151
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Perica K, Curran KJ, Brentjens RJ, Giralt SA. Building a CAR Garage: Preparing for the Delivery of Commercial CAR T Cell Products at Memorial Sloan Kettering Cancer Center. Biol Blood Marrow Transplant 2018; 24:1135-1141. [PMID: 29499327 DOI: 10.1016/j.bbmt.2018.02.018] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 02/16/2018] [Indexed: 10/17/2022]
Abstract
Two commercial chimeric antigen receptor (CAR) T cell therapies for CD19-expressing B cell malignancies, Kymriah and Yescarta, have recently been approved by the Food and Drug Administration. The administration of CAR T cells is a complex endeavor involving cell manufacture, tracking and shipping of apheresis products, and management of novel and severe toxicities. At Memorial Sloan Kettering Cancer Center, we have identified 8 essential tasks that define the CAR T cell workflow. In this review, we discuss practical aspects of CAR T cell program development, including clinical, administrative, and regulatory challenges for successful implementation.
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152
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Scordo M, Morjaria SM, Bhatia A, Littman E, Maloy M, DeAngelis L, Giralt SA, Taur Y, Sauter CS. Patients with Central Nervous System Lymphoma (CNSL) Undergoing Thiotepa, Busulfan, Cyclophosphamide-Conditioned Autologous Stem Cell Transplantation (TBC-ASCT) are at a Higher Risk for DNA Virus Infections Than Patients Receiving Traditional Conditioning. Biol Blood Marrow Transplant 2018. [DOI: 10.1016/j.bbmt.2017.12.600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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153
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Preston EV, Chinapen S, Borrill T, Davis E, Shaffer BC, Tamari R, Jakubowski AA, Perales MA, Ponce DM, Shah GL, Dahi PB, Barker JN, Berman E, Tallman M, Giralt SA, Stein E, Gyurkocza B. Disease Progression is Main Barrier to Allogeneic Hematopoietic Stem Cell Transplantation (HCT) in Patients with Newly Diagnosed and Relapsed Acute Leukemia. Biol Blood Marrow Transplant 2018. [DOI: 10.1016/j.bbmt.2017.12.378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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154
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Shah GL, Landau H, Sarubbi C, Schofield R, Lin A, Bhatt V, Harnicar S, Devlin SM, Castro-Malaspina H, Chung DJ, Dahi PB, Gyurkocza B, Koehne G, Matasar MJ, Moskowitz CH, Papadopoulos EB, Sauter CS, Shaffer BC, Tamari R, Carlow D, Giralt SA. Pharmacokinetics and Toxicities after Evomela® (Propylene Glycol Free Melphalan) with Hematopoietic Stem Cell Transplant (HCT) for Multiple Myeloma (MM), AL Amyloidosis (AL), Lymphoma, Acute Myeloid Leukemia (AML), and Myelodysplastic Syndrome (MDS). Biol Blood Marrow Transplant 2018. [DOI: 10.1016/j.bbmt.2017.12.664] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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155
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Pappacena J, Bhatt V, Shah GL, Hilden P, Maloy M, Buie LW, Giralt SA, Scordo M. More Intensive Fludarabine/Busulfan (Flu/Bu) Conditioning Regimens Result in Similar Outcomes Without Adding Serious Toxicity When Compared to Fludarabine/Melphalan (Flu/Mel) in Patients Undergoing Allogeneic Hematopoietic Cell Transplant (Allo-HCT). Biol Blood Marrow Transplant 2018. [DOI: 10.1016/j.bbmt.2017.12.271] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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156
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Lin RJ, Perales MA, Shahrokni A, Maloy M, Devlin SM, Jakubowski AA, Dahi PB, Shah GL, Korc-Grodzicki B, Giralt SA. Prevalence of Functional Impairment and Geriatric Vulnerability during Pre-Transplant Geriatric Assessment in an Academic Hematopoietic Cell Transplantation Center. Biol Blood Marrow Transplant 2018. [DOI: 10.1016/j.bbmt.2017.12.259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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157
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Richardson PG, Antin JH, Giralt SA, Ryan R, Liang W, Hume R, Tappe W, Kernan NA. Adults Receiving Defibrotide for the Treatment of Hepatic Veno-Occlusive Disease/Sinusoidal Obstruction Syndrome (VOD/SOS) after Hematopoietic Stem Cell Transplantation (HSCT): Final Results From the Expanded-Access Program (T-IND). Biol Blood Marrow Transplant 2018. [DOI: 10.1016/j.bbmt.2017.12.344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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158
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Cho C, Politikos I, Hilden P, Borrill T, Maloy M, Smith K, Giralt SA, Maslak P, O'Reilly RJ, van den Brink MR, Barker JN, Perales MA. Comparison of T Cell Subset Recovery after Cord Blood and CD34-Selected Pbsc Transplantation. Biol Blood Marrow Transplant 2018. [DOI: 10.1016/j.bbmt.2017.12.440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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159
