6 presented with

MDS or AML, and 1 with a solid tumor. The cumulative

incidence at 6 years of developing a clonal complication was 4%

(95% CI, 2%-10%). Twenty-three patients (12%) had a PNH

clone at time of diagnosis, and 14 patients (7%) developed a new

PNH clone during follow-up after immunosuppressive treat-

ment. The cumulative incidence of developing a PNH clone at

6 years was 19% (95% CI, 14%-27%).

Primary and secondary endpoints of first randomization

No difference was observed in OS (P .64; Figure 2A) and in EFS

(P .343; Figure 2B) at 6 years between patients randomly

assigned to receive or not to receive G-CSF. There was neither adifference in overall trilineage hematologic response between

patients treated with or without G-CSF (Table 2). In total, 73% of

patients who received G-CSF and 66% who did not receive G-CSF

responded to immunosuppression (P .535). The response rates

increased progressively over time, but they were similar between

both randomization groups (Figure 3A-B). There was no difference

in death rates between patients randomly assigned to receive

G-CSF or no G-CSF. In patients treated without G-CSF, 23 of

95 patients (24%) died, compared with 21 of 97 patients (22%) in

the G-CSF group (P .673; Table 2). The causes of death, and

particularly deaths because of infections, were not different be-

tween patients treated without and with G-CSF.

Patients treated with G-CSF had fewer episodes of infection

(56 of 234; 24%) than patients who were randomly assigned not to

Table 1. Characteristics of the patients

All patients No G-CSF With G-CSF P

No. of patients in the study 192 95 97

Median age at random assignment, y (range) 46 (2-81) 44 (7-80) 47 (2-81) .279

Age groups

20 y, n (%) 31 (16) 15 (16) 16 (16)

20-40 y, n (%) 51 (27) 27 (29) 24 (25) .362

40-60 y, n (%) 51 (26) 29 (30) 22 (23) 60 y, n (%) 59 (31) 24 (25) 35 (36)

Sex

Male, n (%) 94 (49) 46 (48) 48 (49) .883

Female, n (%) 98 (51) 49 (52) 49 (51)

Severity

SAA, n (%) 122 (64) 56 (59) 66 (68) .191

Very SAA, n (%) 70 (36) 39 (41) 31 (32)

PNH clone at diagnosis

Yes, n (%) 23 (12) 14 (15) 9 (9)

No, n (%) 116 (60) 53 (55) 63 (65) .326

Not done, n (%) 53 (28) 28 (30) 25 (26)

Last follow-up

Alive, n (%) 148 (77) 72 (76) 76 (78) .673

Dead, n (%) 44 (23) 23 (24) 21 (22)

4436 TICHELLI et al BLOOD, 28 APRIL 2011 VOLUME 117, NUMBER 17




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receive G-CSF (81 of 228; 36%; P .006; Table 2). Overall, there

were 3008 hospitalization days for a total period of 3551 observa-

tion days (results available from 120 patients) (Table 2). There

were fewer hospitalization days in patients treated with G-CSF

(82%) than in patients not receiving G-CSF (87%; P .0003).

Randomization with or without G-CSF had no effect on the need

for a subsequent HSCT, the prevalence or cumulative incidence of

relapse, the development of a secondary malignant neoplasm, or aPNH clone (Table 2).

The median neutrophil count was significantly higher from day

30 to day 240 in the G-CSF arm, but this difference did not persist

to day 360, at a time when most patients randomly assigned to

receive G-CSF no longer received the drug (Figure 4).

In the stepwise multivariate Cox regression analysis, age at time

of randomization as a continuous variable (relative risk [RR],

1.043; 95% CI, 1.019-1.067; P .001) and severity of the disease

(RR, 2.935; 95% CI, 1.109-7.766; P .030) were statistically

associated with overall survival. The use of G-CSF compared with

no G-CSF (RR 1) was not significant (RR, 1.00; 95% CI,

0.416-12.403; P .999).

