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Bajwa RPS, Taylor K, Hoyt A, Kamboj MK, Stanek J, Mahadeo KM, Alsaedi H, Abdel-Azim H, O'Kane S, Martin PL, Stafford LA, Dvorak CC. Vitamin D has no impact on outcomes after HSCT in children-A retrospective study. Pediatr Transplant 2021; 25:e14008. [PMID: 33734544 DOI: 10.1111/petr.14008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 02/23/2021] [Accepted: 03/07/2021] [Indexed: 01/22/2023]
Abstract
Vitamin D not only plays an important role in bone metabolism but is also involved in multiple immune-mediated processes in the body which may be adversely affected in those with low levels. Most pediatric studies evaluating the association of vitamin D in patients undergoing allogeneic HSCT are single-center studies. We present the results of retrospective study at 5 centers across the United States in pediatric patients undergoing allogeneic HSCT. (VDD) and (VDI) were defined by vitamin D levels of <20 ng/ml and 21-30 ng/ml, respectively. The mean vitamin D levels pre-HSCT, day +30, and +100 were suggestive of VDI, but normalized thereafter. We compared the transplant characteristics and outcomes in 233 patients with VDD and VDI and those with normal levels and found no statistical difference in neutrophil or platelet engraftment, infections (viral, bacterial, or fungal) post-HSCT, length of hospital stay during HSCT, graft failure, acute or chronic GvHD, survival at day +100 and 1 year, or relapse of primary malignancy. We conclude that VDI or deficiency does not affect any of the common transplant variables after allogeneic HSCT in children. There is a need of a large multicenter prospective study to evaluate its role further.
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Rowan CM, Fitzgerald JC, Agulnik A, Zinter MS, Sharron MP, Slaven JE, Kreml EM, Bajwa RPS, Mahadeo KM, Moffet J, Tarquinio KM, Steiner ME. Risk Factors for Noninvasive Ventilation Failure in Children Post-Hematopoietic Cell Transplant. Front Oncol 2021; 11:653607. [PMID: 34123807 PMCID: PMC8190382 DOI: 10.3389/fonc.2021.653607] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 04/29/2021] [Indexed: 11/13/2022] Open
Abstract
Rationale Little is known on the use of noninvasive ventilation (NIPPV) in pediatric hematopoietic cell transplant (HCT) patients. Objective We sought to describe the landscape of NIPPV use and to identify risk factors for failure to inform future investigation or quality improvement. Methods This is a multicenter, retrospective observational cohort of 153 consecutive children post-HCT requiring NIPPV from 2010-2016. Results 97 (63%) failed NIPPV. Factors associated with failure on univariate analysis included: longer oxygen use prior to NIPPV (p=0.04), vasoactive agent use (p<0.001), and higher respiratory rate at multiple hours of NIPPV use (1hr p=0.02, 2hr p=0.04, 4hr p=0.008, 8hr p=0.002). Using respiratory rate at 4 hours a multivariable model was constructed. This model demonstrated high ability to discriminate NIPPV failure (AUC=0.794) with the following results: respiratory rate >40 at 4 hours [aOR=6.3 9(95% CI: 2.4, 16.4), p<0.001] and vasoactive use [aOR=4.9 (95% CI: 1.9, 13.1), p=0.001]. Of note, 11 patients had a cardiac arrest during intubation (11%) and 3 others arrested prior to intubation. These 14 patients were closer to HCT [14 days (IQR:4, 73) vs 54 (IQR:21,117), p<0.01] and there was a trend toward beginning NIPPV outside of the PICU and arrest during/prior to intubation (p=0.056). Conclusions In this cohort respiratory rate at 4 hours and vasoactive use are independent risk factors of NIPPV failure. An objective model to predict which children may benefit from a trial of NIPPV, may also inform the timing of both NIPPV initiation and uncomplicated intubation.
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Ahmad AH, Mahadeo KM. Corrigendum: Perspective: A Framework to Screen Pediatric and Adolescent Hematopoietic Cellular Therapy Patients for Organ Dysfunction: Time for a Multi-Disciplinary and Longitudinal Approach. Front Oncol 2021; 11:679526. [PMID: 33968787 PMCID: PMC8103829 DOI: 10.3389/fonc.2021.679526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 03/12/2021] [Indexed: 11/13/2022] Open
Abstract
[This corrects the article DOI: 10.3389/fonc.2021.622630.].