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Dahi PB, Clavo CR, Maloy M, Seier K, Devlin SM, Robinson K, Scordo M, Shah GL, Tamari R, Matasar MJ, Hamlin P, Jakubowski AA, Sauter CS, Moskowitz CH, Giralt SA. Toxicities Associated with High Dose Chemotherapy and Autologous Stem Cell Transplantation in Older Patients with Non-Hodgkin Lymphoma. Biol Blood Marrow Transplant 2018. [DOI: 10.1016/j.bbmt.2017.12.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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160
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Bachier-Rodriguez L, Shah GL, Knezevic A, Devlin SM, Maloy M, Koehne G, Chung DJ, Landau H, Giralt SA. Engraftment Kinetics after High-Dose Melphalan Autologous Stem Cell Transplant in Patients with Multiple Myeloma. Biol Blood Marrow Transplant 2018. [DOI: 10.1016/j.bbmt.2017.12.096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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161
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Cho C, Flynn J, Devlin SM, Maloy M, Giralt SA, Koehne G, Maslak P, O'Reilly RJ, Smith K, Tonon JA, Avecilla ST, Perales MA. Universal Engraftment after Allogeneic HCT Using Cryopreserved CD34+ Cell-Selected Grafts. Biol Blood Marrow Transplant 2018. [DOI: 10.1016/j.bbmt.2017.12.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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162
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Bhatt V, Politikos I, Devlin SM, Jacob AG, Maloy M, Naputo K, Afuye A, Scaradavou A, O'Reilly RJ, Castro-Malaspina H, Dahi PB, Giralt SA, Gyurkocza B, Jakubowski AA, Papadopoulos EB, Peled JU, Hanash AM, Perales MA, Sauter CS, Shaffer BC, Shah GL, Tamari R, van den Brink MR, Young JW, Ponce DM, Barker JN. Therapeutic Cyclosporine-a (CSA) Levels in the First 7 Days after Cord Blood Transplantation (CBT) Are Critical to Prevent Severe Acute Graft-Versus-Host Disease (aGVHD). Biol Blood Marrow Transplant 2018. [DOI: 10.1016/j.bbmt.2017.12.298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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163
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Bryant A, Devlin SM, Castro-Malaspina H, Jakubowski AA, Maloy M, Papadopoulos EB, Giralt SA, Perales MA. Efficacy of Donor Lymphocyte Infusion in CD34+ Selected Allogeneic Hematopoietic Stem Cell Transplant for Myeloid and Lymphoid Malignancies: A Single Center Experience. Biol Blood Marrow Transplant 2018. [DOI: 10.1016/j.bbmt.2017.12.349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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164
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Scordo M, Bhatt V, Smith M, Thoren K, Hilden P, Cho C, Shah GL, Maloy M, Papadopoulos EB, Jakubowski AA, O'Reilly RJ, Castro-Malaspina H, Tamari R, Shaffer BC, Perales MA, Giralt SA. Empiric Anti-Thymocyte Globulin (ATG) Dosing in Ex-Vivo CD34-Selected Myeloablative Allogeneic Hematopoietic Cell Transplantation (Allo-HCT) May Result in ATG Overexposure That Negatively Affects Outcomes. Biol Blood Marrow Transplant 2018. [DOI: 10.1016/j.bbmt.2017.12.653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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165
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Lau C, Politikos I, Devlin SM, Jacob AG, Maloy M, Naputo K, Afuye A, Bhatt V, Dahi PB, Perales MA, Giralt SA, O'Reilly RJ, Ponce DM, Prockop SE, Shah GL, Papanicolaou GA, Scaradavou A, Barker JN. Analysis of Cytomegalovirus (CMV) Infections in the First 180 Days in Adult Sero-Positive Cord Blood Transplantation (CBT) Recipients Reveals High Infection Rates and Treatment Burden. Biol Blood Marrow Transplant 2018. [DOI: 10.1016/j.bbmt.2017.12.465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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166
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Lendvai N, Tsakos I, Devlin SM, Schaffer WL, Hassoun H, Lesokhin AM, Landau H, Korde N, Mailankody S, Smith E, Chung DJ, Koehne G, Shah GL, Alexander A, Patel M, Ballagi A, Grundberg I, Giralt SA, Landgren O. Predictive biomarkers and practical considerations in the management of carfilzomib-associated cardiotoxicity. Leuk Lymphoma 2018; 59:1981-1985. [PMID: 29308691 DOI: 10.1080/10428194.2017.1403020] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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167
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Tamari R, Oran B, Hilden P, Maloy M, Kongtim P, Papadopoulos EB, Rondon G, Jakubowski AA, Andersson BS, Devlin SM, Ahmed S, Popat UR, Ponce D, Chen J, Sauter C, Young JW, de Lima M, Perales MA, O'Reilly RJ, Giralt SA, Champlin RE, Castro-Malaspina H. Allogeneic Stem Cell Transplantation for Advanced Myelodysplastic Syndrome: Comparison of Outcomes between CD34 + Selected and Unmodified Hematopoietic Stem Cell Transplantation. Biol Blood Marrow Transplant 2018; 24:1079-1087. [PMID: 29325829 DOI: 10.1016/j.bbmt.2018.01.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 01/01/2018] [Indexed: 11/17/2022]
Abstract