Second randomization

On day 120, 62 of 146 evaluable patients had not achieved a

response to immunosuppression and were therefore eligible for

early retreatment. Thirty-eight patients (17 with G-CSF, 21 without

G-CSF) were randomly assigned to receive a second ATG course,

and 24 patients (14 with G-CSF, 10 without G-CSF) were randomly

assigned to continued care. In an intention-to-treat analysis, there

was no difference in OS between treatment groups: The OS at

6 years was 83% 7% for the early retreatment arm and

77% 10% for the continued care arm (P .441). There were

many study violations because only 20 of 38 patients randomly

assigned to early retreatment actually received an early second

treatment, whereas 7 of 24 patients randomly assigned to continued

care received a second ATG between day 120 and day 180 for

various reasons (4 of these because of disease relapse).

Post hoc, secondary analyses

We further evaluated the effect of severity of the disease and age of

the patients at random assignment on outcomes of all patients as

well as on patients randomly assigned to receive or not G-CSF. OS

was 82% 4% for patients with SAA and 66% 6% for patients

with VSAA (P .001; Figure 1B). Survival was better for young

patients aged 20 or 20-40 years than for olderpatients (P .001;

Figure 1C). EFS was 44% 5% for patients with SAA and

39% 6% for patients with VSAA (P .013). EFS of pa-

tients 20 years (58% 9%) and patients aged between 20 and40 years (49% 9%) was significantly higher than pa-

tients 60 years (29% 6%; P .035 and 0.006, respectively).

When patients were stratified according to age and severity of the

disease, there was no difference in OS, EFS, and in response rates

between patients randomly assigned to receive or not to receive

G-CSF. The number of nonresponders was higher in patients with

VSAA (31 of 70; 44%) than in patients with SAA

(27 of 122; 22%; P .006). Patients 40 years of age were more

often nonresponders (44 of 110; 40%) than younger patients (14 of

82; 17%; P .0012), because of higher death rates before treat-

ment response in older patients.

Patients with VSAA had higher infectious rates during 3 periods

than patients with SAA [first 30 days, VSAA 6 5% v s

SAA 47% (P .015); between 30 and 60 days, VSAA 41%

Figure 1. Six-year OS rate in patients with SAA treated with ATG/CSA with or

without G-CSF. (A) OS of all 192 patients; (B) OS according to disease severity,

comparing patients with SAA (blue), and very SAA (green); (C) OS according to age

groups: patients 20 years (blue), patients aged 20-40 years (green), patients aged

40-60 years (red), and patients aged 60 years (lilac).





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vs SAA 14% (P .0001); between 60 and 90 days,

VSAA 17% vs SAA 5% (P .021)]. The difference ob-

served in episodes of infection between patients treated or not with

G-CSF was mainly because of the excess of infections in patients

with VSAA (P .014) compared with patients with SAA(P .431;

Table 2). Furthermore, there were more hospitalization days in

patients with VSAA (1244 of 1329; 94%) than in patients with

SAA (1764 of 2222; 79%; P .0001).

We further assessed the effect of neutrophil counts

( 0.5 vs 0.5 109 /L) on day 30 after randomization on

prediction for response and survival. We therefore compared

response and survival according to neutrophil counts at day 30 in a

post hoc analysis. For this analysis, only patients who survived

30 days after random assignment were included. Patients

randomly assigned to receive G-CSF with neutrophil

counts

0.5 109

/L had significant better overall response rates(38 of 47; 81%) and better survival at 6 years (87% 14%) than

patients with lower neutrophil counts (response rates: 10 of

18, 56%, P .048; survival: 65% 15%; P .031). This differ-

ence was not observed among patients not receiving G-CSF

(response rate, P .350; survival, P .247) (Figure 5).

Discussion

This is the largest prospective randomized trial on the addition of

G-CSF to standard immunosuppression with ATG/CSA, and we

show that G-CSF had no significant effect on OS, EFS, or on

remission, mortality, and relapse rates. We could solely demon-

strate in G-CSF–treated patients a reduced rate of early infection

episodes and reduced days of hospitalization in VSAA patients.