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Traube C, Gerber LM, Mauer EA, Small K, Broglie L, Chopra YR, Duncan CN, Ebens CL, Fitzgerald JC, Freedman JL, Hudspeth MP, Hurley C, Mahadeo KM, McArthur J, Shapiro MC, Sharron MP, Wall DA, Zinter MS, Greenwald BM, Silver G, Boulad F. Delirium in Children Undergoing Hematopoietic Cell Transplantation: A Multi-Institutional Point Prevalence Study. Front Oncol 2021; 11:627726. [PMID: 33968727 PMCID: PMC8100670 DOI: 10.3389/fonc.2021.627726] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 02/19/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Delirium occurs frequently in adults undergoing hematopoietic cell transplantation, with significant associated morbidity. Little is known about the burden of delirium in children in the peri-transplant period. This study was designed to determine delirium rates, define risk factors (demographic and treatment related), and establish feasibility of multi-institutional bedside screening for delirium in children undergoing hematopoietic cell transplant. Methods: This is a multi-institutional point prevalence study. All subjects were prospectively screened for delirium twice daily using the Cornell Assessment of Pediatric Delirium over a 10-day period. De-identified data, including basic demographics and daily characteristics, were extracted from the electronic medical record. Results: Eleven North American institutions were included, 106 children were enrolled, and 883 hospital days were captured. Delirium screening was successfully completed on more than 98% of the study days. Forty-eight children (45%) developed delirium over the course of the 10-day study. Children were diagnosed with delirium on 161/883 study days, for an overall delirium rate of 18% per day. Higher delirium rates were noted in children <5 years old (aOR 0.41 for children over 5 years), and in association with specific medications (melatonin, steroids, and tacrolimus). Conclusion: Delirium was a frequent occurrence in our study cohort, with identifiable risk factors. Delirium screening is highly feasible in the pediatric hematopoietic cell transplant patient population. A large-scale prospective longitudinal study following children throughout their transplant course is urgently needed to fully describe the epidemiology of pediatric delirium, explore the effects of delirium on patient outcomes, and establish guidelines to prevent and treat delirium in the peri-transplant period.
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Tambaro FP, Singh H, Jones E, Rytting M, Mahadeo KM, Thompson P, Daver N, DiNardo C, Kadia T, Garcia-Manero G, Chan T, Shah RR, Wierda WG. Autologous CD33-CAR-T cells for treatment of relapsed/refractory acute myelogenous leukemia. Leukemia 2021; 35:3282-3286. [PMID: 33833386 PMCID: PMC8550958 DOI: 10.1038/s41375-021-01232-2] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 02/14/2021] [Accepted: 03/12/2021] [Indexed: 11/13/2022]
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Ragoonanan D, Khazal SJ, Abdel-Azim H, McCall D, Cuglievan B, Tambaro FP, Ahmad AH, Rowan CM, Gutierrez C, Schadler K, Li S, Di Nardo M, Chi L, Gulbis AM, Shoberu B, Mireles ME, McArthur J, Kapoor N, Miller J, Fitzgerald JC, Tewari P, Petropoulos D, Gill JB, Duncan CN, Lehmann LE, Hingorani S, Angelo JR, Swinford RD, Steiner ME, Tejada FNH, Martin PL, Auletta J, Choi SW, Bajwa R, Garnes ND, Kebriaei P, Rezvani K, Wierda WG, Neelapu SS, Shpall EJ, Corbacioglu S, Mahadeo KM. Author Correction: Diagnosis, grading and management of toxicities from immunotherapies in children, adolescents and young adults with cancer. Nat Rev Clin Oncol 2021; 18:468. [PMID: 33731864 DOI: 10.1038/s41571-021-00497-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Ahmad AH, Mahadeo KM. Perspective: A Framework to Screen Pediatric and Adolescent Hematopoietic Cellular Therapy Patients for Organ Dysfunction: Time for a Multi-Disciplinary and Longitudinal Approach. Front Oncol 2021; 11:622630. [PMID: 33718184 PMCID: PMC7943835 DOI: 10.3389/fonc.2021.622630] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 01/05/2021] [Indexed: 12/23/2022] Open
Abstract
Hematopoietic Cell Transplantation (HCT) is a potentially curative therapy for children and adolescent/young adults (AYA) with high-risk malignancies as well as some non-malignant genetic diseases. However, HCT may be associated with endotheliopathies and/or organ dysfunction that may progress to pediatric multi-organ dysfunction syndrome (pMODS) and require critical care intervention. Discipline specific scoring systems may be used to characterize individual organ dysfunction, but the extent to which they are used to prospectively monitor HCT patients with mild dysfunction is unknown. Further, separate scoring systems may be used to define risk of mortality and inform prognostication among those who require critical care support. Our understanding of the epidemiology, risk factors, morbidity, mortality, required monitoring, optimal prevention strategies and appropriate management of children undergoing HCT who develop organ dysfunction, endotheliopathies and/or progress to pMODS is poor. Discipline-specific registries and clinical studies have described improving outcomes for children undergoing HCT, including those who require critical care support; however, longitudinal studies/prospective registries that capture common data elements among HCT patients with and without organ dysfunction, endotheliopathies and pMODS are needed to facilitate inter-disciplinary collaboration and optimally characterize the risk profiles, define screening and prophylaxis regimens and mitigate toxicity.