In this study, we compared transplantation outcomes of allogeneic hematopoietic stem cell transplantation (HSCT) in patients with advanced myelodysplastic syndrome (MDS) who received a CD34+ cell-selected and those who received an unmodified allograft. This analysis initially included 181 patients, 60 who received a CD34+ cell-selected transplant and 121 who received an unmodified transplant. Owing to significant differences in disease characteristics, the analysis was limited to patients with <10% blasts before HSCT (n = 145). Two groups were defined: low risk, with low- and intermediate-risk cytogenetics (CD34+, n = 39; unmodified, n = 46), and high risk: poor and very poor risk cytogenetics (CD34+, n = 19; unmodified, n = 41). In the low-risk group, the incidence of grade II-IV acute graft-versus-host disease (aGVHD) at 1 year post-transplantation was 18% in the CD34+ subgroup versus 41.3% in the unmodified subgroup (P = .015). There were no differences between the subgroups in the incidence of grade III-IV aGVHD. The incidence of chronic graft-versus-host disease (cGVHD) at 3 years in the 2 subgroups was 5.3% and 56%, respectively (P < .001). At 3 years post-transplantation, relapse, overall survival (OS), and relapse-free survival (RFS) were similar in the CD34+ and unmodified subgroups: 8.1% versus 19.4% (P = .187), 58.5% versus 53.7% (P = .51), and 59.5% versus 52.4% (P = .448). However, the composite outcome combining extensive cGVHD-free status and relapse-free status (CRFS) at 3 years was 59.5% in the CD34+ group versus 19.2% in the unmodified group (P < .001). In the high-risk group, grade II-IV aGVHD at 1 year was 31.6% in the CD34+ subgroup versus 24.4% in the unmodified subgroup (P = .752). There were no differences between the subgroups in the incidence of grade III-IV aGVHD. The incidence of cGVHD at 3 years in the 2 subgroups was 0% versus 27.6% (P = .013). At 3 years post-transplantation, relapse, OS, RFS, and CRFS in the 2 subgroups were 31.6% versus 69.3% (P = .007), 35.5% versus 14.5% (P = .068), 31.6% versus 10.7% (P = .045), and 31.6% versus 6.1% (P = .001), respectively. Cytogenetic abnormalities at diagnosis and transplant type had significant univariate associations with RFS in the high-risk cohort. Only cytogenetics (P = .03) remained associated with this outcome in a multivariate model. OS was similar in the 2 transplant groups; however, CRFS was superior in the CD34+ cell-selected transplant group.
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168
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Bach PB, Giralt SA, Saltz LB. FDA Approval of Tisagenlecleucel: Promise and Complexities of a $475 000 Cancer Drug. JAMA 2017; 318:1861-1862. [PMID: 28975266 DOI: 10.1001/jama.2017.15218] [Citation(s) in RCA: 117] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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169
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Ghosh A, Mailankody S, Giralt SA, Landgren CO, Smith EL, Brentjens RJ. CAR T cell therapy for multiple myeloma: where are we now and where are we headed? Leuk Lymphoma 2017; 59:2056-2067. [PMID: 29105517 DOI: 10.1080/10428194.2017.1393668] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
While recent progress has been made in the management of multiple myeloma, it remains a highly fatal malignancy especially among patients with relapsed-refractory disease. Immunotherapy with adoptive T cells targeting myeloma-associated antigens are at various stages of development and have brought about a new hope for cure. This is a review on the emerging field of adoptively transferred engineered T cell based approaches, with an in-depth focus on chimeric antigen receptors (CAR) targeting multiple myeloma. The recent results from CAR T cells targeting B cell maturation antigen are encouraging but eventual resistance to the CAR T cell therapies remain problematic. With newer approaches in therapies for multiple myeloma, the role of transplantation is evolved to form a platform for T cell therapies.
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170
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Scordo M, Shah GL, Peled JU, Preston EV, Buchan ML, Epstein JB, Barasch A, Giralt SA. Unlocking the Complex Flavors of Dysgeusia after Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2017; 24:425-432. [PMID: 29051023 DOI: 10.1016/j.bbmt.2017.10.022] [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: 08/10/2017] [Accepted: 10/09/2017] [Indexed: 01/11/2023]
Abstract
Dysgeusia is a frequently occurring symptom after hematopoietic cell transplantation (HCT) that has important long-term effects on physical, nutritional, and immunologic recovery, as well as on quality of life. Despite the relevance of this symptom, the study of dysgeusia in patients undergoing HCT has been limited, owing in part to its complexity. In this article, we review normal taste function and its clinical evaluation, discuss how dysgeusia uniquely affects patients undergoing HCT, and examine distinct, transplantation-related contributors to dysgeusia that may help elucidate strategies to ultimately reduce this symptom burden after transplantation.