Despite there being no survival advantage by adding G-CSF to

ATG/CSA treatment, some findings may be relevant for the early

management of patients with SAA. Shorter hospitalization and

fewer infections have clinical implications in the daily care in

SAA, particularly in high-risk patients. Furthermore, the detection

of an early factor that might predict response and detect patients

who are likely to fail to immunosuppressive treatment is of major

importance. This finding has to be interpreted with great caution

because it is the result of a post hoc analysis and requires

independent confirmation. We show in a subgroup analysis that the

neutrophil response to G-CSF at 1 month predicted subsequent

clinical outcome. Patients with neutrophil counts 0.5 109 /L at

day 30 had a significantly better response rate and survival than

patients with lower values. The relevance of early neutrophil

response to G-CSF as an outcome indicator has already beensupported in a previous study, using a different cutoff for neutrophil

count and time of evaluation.19 Patients who are refractory to

conventional immunosuppression represent difficult management

problems. For these patients, new approaches, including early

HSCT with an alternative donor, are being evaluated.20,21 There-

fore, early signs of response to treatment with G-CSF, as well as

other predictive factors,4 could help to identify early nonresponders

and justify exploring these novel treatment approaches.22

Our other results corroborate those of previous, smaller random-

ized studies on the use of hematopoietic growth factors with respect

to OS. No study has ever shown a survival advantage attributable to

the use of G-CSF or granulocyte-macrophage CSF. However, there

are differences in other endpoints. In a Japanese study of 101 adults,

there were significantly better response rates at 6 months but not at

Table 2. Response rates, infections, hospitalization days, relapses, late complications, and deaths

All patients No G-CSF With G-CSF P

Best response ever reached

Complete response, n (%) 21 (11) 9 (9) 12 (12) .535

Partial response, n (%) 113 (59) 54 (57) 59 (61)

No response, n (%) 58 (30) 32 (34) 26 (27)

Best response ever reached for very SAA

Complete response, n (%) 6 (8) 2 (5) 4 (13)Partial response, n (%) 33 (47) 19 (49) 14 (45) .513

No response, n (%) 31 (44) 18 (46) 13 (42)

Best response ever reached for SAA

Complete response, n (%) 15 (12) 7 (12) 8 (12)

Partial response, n (%) 80 (66) 35 (63) 45 (68) .764

No response, n (%) 27 (22) 14 (25) 13 (20)

No. of infectious episodes per month at risk during the first

90 days

All patients, n/N (%) 137/462 (30) 81/228 (36) 56/234 (24) .006

Patients with SAA, n/N (%) 67/302 (22) 33/136 (24) 34/16 (20) .431

Patients with very SAA, n/N (%) 70/160 (44) 48/92 (52) 22/68 (32) .014

Days spent in the hospital during the first 30 days, n/N (%) 3008/3551 (84) 1612/1858 (87) 1396/1693 (82) .0003

No. of patients with first relapse (%) 38 (20) 19 (20) 19 (20) .679

No. of HSCT as second- or third-line therapy (%) 19 (10) 11 (11) 9 (9) .570

Secondary malignant neoplasm, n (%) 7 (3.6) 4 (4) 3 (3) .488PNH

At diagnosis, n (%) 23 (12) 14 15) 9 (9) .350

Since first IS treatment, n (%) 14 (7) 8 (8) 6 (6) .590

Number of deaths (%) 44 (23) 23 (24) 21 (22) .673

Cumulative incidence of a complications at 6 years (95% CI)

Relapse 33 (24-46) 33 (21-53) 32 (21-51) .792

Malignant neoplasm 4 (2-10) 6 (2-16) 3 (1-11) .537

PNH clone 19 (14-27) 22 (15-33) 16 (9-27) .067

IS indicates immunosuppression.





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3 months or at 1 year after immunosuppressive therapy in patients

receiving G-CSF.13 This improved response rate at 6 months was

restricted to patients with VSAA. We looked for response rates at

6 different time points but could not confirm such results. Teramura et

al13 also showed differences in the probability of relapse. Patients treated

with G-CSF had a significantly lower cumulative incidence of relapse.