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Ragoonanan D, Khazal SJ, Abdel-Azim H, McCall D, Cuglievan B, Tambaro FP, Ahmad AH, Rowan CM, Gutierrez C, Schadler K, Li S, Di Nardo M, Chi L, Gulbis AM, Shoberu B, Mireles ME, McArthur J, Kapoor N, Miller J, Fitzgerald JC, Tewari P, Petropoulos D, Gill JB, Duncan CN, Lehmann LE, Hingorani S, Angelo JR, Swinford RD, Steiner ME, Hernandez Tejada FN, Martin PL, Auletta J, Choi SW, Bajwa R, Dailey Garnes N, Kebriaei P, Rezvani K, Wierda WG, Neelapu SS, Shpall EJ, Corbacioglu S, Mahadeo KM. Diagnosis, grading and management of toxicities from immunotherapies in children, adolescents and young adults with cancer. Nat Rev Clin Oncol 2021; 18:435-453. [PMID: 33608690 PMCID: PMC9393856 DOI: 10.1038/s41571-021-00474-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2021] [Indexed: 02/07/2023]
Abstract
Cancer immunotherapies are associated with remarkable therapeutic response rates but also with unique and severe toxicities, which potentially result in rapid deterioration in health. The number of clinical applications for novel immune effector-cell therapies, including chimeric antigen receptor (CAR)-expressing cells, and other immunotherapies, such as immune-checkpoint inhibitors, is increasing. In this Consensus Statement, members of the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network Hematopoietic Cell Transplantation-Cancer Immunotherapy (HCT-CI) Subgroup, Paediatric Diseases Working Party (PDWP) of the European Society of Blood and Marrow Transplantation (EBMT), Supportive Care Committee of the Pediatric Transplantation and Cellular Therapy Consortium (PTCTC) and MD Anderson Cancer Center CAR T Cell Therapy-Associated Toxicity (CARTOX) Program collaborated to provide updated comprehensive recommendations for the care of children, adolescents and young adults receiving cancer immunotherapies. With these recommendations, we address emerging toxicity mitigation strategies, we advocate for the characterization of baseline organ function according to age and discipline-specific criteria, we recommend early critical care assessment when indicated, with consideration of reversibility of underlying pathology (instead of organ failure scores) to guide critical care interventions, and we call for researchers, regulatory agencies and sponsors to support and facilitate early inclusion of young patients with cancer in well-designed clinical trials.
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Ragoonanan D, Khazal SJ, Mejia R, Ewing L, Durand JB, Bashoura L, Tayar J, Dailey Garnes N, Petropoulos D, Tewari P, Bhatti M, Ahmad AH, Cortes J, Razvi S, McBeth K, Swinford R, Shoberu B, Waseemuddin W, Chi L, Gill JB, Zaky W, Daw N, Gutierrez C, Tereffe W, Kebriaei P, Rezvani K, Shpall EJ, Champlin RE, Mahadeo KM. Case Discussion and Literature Review: Cancer Immunotherapy, Severe Immune-Related Adverse Events, Multi-Inflammatory Syndrome, and Severe Acute Respiratory Syndrome Coronavirus 2. Front Oncol 2021; 11:625707. [PMID: 33614514 PMCID: PMC7891040 DOI: 10.3389/fonc.2021.625707] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 01/05/2021] [Indexed: 12/15/2022] Open
Abstract
Pediatric, adolescent and young adult (AYA) patients receiving novel cancer immunotherapies may develop associated toxicities with overlapping signs and symptoms that are not always easily distinguished from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection/clinical sequelae. We describe 2 diagnostically challenging cases of SARS-CoV-2 and Multi-Inflammatory Syndrome-Adult (MIS-A), in patients with a history of acute lymphoblastic leukemia following cellular therapy administration and review evolving characterization of both the natural course of SARS-CoV-2 infection and toxicities experienced in younger cancer immunotherapy patients. Vigilant monitoring for unique presentations and epidemiologic surveillance to promptly detect changes in incidence of either condition may be warranted.
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Dao L, Ragoonanan D, Yi S, Swinford R, Petropoulos D, Mahadeo KM, Li S. The Organ Trail: A Review of Biomarkers of Organ Failure. Front Oncol 2020; 10:579219. [PMID: 33262945 PMCID: PMC7686565 DOI: 10.3389/fonc.2020.579219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 10/15/2020] [Indexed: 11/13/2022] Open
Abstract
Pediatric organ failure and transplant populations face significant risks of morbidity and mortality. The risk of organ failure itself may be disproportionately higher among pediatric oncology patients, as cancer may originate within and/or metastasize to organs and adversely affect their function. Additionally, cancer directed therapies are frequently toxic to organs and may contribute to failure. Recent reports suggest that nearly half of providers find it difficult to provide prognostic information regarding organ failure due to unknown disease trajectories. Unfortunately, there is a lack of uniform methodology in detecting the early symptoms of organ failure, which may delay diagnosis, initiation of treatment and hinder prognostic planning. There remains a wide array of outstanding scientific questions regarding organ failure in pediatrics but emerging data may change the landscape of prognostication. Liquid biopsy, in which disease biomarkers are detected in bodily fluids, offers a noninvasive alternative to tissue biopsy and may improve prompt detection of organ failure and prognostication. Here, we review potential liquid biopsy biomarkers for organ failure, which may be particularly useful among pediatric oncology patients. We synthesized information from publications obtained on PubMed, Google Scholar, clinicaltrials.gov, and Web of Science and categorized our findings based on the type of biomarker used to detect organ failure. We highlight the advantages and disadvantages specific to each type of organ failure biomarker. While much work needs to be done to advance this field and validate its applicability to pediatric cancer patients facing critical care complications, herein, we highlight promising areas for future discovery.