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171
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Shah GL, Scordo M, Kosuri S, Herrera DA, Cho C, Devlin SM, Borrill T, Carlow DC, Avecilla ST, Meagher RC, O'Reilly RJ, Jakubowski AA, Papadopoulos EB, Koehne G, Gyurkocza B, Castro-Malaspina H, Shaffer BC, Perales MA, Giralt SA, Tamari R. Impact of Toxicity on Survival for Older Adult Patients after CD34 + Selected Allogeneic Hematopoietic Stem Cell Transplantation. Biol Blood Marrow Transplant 2017; 24:142-149. [PMID: 28951193 DOI: 10.1016/j.bbmt.2017.08.040] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 08/29/2017] [Indexed: 11/27/2022]
Abstract
Ex vivo CD34+ selection before allogeneic hematopoietic stem cell transplantation (allo-HCT) reduces graft-versus-host disease without increasing relapse but usually requires myeloablative conditioning. We aimed to identify toxicity patterns in older patients and the association with overall survival (OS) and nonrelapse mortality (NRM). We conducted a retrospective analysis of 200 patients who underwent CD34+ selection allo-HCT using the ClinicMACS® system between 2006 and 2012. All grade 3 to 5 toxicities by CTCAE v4.0 were collected. Eighty patients aged ≥ 60 years with a median age of 64 (range, 60 to 73) were compared with 120 patients aged < 60 years. Median follow-up in survivors was 48.2 months. OS and NRM were similar between ages ≥ 60 and <60, with 1-year OS 70% versus 78% (P = .07) and 1-year NRM 23% versus 13% (P = .38), respectively. In patients aged ≥ 60 the most common toxicities by day 100 were metabolic, with a cumulative incidence of 88% (95% CI, 78% to 93%), infectious 84% (95% CI, 73% to 90%), hematologic 80% (95% CI, 69% to 87%), oral/gastrointestinal (GI) 48% (95% CI, 36% to 58%), cardiovascular (CV) 35% (95% CI, 25% to 46%), and hepatic 25% (95% CI, 16% to 35%). Patients aged ≥ 60 had a higher risk of neurologic (HR, 2.63 [95% CI, 1.45 to 4.78]; P = .001) and CV (HR, 1.65 [95% CI, 1.04 to 2.63]; P = .03) toxicities but a lower risk of oral/GI (HR, .58 [95% CI, .41 to .83]; P = .003) compared with those aged < 60. CV, hepatic, neurologic, pulmonary, and renal toxicities remained independent risk factors for the risk of death and NRM in separate multivariate models adjusting for age and hematopoietic cell transplantation-specific comorbidity index. Overall, the toxicity of a more intense regimen is potentially balanced by the absence of toxicity related to methotrexate and calcineurin inhibitors in older patients. Prospective study of toxicities after allo-HCT in older patients is essential.
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172
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Getta BM, Devlin SM, Levine RL, Arcila ME, Mohanty AS, Zehir A, Tallman MS, Giralt SA, Roshal M. Multicolor Flow Cytometry and Multigene Next-Generation Sequencing Are Complementary and Highly Predictive for Relapse in Acute Myeloid Leukemia after Allogeneic Transplantation. Biol Blood Marrow Transplant 2017; 23:1064-1071. [PMID: 28315400 PMCID: PMC9810388 DOI: 10.1016/j.bbmt.2017.03.017] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 03/12/2017] [Indexed: 01/05/2023]
Abstract
Minimal residual disease (MRD) in acute myeloid leukemia (AML) is typically measured using multiparameter flow cytometry (MFC). Detection of leukemia mutations using multigene next-generation sequencing (NGS) can potentially be used to measure residual disease. We used a targeted 28-gene NGS panel to detect mutations and different-from-normal 10-color MFC to measure MRD in AML patients before allogeneic hematopoietic stem cell transplantation (HCT). Residual disease was defined when any abnormal blast population was detected using MFC and when any leukemia allele was detected with a variant allele frequency (VAF) ≥ 5% using NGS. We tracked the clearance of leukemia alleles between AML diagnosis and immediately before HCT and found that mutations in DNMT3A, TET2, and JAK2 were less likely to be cleared than NPM1, IDH 1/2, and FLT3-ITD. Despite varying sensitivities, the concordance rate of residual disease detection before HCT using the 2 assays was 44 of 62 (71%) evaluable cases. Discordance could be explained by residual mutations in DNMT3A and TET2 that were not detected by MFC and presence of residual leukemia mutations with VAF below the established thresholds for mutation calling. Presence of flow MRD and residual mutations immediately before HCT using the 2 assays was associated with relapse risk (MFC: hazard ratio, 4.62; 95% confidence interval [CI], 1.32 to 16.09; P = .016 and NGS: hazard ratio, 4.35; 95% CI, 1.63 to 11.6; P = .003) and survival (MFC: hazard ratio, 2.44; 95% CI, 1 to 5.97; P = .05 and NGS: hazard ratio, 2.1; 95% CI, .97 to 4.55; P = .059) after HCT. Residual disease detected concurrently by MFC and NGS conferred the highest relapse risk compared with patients who were either negative by both assays or had discordant status (overall, P = .008). Although MFC is universally applicable, a multigene NGS approach to measuring residual disease in AML provides additional information on differential clearance of disease alleles and can assess clonal architecture before transplantation.