We and other groups were not able to show a similar effect of G-CSF onrelapse rates.11 Only one other randomized trial showed a reduction in

severe infectious episodes in patients treated with G-CSF.9 Ethnic

differences as well as differences in study designs could explain some of

the discrepancies between trials. In a pediatric Japanese trial, all patients

with VSAAreceived G-CSF, and randomization appliedonly to patients

with higher neutrophil counts.11 We found a reduction in the number of

infectious episodes but only in patients with VSAA. In a meta-analysis

on the use of growth factors in patients with aplastic anemia, including

6 randomized trials, the additionof hematopoietic growth factors did not

affect mortality, response rate, or infectious complications.23

This prospective trial documents other new information. In

contrast to what has been claimed recently,15,24 the severity of the

disease is still the most important factor affecting overall survival.

Excellent OS of children and young adults does not comprehen-

sively reflect long-term outcome. Indeed, EFS in the younger

cohort of the patients decreases over time as it does in the older age

groups, because nonresponse, relapse, PNH, or clonal malignant

transformation occur in patients at any age. Therefore, survival is

no longer the major endpoint to be evaluated in SAA. This is of

Figure 2. OS and EFS rates. Six-year OS rate (A) and EFS (B) in patients with SAA

treated with ATG/CSA with (green) or without (blue) G-CSF.

Figure 3. Response rates according to the time since randomization. (A)

Patients randomly assigned to ATG/CSA without G-CSF; (B) patients randomly

assigned to ATG/CSA with G-CSF.

Figure 4. Evolution of neutrophil counts during the first year in patients treated

with ATG and CSA with and without G-CSF. The bold red line represents the

median, and the yellow surface represents the 75% CI of the neutrophil counts in

patients treated with G-CSF; the bold blue line represents the median, and the blue

surface represents the 75% CI of the neutrophil counts in patients treated without

G-CSF; the gray surface represents the overlapping surface of 75% CI of patients

treated with and without G-CSF.





7/9

particular importance, in younger, nonresponding patients for

whom unrelated HSCT should be considered early.

One of the strengths of this trial is that it included an unselected

cohort of patients with SAA. Inclusion criteria were not restrictive

and permitted recruitment of any patient with newly, diagnosed,

untreated acquired SAA. Furthermore, the study was not restricted to

specialized centers. In total, 54 European centers from 8 countries

participated in this study, and 36 of the 54 participating centers included

only 1 or 2 patients (supplemental Appendix, available on the Blood

Web site; see the Supplemental Materials link at the top of the online

article). Therefore, we considered the cohort of the patients to be

representative of what is observed in daily practice.

Our study has some limitations. The randomized study, de-

signed to detect a statistical difference for EFS of 15%, planned to

enroll a total of 340 patients. Unfortunately, because of slow

accrual for this rare disease and the withdrawal of horse ATG in

Europe, the EBMT was forced to close the study early. Despite this,

this is still the largest trial ever done comparing in patients with

SAA treated with immunosuppression with and without G-CSF.

Most of the previous studies included 50 patients in each

arm.10-14 In view of the data presented here, it is unlikely that a

larger number of patients would have changed the conclusions. It is

also unlikely that another trial of G-CSF with a larger number of

patients will ever be performed. Furthermore, the definition of

infectious episodes and the decision on the duration of hospitaliza-

tion was not standardized and may be unequal, given the large

number of participating centers. Some institutions may havehospital discharge protocols that require a given level of neutro-

phils. This could bias the number of hospitalized days to be in favor

of the growth factor arm. To minimize a center effect randomiza-

tion was stratified for centers. We furthermore performed an

analysis to evaluate the center effect in patients who were randomly

assigned with or without G-CSF on the number of infections and

days of hospitalization. Therefore, we compared the results be-

tween large centers ( 4 patients included into the study) and small

centers ( 4 patients included). There was no difference for each

randomization arm (with or without G-CSF) between large and

small centers. The difference between both arms (G-CSF, no

G-CSF) remained similar for the number of infections and the

number of hospitalization days for large centers. However, for the

small centers, despite that a similar trend existed, the difference

was no longer significant between patients randomly assigned to

G-CSF and no G-CSF. Therefore, we cannot exclude a bias for the

small centers with respect to number of infections and hospitaliza-

tion days. Early retreatment with ATG in patients not responding at

3 months does not appear to be of benefit in terms of OS. However,

these data have to be interpreted cautiously, given the low number

of patients in each arm and the many protocol violations. Survival

of patients eligible for early retreatment is good, (83% and 77%),but this only includes patients alive without response at one time

point, day 120.