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Kohorst MA, Khazal SJ, Tewari P, Petropoulos D, Mescher B, Wang J, Mahadeo KM, Kelley JM. Transfusion reactions in pediatric and adolescent young adult haematology oncology and immune effector cell patients. EClinicalMedicine 2020; 26:100514. [PMID: 32964199 PMCID: PMC7490993 DOI: 10.1016/j.eclinm.2020.100514] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 07/27/2020] [Accepted: 08/04/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Active surveillance for transfusion reactions is critically important among pediatric patients undergoing chemotherapy. Among pediatric-adolescent-young-adult (AYA) hematology/oncology patients, who have been typically excluded from transfusion reaction studies, this profile remains poorly characterized. METHODS We assessed the incidence and clinical characteristics of transfusion reactions (n = 3246 transfusions) in this population (n = 201 patients) at our center. FINDINGS The incidence of adjudicated transfusion reactions was 2·04%. The incidence was higher for platelet (2·78%) compared to packed red blood cell transfusions (1·49%) (p = 0·0149). The majority (61·4%) of all reactions were classified as febrile non-haemolytic transfusion, while 35·7% were considered allergic, and 2·9% were classified as transfusion-associated circulatory overload. The incidence of transfusion reactions in patients who were pre-medicated was higher (2·51%) than in patients who were not (1·52%) (p = 0·0406). Sub-set analysis revealed a 3·95% incidence of adjudicated transfusion reactions among recipients of immune effector cells (IECs) (n = 3), all of which occurred during the potential window for cytokine release syndrome; two-thirds of these reactions were severe/potentially life-threatening. INTERPRETATION The incidence of transfusion reactions among pediatric-AYA hematology/oncology patients may be lower than the general pediatric population. Patients with a prior history of transfusion reactions and those receiving platelet transfusions may be at higher risk for reaction. From our limited sample, IEC recipients may be at risk for severe transfusion reactions. Large multi-center prospective studies are needed to characterize transfusion reactions in this population. Appropriate characterization of reactions in this population may inform risk stratification and mitigate missed opportunities for prompt recognition and appropriate management. FUNDING None.
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Harden A, Ragoonanan D, Anildes-Gubman D, McCall D, Faltus K, Featherston S, Shoberu B, Moffet JR, Petropoulos D, Khazal SJ, Razvi S, Mahadeo KM, Tewari P. Chimeric Antigen Receptor, Teamwork, Education, Assessment, and Management (CAR-TEAM): A Simulation-Based Inter-professional Education (IPE) Intervention for Management of CAR Toxicities. Front Oncol 2020; 10:1227. [PMID: 32850365 PMCID: PMC7419673 DOI: 10.3389/fonc.2020.01227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 06/16/2020] [Indexed: 11/13/2022] Open
Abstract
Chimeric antigen receptor (CAR) therapies such as tisagenlecleucel, indicated for children and young adults with relapsed and/or refractory CD19+ acute lymphoblastic leukemia (ALL), have been associated with striking treatment outcomes and overall survival. Yet, they are also associated with unique and potentially life-threatening complications. Cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity (ICANS) are generally reversible complications of CAR therapies, but many patients may require critical care support especially if they are not promptly recognized and appropriately managed by frontline healthcare staff. As CAR therapies become more widely available, it is important that inter-professional staff members be aware of general principles regarding diagnosis and management. We hypothesized that an inter-professional education (IPE) simulation-based education intervention (CAR-TEAM) would improve knowledge base and confidence regarding complications of CAR therapies among inter-professional staff. Here, we demonstrate that following CAR-TEAM training, >90% of participants demonstrated knowledge proficiency and confidence in the IPE content area. CAR-TEAM training may serve as an important tool to establish initial and continued competency among sites introducing CAR therapies.
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Ragoonanan D, Khazal SJ, Wang J, Payne A, Kohorst M, Harden A, Tewari P, Petropoulos D, Shoberu B, Kebriaei P, Mahadeo KM, Tambaro FP. Improved detection of sinusoidal obstructive syndrome using pediatric-AYA diagnostic criteria and severity grading. Bone Marrow Transplant 2020; 56:175-184. [PMID: 32665674 DOI: 10.1038/s41409-020-00998-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 06/23/2020] [Accepted: 07/02/2020] [Indexed: 01/19/2023]
Abstract
New diagnostic criteria and severity grading for sinusoidal obstructive syndrome (SOS) among pediatric and adolescent young adult (AYA) patients have been recently endorsed by international consensus. The extent to which these have been adopted in the US remains unclear. We sought to assess the potential impact via retrospective application of these criteria among patients treated at a large academic center in the United States. This is a single center retrospective study of pediatric-AYA patients who underwent hematopoietic cell transplantation (HCT) between July 2009 and 2019. The incidence of SOS was assessed using historic Baltimore and Seattle diagnostic criteria and compared with more recent guidelines (pEBMT) as proposed by the Paediatric Diseases Working Party of the European Society for Blood and Marrow Transplantation. Among 226 patients, application of the pEBMT diagnostic criteria was associated with a higher incidence (15.9%) and earlier time to diagnosis of SOS (by 2.5-3 days) compared with the modified Seattle (12.3%), and Baltimore (6.6%) criteria, respectively. The pEBMT criteria were sensitive and highly specific. Refractory thrombocytopenia was present in 75% of patients at diagnosis. Approximately 61% of patients with SOS were anicteric at diagnosis, though the majority (94.4%) developed hyperbilirubinemia as SOS progressed over a median time of 4 (1-57) days. Application of pEBMT criteria may have resulted in earlier indication for definitive treatment by 3 days. Timely diagnosis and administration of definitive treatment of SOS has been associated with improved outcomes. Prospective studies may better characterize the risk factors and natural course of SOS using pEBMT criteria.