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173
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Huang YT, Kim SJ, Lee YJ, Burack D, Nichols P, Maloy M, Perales MA, Giralt SA, Jakubowski AA, Papanicolaou GA. Co-Infections by Double-Stranded DNA Viruses after Ex Vivo T Cell-Depleted, CD34 + Selected Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2017; 23:1759-1766. [PMID: 28668490 DOI: 10.1016/j.bbmt.2017.06.008] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 06/14/2017] [Indexed: 12/16/2022]
Abstract
Recipients of ex vivo T cell-depleted (TCD) hematopoietic cell transplantation (HCT) are at risk of infection by double-stranded (ds) DNA viruses. We report rates of dsDNA viremia, end-organ disease (EOD), infection-related mortality, and overall survival (OS) in a contemporary cohort of adult TCD HCT recipients routinely monitored for cytomegalovirus (CMV), adenovirus (ADV), human herpesvirus 6 (HHV6), and Epstein-Barr virus (EBV). Healthcare utilization in the first 6 months post-HCT was compared between patients with dsDNA viremia versus no viremia. This was an observational study of adult patients with acute leukemia and myelodysplastic syndrome who received CD34+ selected, peripheral blood HCT at Memorial Sloan Kettering Cancer Center from March 2012 through December 2014. Patients were prospectively monitored by quantitative PCR assays for CMV, ADV, HHV6, and EBV in whole blood or plasma. The cumulative incidence of viremia(s) at day +180, EOD at 1 year, and OS at 1 year were estimated by the Kaplan-Meier method and compared by the log-rank test among patient with and without viremia/EOD. Standardized incidence ratios were used to compare overall length of hospital stay (LOS), number of readmissions after HCT, and length of readmissions through day +180. Of 156 patients, 96 (62%) were CMV recipient seropositive. Forty-two patients received grafts from matched related (27%), 86 from matched unrelated (55%), and 28 from mismatched (18%) donors. Overall, 132 patients (85%) had ≥1 viremia and 52 (33%) ≥2 viremias by day +180. The cumulative incidences for CMV, HHV6, ADV, and EBV viremia were 44%, 61%, 7%, and 16%, respectively, with median times of onset 28 days (interquartile range [IQR], 25 to 33), 33 days (IQR, 25 to 47), 60 days (IQR, 19 to 84), and 79 days (IQR, 54 to 106) post-HCT, respectively. Twenty-eight patients (18%) developed EOD by dsDNA viruses at 1 year post-HCT. Treatment for CMV accounted for 91% total antiviral treatment-days. Compared with patients with no viremia, patients with CMV viremia, HHV6 viremia, or ≥2 viremias experienced longer LOS (P <.001) and a higher number of readmissions (P <.001) by day +180. OS rate at 1 year was 79% and was similar between patients with or without dsDNA viremias. EOD was associated with lower 1-year OS rates (63.4%) versus without EOD (81.1%) (P = .02). Of 33 patients who died, 10 died due to infection, and 7 of these infection-related deaths were due to dsDNA viruses. Viremia by dsDNA viruses occurred in 85% of TCD HCT recipients by day +100 and 33% of patients experienced ≥2 viremias by day +180. CMV accounted for most antiviral use. CMV, HHV6, or ≥2 viremias were associated with more readmissions and longer LOS. One year OS rate was 78%. EOD by dsDNA viruses was associated with decreased 1-year OS. Infections by dsDNA viruses pose a substantial burden after TCD HCT.
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174
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Hassoun H, Roshal M, Sabari J, Nguyen J, Gao Q, Devlin SM, Landau H, Lendvai N, Chung DJ, Lesokhin AM, Korde N, Mailankody S, Dogan A, Giralt SA, Landgren CO. Immunophenotypic evidence for reactive polyclonal marrow plasmacytosis in multiple myeloma patients receiving lenalidomide maintenance. Leuk Lymphoma 2017; 58:2962-2965. [DOI: 10.1080/10428194.2017.1312382] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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175
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Peled JU, Devlin SM, Staffas A, Lumish M, Khanin R, Littmann ER, Ling L, Kosuri S, Maloy M, Slingerland JB, Ahr KF, Porosnicu Rodriguez KA, Shono Y, Slingerland AE, Docampo MD, Sung AD, Weber D, Alousi AM, Gyurkocza B, Ponce DM, Barker JN, Perales MA, Giralt SA, Taur Y, Pamer EG, Jenq RR, van den Brink MRM. Intestinal Microbiota and Relapse After Hematopoietic-Cell Transplantation. J Clin Oncol 2017; 35:1650-1659. [PMID: 28296584 DOI: 10.1200/jco.2016.70.3348] [Citation(s) in RCA: 212] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Purpose The major causes of mortality after allogeneic hematopoietic-cell transplantation (allo-HCT) are relapse, graft-versus-host disease (GVHD), and infection. We have reported previously that alterations in the intestinal flora are associated with GVHD, bacteremia, and reduced overall survival after allo-HCT. Because intestinal bacteria are potent modulators of systemic immune responses, including antitumor effects, we hypothesized that components of the intestinal flora could be associated with relapse after allo-HCT. Methods The intestinal microbiota of 541 patients admitted for allo-HCT was profiled by means of 16S ribosomal sequencing of prospectively collected stool samples. We examined the relationship between abundance of microbiota species or groups of related species and relapse/progression of disease during 2 years of follow-up time after allo-HCT by using cause-specific proportional hazards in a retrospective discovery-validation cohort study. Results Higher abundance of a bacterial group composed mostly of Eubacterium limosum in the validation set was associated with a decreased risk of relapse/progression of disease (hazard ratio [HR], 0.82 per 10-fold increase in abundance; 95% CI, 0.71 to 0.95; P = .009). When the patients were categorized according to presence or absence of this bacterial group, presence also was associated with less relapse/progression of disease (HR, 0.52; 95% CI, 0.31 to 0.87; P = .01). The 2-year cumulative incidences of relapse/progression among patients with and without this group of bacteria were 19.8% and 33.8%, respectively. These associations remained significant in multivariable models and were strongest among recipients of T-cell-replete allografts. Conclusion We found associations between the abundance of a group of bacteria in the intestinal flora and relapse/progression of disease after allo-HCT. These might serve as potential biomarkers or therapeutic targets to prevent relapse and improve survival after allo-HCT.
