Sequential treatment with FLAG-IDA/treosulfan conditioning regimen for patients with active acute myeloid leukemia

Liat Shargian-Alon*, Ofir Wolach, Uri Rozovski, Dafna Yahav, Michal Sela-Navon, Mazal Rubinstein, Nino Oniashvilli, Oren Pasvolsky, Pia Raanani, Moshe Yeshurun

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review


Sequential protocols combining salvage chemotherapy with reduced intensity conditioning (RIC) and allogeneic hematopoietic cell transplantation (alloHCT) for high-risk acute myeloid leukemia (AML) have been studied more than a decade. Purpose of this retrospective analysis was to evaluate the anti-leukemic efficacy and toxicity of FLAG-IDA protocol (fludarabine, cytarabine, and idarubicin) followed by treosulfan-based conditioning for patients with active AML. From January 2014 to November 2019, a total of 29 active AML patients [median age, 64 years (range, 23–73)] were treated. All patients completed protocol regimen and were transplanted. Five patients (17%) had grade 3–4 toxicities; therefore, treosulfan was substituted with total body irradiation (TBI) non-myeloablative conditioning. Six (20%) patients died within 30 post-transplant days, all from infectious complications. Out of 23 evaluable patients on day 30, 22 (96%) achieved complete hematologic remission with full donor chimerism. Non-relapse mortality (NRM) rates at 1 and 3 years were 22% and 49%, respectively. Median overall survival (OS) was 12 (95% CI, 4–20) months. OS and disease-free survival were 50% and 46% at 1 year and 28% and 17% at 2 years, respectively. Age, gender, disease burden, number of previous lines, and comorbidity score did not predict survival. Sequential strategy combining FLAG-IDA and treosulfan may offer a salvage option for few selected patients with active AML; however, high NRM presents a major obstacle to treatment success. Future efforts should focus on reducing NRM by moderating regimen intensity and by better selection of patients.

Original languageEnglish
Pages (from-to)2939-2945
Number of pages7
JournalAnnals of Hematology
Issue number12
StatePublished - Dec 2020


  • Allogeneic hematopoietic cell transplantation
  • Relapsed and refractory AML
  • Salvage
  • Sequential


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