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Kohorst MA, Nunez CA, Tewari P, Petropoulos D, Mahadeo KM, Neelapu SS, Shpall EJ, Khazal S. Primary mediastinal large B-cell lymphoma in paediatric and adolescent patients: emerging questions in the era of immunotherapy. Br J Haematol 2020; 190:e114-e117. [PMID: 32469086 DOI: 10.1111/bjh.16761] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Hu J, Zhang W, Xia X, Yang Q, Chen Y, Fowlkes NW, Livingston JA, Zhang Z, Mahadeo KM, Gill JB, Dotti G, Kopetz S, Gorlick R, Li S. CRS free T cell therapy: T cell membrane anchored and tumor targeted IL12 (ATTIL12)-T cell therapy eliminates large tumors, overcomes heterogeneity, and avoids adverse effects. THE JOURNAL OF IMMUNOLOGY 2020. [DOI: 10.4049/jimmunol.204.supp.239.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Abstract
Adoptive transfer of genetic engineered T cells becomes an effective approach in treating hematologic malignancies, but shows poor responses against solid tumors due to multifactorial reasons. Interleukin-12 exhibits robust T cell activating and anti-tumor efficacy. However, its clinical application was impeded due to the lethal adverse effects. We demonstrated previously that tumor targeted IL-12 (ttIL12) gene therapy avoids the toxicity of wildtype IL12 and effectively eliminate tumor metastasis. In this study, we developed a second generation of ttIL12— membrane-anchored ttIL-12 (attIL12)—to modify naive T cells, CD19CAR-T cells and OT1 T cells. This attIL12-modified T cells silent the toxicity of both IL12 and CAR-T cells associated cytokine release syndrome (CRS). Surprisingly, this ATTIL12-T cell therapy is able to eliminate multiple types of tumors with either homo- or hetero-generous environment or large size. We are in full speed to prepare a phase I clinical trial.
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Gertz SJ, McArthur J, Hsing DD, Nitu ME, Smith LS, Loomis A, Fitzgerald JC, Duncan CN, Mahadeo KM, Moffet J, Hall MW, Pinos EL, Cheifetz IM, Rowan CM. Respiratory pathogens associated with intubated pediatric patients following hematopoietic cell transplant. Transpl Infect Dis 2020; 22:e13297. [PMID: 32306533 DOI: 10.1111/tid.13297] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 03/23/2020] [Accepted: 03/31/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND We describe organisms found in the respiratory tracts of a multicenter cohort of pediatric hematopoietic cell transplant (HCT) recipients with respiratory failure. METHODS Twelve centers contributed up to 25 pediatric allogeneic HCT recipients requiring mechanical ventilation for respiratory failure to a retrospective database. Positive respiratory pathogens and method of obtaining sample were recorded. Outcomes were assessed using Mann-Whitney U test or chi-squared analysis. RESULTS Of the 222 patients in the database, ages 1 month through 21 years, 34.6% had a positive respiratory culture. 105 pathogens were identified in 77 patients; of those, 48.6% were viral, 34.3% bacterial, 16.2% fungal, and 1% parasitic. PICU mortality with a respiratory pathogen was 68.8% compared to 54.9% for those without a respiratory pathogen (P = .045). Those with a positive respiratory pathogen had longer PICU length of stay, 20 days (IQR 14.0, 36.8) vs 15 (IQR 6.5, 32.0), P = .002, and a longer course of mechanical ventilation, 17 days (IQR 10, 29.5) vs 8 (3, 17), P < .0001. Method of pathogen identification, type of pathogen, and the presence of multiple pathogens were not associated with changes in PICU outcomes. CONCLUSIONS In this multicenter retrospective cohort of intubated pediatric post-HCT patients, there was high variability in the respiratory pathogens identified. Type of pathogen and method of detection did not affect PICU mortality. The presence of any organism leads to increased PICU mortality, longer PICU stay, and increased duration of mechanical ventilation suggesting that early detection and treatment of pathogens may be beneficial in this population.