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Sola M, Devlin SM, Maloy M, Dierov D, Barker JN, Castro-Malaspina H, Dahi P, Jakubowski AA, Koehne G, Papadopoulos EB, Sauter CS, Tamari R, van den Brink MR, Young JW, Giralt SA, Perales MA, Ponce DM. Graft-Versus Host Disease (GVHD Status and Severity Mediate Late Effects of Allogeneic Hematopoietic Stem Cell Transplantation (HSCT) in a 1-Year Landmark Analysis. Biol Blood Marrow Transplant 2017. [DOI: 10.1016/j.bbmt.2016.12.406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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177
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Scordo M, Shah GL, Kosuri S, Herrera DA, Cho C, Devlin SM, Maloy M, Nieves J, Borrill T, Carlow D, Avecilla ST, Meagher R, O'Reilly RJ, Koehne G, Gyurkocza B, Castro-Malaspina H, Tamari R, Perales MA, Giralt SA, Shaffer B. Post-Transplant Toxicities and Outcomes in Long-Term Survivors of Ex-Vivo CD34+ Selected Allogeneic Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2017. [DOI: 10.1016/j.bbmt.2016.12.405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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178
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Boughan KM, Dahi P, Devlin SM, Byam C, Yoo Y, Mazis C, Davis E, Nhaissi M, Paulson J, Wells DS, Cooper C, Ponce DM, Giralt SA, Papadopoulos EB, Kernan NA, Scaradavou A, Barker JN. Despite Increasing Size of Unrelated Donor (URD) Registries and the Global CB Inventory Racial Disparities in Access to URD and CB Grafts Persist: A Prospective 10 Year Analysis of 1,112 Patients. Biol Blood Marrow Transplant 2017. [DOI: 10.1016/j.bbmt.2016.12.283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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179
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Lahoud OB, Hilden P, Maloy M, Dahi P, Castro-Malaspina H, Giralt SA, Perales MA, Sauter CS. Prognostic Factors of CLL Patients Undergoing Reduced Intensity Allogeneic Hematopoietic Stem Cell Transplantation in the Immunochemotherapy Era. Biol Blood Marrow Transplant 2017. [DOI: 10.1016/j.bbmt.2016.12.414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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180
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Lau C, Bhatt V, Dahi P, Devlin SM, Yoo Y, Adel NG, Mazis C, Perales MA, Giralt SA, Koehne G, Ponce DM, Papanicolaou GA, Barker JN. Incidence, Severity, Day 100 Treatment Efficacy and Therapy Toxicity of Cytomegalovirus (CMV) Infections with Early Pre-Emptive Therapy in Adult Cord Blood (CB) Transplant Recipients. Biol Blood Marrow Transplant 2017. [DOI: 10.1016/j.bbmt.2016.12.371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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181
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Cho C, Hilden P, Politikos I, Borrill T, Ciolino C, Devlin SM, Maloy M, Smith K, Giralt SA, O'Reilly RJ, van den Brink MR, Perales MA. CMV Seropositivity and Viremia Drive T-Cell Reconstitution after CD34-Selected Allogeneic HCT. Biol Blood Marrow Transplant 2017. [DOI: 10.1016/j.bbmt.2016.12.344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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182
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Scordo M, Shah GL, Kosuri S, Herrera DAA, Hsu M, Devlin SM, Maloy M, Nieves J, Borrill T, Avecilla ST, Meagher R, O'Reilly RJ, Koehne G, Gyurkocza B, Castro-Malaspina H, Tamari R, Perales MA, Giralt SA, Shaffer B. Immune-Mediated Hemolytic Anemia (IMHA) and Immune Thrombocytopenia (ITP) after Ex-Vivo CD34+ Selected Allogeneic Hematopoietic Stem Cell Transplantation. Biol Blood Marrow Transplant 2017. [DOI: 10.1016/j.bbmt.2016.12.243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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183
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Shah GL, Scordo M, Kosuri S, Herrera DAA, Cho C, Maloy M, Nieves J, Devlin SM, Borrill T, Carlow D, Avecilla ST, Meagher R, O'Reilly RJ, Koehne G, Shaffer B, Perales MA, Gyurkocza B, Castro-Malaspina H, Giralt SA, Tamari R. Comparable Survival with Organ Toxicity Predicting for Overall Survival (OS) and Non-Relapse Mortality (NRM) in Older Adult Patients after CD34+ Selected Allogeneic Hematopoietic Stem Cell Transplantation (Allo-HCT). Biol Blood Marrow Transplant 2017. [DOI: 10.1016/j.bbmt.2017.01.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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184
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Politikos I, Devlin SM, Mazis C, Maloy M, Scaradavou A, Dahi P, Perales MA, Giralt SA, Ponce DM, Barker JN. A Novel Intermediate Intensity Conditioning Regimen Achieves High Rates of Long-Term Outpatient Progression-Free Survival Offsetting the Disadvantage of Early Post-Transplant Complications in Adult Cord Blood (CB) Transplant Recipients. Biol Blood Marrow Transplant 2017. [DOI: 10.1016/j.bbmt.2016.12.292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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185