The issue about the risk of secondary MDS/AML related to the

use of G-CSF in SAA is still unresolved. We did not demonstrate an

excess risk of a clonal disorder with the use of G-CSF. Despite that

the follow-up time is still too short for a definitive statement, most

other studies did not show more clonal diseases with G-CSF. The

Italian Aplastic Anemia Study Group also showed no excess risk of

developing clonal disorders even when larger G-CSF doses were

used over a 6-month period.25 Furthermore, neither the meta-

analysis nor any of the randomized trials referred to previously

showed an increased risk of a clonal disorder associated with the

use of G-CSF.9-14,23 In contrast, in a large registry-based retrospec-

tive study of the EBMT, the use of G-CSF was associated with a

higher hazard of MDS/AML in patients with AA treated with

immunosuppression.26 An increased risk of MDS/AML has also

been described in patients from Japan treated with immunosuppres-

sion and G-CSF, mainly in nonresponse patients.27 In conclusion,

G-CSF added to standard immunosuppression with ATG and CSA

reduces the rate of early infectious episodes and days of hospitaliza-

tion in VSAA patients and might allow early identification of

nonresponders, but it has no effect on OS, EFS, remission, relapse

rates, and mortality.

Acknowledgments

We thank all patients who accepted to enter the study and the

treating centers for including patients into the study (see the

supplemental Appendix).

This study was supported by an unrestricted grant from

Chugai-Aventis, France, for data acquisition in the amount of

50 000 EU.

Authorship

Contribution: A.T. served as the principal investigator for this study

and wrote the paper; J.R.P., G.S., H.S., A. Bacigalupo, and J.M.

contributed to data analysis and writing the paper; H.S., G.S., J.M.,

A. Bacigalupo, U.D., A.F., M.H., E.T., M.W., B.H., and A.T.

contributed to patient recruitment; A.T., H.S., G.S., J.M., and J.R.P.

served as investigators in this study; A. Barrois, K.C., and B.H.

contributed to the data collection; A.T., H.S., G.S., J.M., and J.R.P.

contributed to the study design; and J.P. and A.T. contributed to the

statistical analysis of the study.

Conflict-of-interest disclosure: J.M. was a consultant for Gen-

zyme Therapeutics from 2008-2009, and received research funding

from Genzyme in 2010. The remaining authors declare no compet-

ing financial interests.

Correspondence: André Tichelli, Hematology, University Hos-

pitals, Petersgraben 4, 4031 Basel, Switzerland; e-mail:

[email protected].

Figure 5. Survival of patients randomly assigned to receive G-CSF with

neutrophil counts > 0.50 109 /L (blue) at day 30 compared with patients with

neutrophil counts < 0.50 109 /L (green).





8/9

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online January 13, 2011 originally publisheddoi:10.1182/blood-2010-08-304071

2011 117: 4434-4441

Barrois, Kim Champion and Jakob R. PasswegDührsen, Anke Franzke, Michael Hallek, Eckhard Thiel, Martin Wilhelm, Britta Höchsmann, AlainAndré Tichelli, Hubert Schrezenmeier, Gérard Socié, Judith Marsh, Andrea Bacigalupo, Ulrich European Group for Blood and Marrow Transplantationwith or without G-CSF: a study of the SAA Working Party of theaplastic anemia receiving antithymocyte globulin (ATG), cyclosporine,A randomized controlled study in patients with newly diagnosed severe

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A randomized controlled study in patients with newly diagnosed severe aplastic.pdf