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Khazal S, Ragoonanan D, Hosing C, Williams L, Medeiros LJ, Mahadeo KM, Thompson PA. Epstein - Barr virus specific cytotoxic T lymphocytes for the treatment of severe epstein-barr virus mucocutaneous ulcer. Br J Haematol 2020; 189:e33-e36. [PMID: 32150641 DOI: 10.1111/bjh.16423] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Mahadeo KM, Bajwa R, Abdel-Azim H, Lehmann LE, Duncan C, Zantek N, Vittorio J, Angelo J, McArthur J, Schadler K, Chan S, Tewari P, Khazal S, Auletta JJ, Choi SW, Shoberu B, Kalwak K, Harden A, Kebriaei P, Abe JI, Li S, Moffet JR, Abraham S, Tambaro FP, Kleinschmidt K, Richardson PG, Corbacioglu S. Diagnosis, grading, and treatment recommendations for children, adolescents, and young adults with sinusoidal obstructive syndrome: an international expert position statement. Lancet Haematol 2020; 7:e61-e72. [PMID: 31818728 DOI: 10.1016/s2352-3026(19)30201-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 08/05/2019] [Accepted: 08/06/2019] [Indexed: 02/03/2023]
Abstract
Sinusoidal obstructive syndrome, also known as hepatic veno-occlusive disease, is a potentially life-threatening complication that occurs in children undergoing haemopoietic stem-cell transplantation (HSCT). Differences in the incidence of genetic predisposition and clinical presentation of sinusoidal obstructive syndrome between children and adults have rendered the historical Baltimore and Seattle diagnostic criteria insufficient for children. In 2017, the European Society for Blood and Marrow Transplantation (EBMT) proposed the first paediatric diagnostic and severity grading guidelines for sinusoidal obstructive syndrome, intended for implementation across European centres. However, universally accepted paediatric criteria are needed to ensure prompt diagnosis, definitive treatment, and improved outcomes for children, adolescents, and young adults with sinusoidal obstructive syndrome, and to facilitate international clinical research collaboration. We convened an international panel of multidisciplinary experts including physicians with expertise in HSCT, paediatric intensive care, nephrology, hepatology, radiology, pathology, and transfusion medicine; HSCT advanced-practice providers and medical trainees; pharmacists; and translational and basic science researchers from the Pediatric Acute Lung Injury and Sepsis Investigators Network, the EBMT, the Pediatric Blood and Marrow Transplant Consortia, and several other institutions with extensive experience in sinusoidal obstructive syndrome. Panellists convened at The University of Texas, MD Anderson Cancer Center (Houston, TX, USA) in February, 2019, to evaluate the available evidence. In this expert position statement paper, we provide consensus recommendations for the international implementation of guidelines for the diagnosis, severity grading, and treatment of sinusoidal obstructive syndrome among children, adolescents, and young adults. We endorse universal adoption of paediatric diagnostic guidelines for sinusoidal obstruction syndrome as proposed by the EBMT, and provide implementation guidance for standardisation across centres; we have further proposed adjunctive use of age-appropriate organ-specific toxicity criteria for severity grading and provided prophylaxis and treatment considerations among children and adolescent and young adult patients. Key recommendations include: (1) liver biopsy, portal venous wedge pressure, and reversal of portal venous flow on Doppler ultrasonography should not be used for the routine diagnosis of sinusoidal obstructive syndrome in children, adolescents, and young adults; (2) platelet refractoriness can be defined as a corrected count increment of less than 5000-7500 following at least two sequential ABO-compatible fresh platelet transfusions; (3) hepatomegaly is best defined as an absolute increase of at least 1 cm in liver length at the midclavicular line; and if a baseline measurement is not available, hepatomegaly can be defined as greater than 2 SDs above normal for age; and (4) the presence and volume of ascites can be categorised as mild (minimal fluid by liver, spleen, or pelvis), moderate (<1 cm fluid), or severe (fluid in all three regions with >1 cm fluid in at least two regions).
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Moffet JR, Mahadeo KM, McArthur J, Hsing DD, Gertz SJ, Smith LS, Loomis A, Fitzgerald JC, Nitu ME, Duncan CN, Hall MW, Pinos EL, Tamburro RF, Simmons RA, Troy J, Cheifetz IM, Rowan CM. Correction to: Acute respiratory failure and the kinetics of neutrophil recovery in pediatric hematopoietic cell transplantation: a multicenter study. Bone Marrow Transplant 2019; 55:476. [PMID: 31822810 PMCID: PMC7608367 DOI: 10.1038/s41409-019-0767-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
An amendment to this paper has been published and can be accessed via a link at the top of the paper.