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Costa LJ, Landau H, Chhabra S, Hari P, Innis-Shelton R, Saad A, Salzman D, Hamadani M, Tamari R, Williams L, Orlando E, Dixon P, Giralt SA. A Phase 1/2 Trial of Carfilzomib + High Dose Melphalan Conditioning for Auto-HCT Followed by Carfilzomib Maintenance for Patients with Relapsed Multiple Myeloma. Biol Blood Marrow Transplant 2017. [DOI: 10.1016/j.bbmt.2016.12.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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186
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Cho C, Devlin SM, Maloy M, Horowitz MM, Rizzo JD, Giralt SA, Perales MA. Application of the CIBMTR Survival Outcomes Calculator to CD34-Selected Allogeneic HCT for Acute Leukemia and Myelodysplastic Syndrome. Biol Blood Marrow Transplant 2017. [DOI: 10.1016/j.bbmt.2016.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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187
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Kosuri S, Herrera DAA, Scordo M, Shah GL, Devlin SM, Maloy M, Nieves J, Cho C, Borrill T, Carlow D, Avecilla ST, Meagher R, O'Reilly RJ, Koehne G, Gyurkocza B, Shaffer B, Castro-Malaspina H, Tamari R, Giralt SA, Perales MA. Toxicities and Outcomes in the First Year after Ex-Vivo CD34+ Selected Allogeneic Hematopoietic Cell Transplantation in Adults with Hematologic Malignancies. Biol Blood Marrow Transplant 2017. [DOI: 10.1016/j.bbmt.2016.12.196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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188
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Glezerman IG, Devlin S, Maloy M, Bui M, Jaimes EA, Giralt SA, Jakubowski AA. Long term renal survival in patients undergoing T-Cell depleted versus conventional hematopoietic stem cell transplants. Bone Marrow Transplant 2017; 52:733-738. [PMID: 28092350 PMCID: PMC5415423 DOI: 10.1038/bmt.2016.343] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 11/04/2016] [Accepted: 11/14/2016] [Indexed: 12/04/2022]
Abstract
Calcineurin inhibitor-sparing T cell depleted (TCD) hematopoietic stem cell transplants HSCTs are presumed less nephrotoxic than conventional HSCTs. We evaluated incidence and risk factors for kidney failure and chronic kidney disease (CKD) in 231 TCD and 212 conventional HSCT recipients. Kidney failure required a median glomerular filtration rate (GFR) <60 mL/min/1.73 m2 for ≥ 100 days anytime after 180 days post-HSCT. Two year cumulative incidence (CI) of kidney failure was 42% in the conventional vs. 31% in the TCD group (p=0.005). TCD, age, acute kidney injury and number of toxic CNI levels all impacted on kidney failure, which was associated with increased all-cause mortality (hazard ratio 2.86 (95% CI: 1.88–4.36), p <0.001). Renal recovery occurred in 28% of kidney failure patients, while the remaining patients were defined to have chronic kidney disease (CKD). In those with baseline GFR>60 mL/min/1.73 m2 only exposure to nephrotoxic medications was associated with CKD (p=0.033). In the myeloablative conditioning subgroup only total body irradiation was associated with CKD (p=0.013). Of all patients, five (1.13%) required dialysis. These results confirm an impact of TCD on kidney failure but not CKD for which other risk factors such as radiation or nephrotoxic drug exposure may play a role.
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Shah GL, Landau H, Londono D, Devlin SM, Kosuri S, Lesokhin AM, Lendvai N, Hassoun H, Chung DJ, Koehne G, Jhanwar SC, Landgren O, Levine R, Giralt SA. Gain of chromosome 1q portends worse prognosis in multiple myeloma despite novel agent-based induction regimens and autologous transplantation. Leuk Lymphoma 2017; 58:1823-1831. [PMID: 28078910 DOI: 10.1080/10428194.2016.1260126] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
We aimed to identify whether the use of autologous hematopoietic cell transplantation (HCT) impacts outcomes for multiple myeloma patients with gains of chromosome 1q (+1q). We retrospectively identified 95 patients, 21% having +1q. For patients with +1q, the overall response rate to induction was 85%, with 40% having ≥ VGPR and 20% achieving a CR, similar to non +1q patients (p = .64). The median PFS from diagnosis with +1q was 2.1 years (95% CI: 1.2-not reached (NR)) vs 4.3 years (95% CI: 3.3 yrs-NR) without +1q (p = .003). Median OS from diagnosis was 4.4 years (95% CI: 2.9-NR) vs not reached, respectively (p = .005). On molecular analysis using the Foundation One Heme assay, the most common mutations seen in +1q patients included TP53 (38%) and KRAS (25%). Overall, gain of 1q portends worse PFS and OS which was not negated by auto HCT. Such patients will likely require additional therapy to improve their survival.