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Moffet JR, Mahadeo KM, McArthur J, Hsing DD, Gertz SJ, Smith LS, Loomis A, Fitzgerald JC, Nitu ME, Duncan CN, Hall MW, Pinos EL, Tamburro RF, Simmons RA, Troy J, Cheifetz IM, Rowan CM. Acute respiratory failure and the kinetics of neutrophil recovery in pediatric hematopoietic cell transplantation: a multicenter study. Bone Marrow Transplant 2019; 55:341-348. [PMID: 31527817 PMCID: PMC7091821 DOI: 10.1038/s41409-019-0649-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 07/09/2019] [Accepted: 08/10/2019] [Indexed: 11/23/2022]
Abstract
In this multicenter study, we investigated the kinetics of neutrophil recovery in relation to acuity and survival among 125 children undergoing allogeneic hematopoietic cell transplantation (allo-HCT) who required invasive mechanical ventilation (IMV). Recovery of neutrophils, whether prior to or after initiation of IMV, was associated with a significantly decreased risk of death relative to never achieving neutrophil recovery. A transient increase in acuity (by oxygenation index and vasopressor requirements) occurred among a subset of the patients who achieved neutrophil recovery after initiation of IMV; 61.5% of these patients survived to discharge from the intensive care unit (ICU). Improved survival among patients who subsequently achieved neutrophil recovery on IMV was not limited to those with peri-engraftment respiratory distress syndrome. The presence of a respiratory pathogen did not affect the risk of death while on IMV but was associated with an increased length of IMV (p < 0.01). Among patients undergoing HCT who develop respiratory failure and require advanced therapeutic support, neutrophil recovery at time of IMV and/or presence of a respiratory pathogen should not be used as determining factors when counseling families about survival.
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Batth IS, Zaky W, Khatua S, Daw NC, Mahadeo KM, Khazal S, Albert A, Huang W, Chen D, Gill JB, Kleinerman E, Gorlick R, Li S. Abstract 1345: Automated capture and analysis of circulating tumor cells across different types of tumors in pediatric cancer patients. Cancer Res 2019. [DOI: 10.1158/1538-7445.am2019-1345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
The clinical utility of blood analysis such as circulating tumor cells (CTCs) has garnered increasing interest in recent years. However very few studies were conducted in pediatric cancer patients especially in brain tumor, osteosarcoma, and leukemia patients due to the lack of an effective tool to isolate/capture CTC from these patients. For example, only three independent studies were published to investigate CTC capture from adult brain tumor patients but zero studies were conducted with pediatric brain cancer patients. Our previous studies showed the high specificity of using cell surface vimentin (CSV) to identify and capture CTCs from various types of adult tumor patients using a manual isolation method. Here we present the first automated system for capturing CTCs across different types of pediatric tumors. This automated system utilizes the Abnova CytoQuest system loaded with the CSV antibody 84-1-coated microfluidic cassette for capturing CTCs from peripheral blood samples. This automated assay was very sensitive because as few as one tumor cell can be captured out from one million normal cells. Based on our preliminary study, our success rate for non-DIPG brain tumor, ALL, and AML patients is 100%. This success provides a potential opportunity for analyzing brain tumor genetic properties using blood samples instead of the invasive tumor biopsy; likewise, this high sensitivity assay opens up clinical opportunities to use this assay for transplant and treatment decision making.
Note: This abstract was not presented at the meeting.
Citation Format: Izhar S. Batth, Wafik Zaky, Soumen Khatua, Najat C. Daw, Kris M. Mahadeo, Sajad Khazal, Aisha Albert, Wilber Huang, Diva Chen, Jonathan B. Gill, Eugenie Kleinerman, Richard Gorlick, Shulin Li. Automated capture and analysis of circulating tumor cells across different types of tumors in pediatric cancer patients [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 1345.
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Mahadeo KM, Khazal SJ, Abdel-Azim H, Fitzgerald JC, Taraseviciute A, Bollard CM, Tewari P, Duncan C, Traube C, McCall D, Steiner ME, Cheifetz IM, Lehmann LE, Mejia R, Slopis JM, Bajwa R, Kebriaei P, Martin PL, Moffet J, McArthur J, Petropoulos D, O'Hanlon Curry J, Featherston S, Foglesong J, Shoberu B, Gulbis A, Mireles ME, Hafemeister L, Nguyen C, Kapoor N, Rezvani K, Neelapu SS, Shpall EJ. Management guidelines for paediatric patients receiving chimeric antigen receptor T cell therapy. Nat Rev Clin Oncol 2019; 16:45-63. [PMID: 30082906 PMCID: PMC7096894 DOI: 10.1038/s41571-018-0075-2] [Citation(s) in RCA: 143] [Impact Index Per Article: 28.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
In 2017, an autologous chimeric antigen receptor (CAR) T cell therapy indicated for children and young adults with relapsed and/or refractory CD19+ acute lymphoblastic leukaemia became the first gene therapy to be approved in the USA. This innovative form of cellular immunotherapy has been associated with remarkable response rates but is also associated with unique and often severe toxicities, which can lead to rapid cardiorespiratory and/or neurological deterioration. Multidisciplinary medical vigilance and the requisite health-care infrastructure are imperative to ensuring optimal patient outcomes, especially as these therapies transition from research protocols to standard care. Herein, authors representing the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network Hematopoietic Stem Cell Transplantation (HSCT) Subgroup and the MD Anderson Cancer Center CAR T Cell Therapy-Associated Toxicity (CARTOX) Program have collaborated to provide comprehensive consensus guidelines on the care of children receiving CAR T cell therapy.
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Khazal S, Polishchuk V, Soffer G, Prinzing S, Gill J, Mahadeo KM. Allogeneic hematopoietic stem cell transplantation is associated with cure and durable remission of late-onset primary isolated central nervous system hemophagocytic lymphohistiocytosis. Pediatr Transplant 2018; 22. [PMID: 29239076 DOI: 10.1111/petr.13101] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/22/2017] [Indexed: 11/27/2022]
Abstract
Primary isolated CNS presentation of HLH is exceedingly rare and typically associated with significant morbidity and mortality. We describe an adolescent patient with late-onset, primary isolated CNS HLH and a compound heterozygous PRF1 mutation (c50delT (p.L17 fs); c.1229G>C (p.R410P)), not previously reported with this phenotype. He was successfully treated with allogeneic HSCT following a reduced-intensity conditioning regimen, despite a high pre-HSCT comorbidity index. Two years after transplant, he is alive and in disease remission. While patients with systemic HLH and active CNS disease have relatively poorer outcomes, a high index of suspicion may aid with early diagnosis of primary isolated CNS HLH; prompt treatment with HSCT may be associated with improved cure and durable remission of this rare disease.
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Rowan CM, Loomis A, McArthur J, Smith LS, Gertz SJ, Fitzgerald JC, Nitu ME, Moser EA, Hsing DD, Duncan CN, Mahadeo KM, Moffet J, Hall MW, Pinos EL, Tamburro RF, Cheifetz IM. High-Frequency Oscillatory Ventilation Use and Severe Pediatric ARDS in the Pediatric Hematopoietic Cell Transplant Recipient. Respir Care 2017; 63:404-411. [PMID: 29279362 DOI: 10.4187/respcare.05765] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION The effectiveness of high-frequency oscillatory ventilation (HFOV) in the pediatric hematopoietic cell transplant patient has not been established. We sought to identify current practice patterns of HFOV, investigate parameters during HFOV and their association with mortality, and compare the use of HFOV to conventional mechanical ventilation in severe pediatric ARDS. METHODS This is a retrospective analysis of a multi-center database of pediatric and young adult allogeneic hematopoietic cell transplant subjects requiring invasive mechanical ventilation for critical illness from 2009 through 2014. Twelve United States pediatric centers contributed data. Continuous variables were compared using a Wilcoxon rank-sum test or a Kruskal-Wallis analysis. For categorical variables, univariate analysis with logistic regression was performed. RESULTS The database contains 222 patients, of which 85 subjects were managed with HFOV. Of this HFOV cohort, the overall pediatric ICU survival was 23.5% (n = 20). HFOV survivors were transitioned to HFOV at a lower oxygenation index than nonsurvivors (25.6, interquartile range 21.1-36.8, vs 37.2, interquartile range 26.5-52.2, P = .046). Survivors were transitioned to HFOV earlier in the course of mechanical ventilation, (day 0 vs day 2, P = .002). No subject survived who was transitioned to HFOV after 1 week of invasive mechanical ventilation. We compared subjects with severe pediatric ARDS treated only with conventional mechanical ventilation versus early HFOV (within 2 d of invasive mechanical ventilation) versus late HFOV. There was a trend toward difference in survival (conventional mechanical ventilation 24%, early HFOV 30%, and late HFOV 9%, P = .08). CONCLUSIONS In this large database of pediatric allogeneic hematopoietic cell transplant subjects who had acute respiratory failure requiring invasive mechanical ventilation for critical illness with severe pediatric ARDS, early use of HFOV was associated with improved survival compared to late implementation of HFOV, and the subjects had outcomes similar to those treated only with conventional mechanical ventilation.
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Mahadeo KM, McArthur J, Adams RH, Radhi M, Angelo J, Jeyapalan A, Nicol K, Su L, Rabi H, Auletta JJ, Pai V, Duncan CN, Tamburro R, Dvorak CC, Bajwa RPS. Consensus Report by the Pediatric Acute Lung Injury and Sepsis Investigators and Pediatric Blood and Marrow Transplant Consortium Joint Working Committees on Supportive Care Guidelines for Management of Veno-Occlusive Disease in Children and Adolescents: Part 2-Focus on Ascites, Fluid and Electrolytes, Renal, and Transfusion Issues. Biol Blood Marrow Transplant 2017; 23:2023-2033. [PMID: 28823876 DOI: 10.1016/j.bbmt.2017.08.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 08/10/2017] [Indexed: 01/19/2023]
Abstract
Even though hepatic veno-occlusive disease (VOD) is a potentially fatal complication of hematopoietic cell transplantation (HCT), there is paucity of research on the management of associated multiorgan dysfunction. To help provide standardized care for the management of these patients, the HCT Subgroup of the Pediatric Acute Lung Injury and Sepsis Investigators and the Supportive Care Committee of the Pediatric Blood and Marrow Transplant Consortium, collaborated to develop evidence-based consensus guidelines. After conducting an extensive literature search, in part 2 of this series we discuss the management of fluids and electrolytes, renal dysfunction; ascites, pleural effusion, and transfusion and coagulopathy issues in patients with VOD. We consider the available evidence using the GRADE criteria.
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