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190
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Goldberg JD, Zheng J, Ratan R, Small TN, Lai KC, Boulad F, Castro-Malaspina H, Giralt SA, Jakubowski AA, Kernan NA, O'Reilly RJ, Papadopoulos EB, Young JW, van den Brink MRM, Heller G, Perales MA. Early recovery of T-cell function predicts improved survival after T-cell depleted allogeneic transplant. Leuk Lymphoma 2017; 58:1859-1871. [PMID: 28073320 DOI: 10.1080/10428194.2016.1265113] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Infection, relapse, and GVHD can complicate allogeneic hematopoietic stem cell transplantation (allo-HSCT). Although the effect of poor immune recovery on infection risk is well-established, there are limited data on the effect of immune reconstitution on relapse and survival, especially following T-cell depletion (TCD). To characterize the pattern of immune reconstitution in the first year after transplant and its effects on survival and relapse, we performed a retrospective study in 375 recipients of a myeloablative TCD allo-HSCT for hematologic malignancies. We noted that different subsets recover sequentially, CD8 + T cells first, followed by total CD4 + and naïve CD4 + T cells, indicating thymic recovery during the first year after HSCT. In the multivariate model, a fully HLA-matched donor and recovery of T-cell function, assessed by PHA response at 6 months, were the only factors independently associated with OS and EFS. In conclusion, T-cell recovery is an important predictor of outcome after TCD allo-HSCT.
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191
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Shah GL, Giralt SA. Recommend upfront consolidation with high-dose melphalan and autologous stem cell support. Semin Oncol 2016; 43:707-708. [PMID: 28061992 DOI: 10.1053/j.seminoncol.2016.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 11/07/2016] [Indexed: 11/11/2022]
Abstract
The overall goal of treatment for multiple myeloma (MM) is to prolong survival for as long as possible with the minimal treatment burden for each patient. Consolidation with upfront high-dose melphalan and autologous hematopoietic stem cell transplantation (ASCT) can prolong progression-free and overall survival by deepening response. It thereby can improve quality of life by allowing patients to have a time on maintenance therapy along with infrequent office visits, making it cost-effective in many situations. The impact of minimal residual disease (MRD) negativity is important, but further studies are needed to quantify the pharmacoeconomic and quality-of-life differences between early and delayed transplant strategies. Therefore, with the currently available evidence, upfront ASCT is standard of care regardless of MRD status.
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192
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Barba P, Ratan R, Cho C, Ceberio I, Hilden P, Devlin SM, Maloy MA, Barker JN, Castro-Malaspina H, Jakubowski AA, Koehne G, Papadopoulos EB, Ponce DM, Sauter C, Tamari R, van den Brink MRM, Young JW, O'Reilly RJ, Giralt SA, Perales MA. Hematopoietic Cell Transplantation Comorbidity Index Predicts Outcomes in Patients with Acute Myeloid Leukemia and Myelodysplastic Syndromes Receiving CD34 + Selected Grafts for Allogeneic Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2016; 23:67-74. [PMID: 27789361 DOI: 10.1016/j.bbmt.2016.10.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 10/15/2016] [Indexed: 12/20/2022]
Abstract
To evaluate the association between the hematopoietic cell transplantation-comorbidity index (HCT-CI) and the recently developed age-adjusted HCT-CI (HCT-CI/age) and transplant outcomes in the setting of CD34-selected allogeneic HCT, we analyzed a homogeneous population of patients undergoing allogeneic HCT with CD34-selected grafts for acute myeloid leukemia and myelodysplastic syndrome (n = 346). Median HCT-CI and HCT-CI/age scores were 2 (percentile 25 to 75, 1 to 4) and 3 (percentile 25 to 75, 1 to 5), respectively. Higher HCT-CI and HCT-CI/age scores were associated with higher nonrelapse mortality (NRM) and lower overall survival (OS). The HCT-CI distinguished 2 risk groups (0 to 2 versus ≥3), whereas, with the HCT-CI/age, there was a progressive increase in NRM and decrease in OS with increasing scores in all 4 groups (0 versus 1 to 2 versus 3 to 4 versus ≥5). Higher scores in both models were associated with lower chronic graft-versus-host disease relapse-free survival but not with higher relapse. Both models showed a promising predictive accuracy for NRM (c- = .616 for HCT-CI and c- = .647 for HCT-CI/age). In conclusion, the HCT-CI and HCT-CI/age predict transplant outcomes in CD34-selected allo-HCT, including NRM, OS, and chronic graft-versus-host disease relapse-free survival and may be used to select appropriate patients for this approach.
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193
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Scordo M, Bhatt V, Hsu M, Omuro AM, Matasar MJ, DeAngelis LM, Dahi PB, Moskowitz CH, Giralt SA, Sauter CS. A Comprehensive Assessment of Toxicities in Patients with Central Nervous System Lymphoma Undergoing Autologous Stem Cell Transplantation Using Thiotepa, Busulfan, and Cyclophosphamide Conditioning. Biol Blood Marrow Transplant 2016; 23:38-43. [PMID: 27713090 DOI: 10.1016/j.bbmt.2016.09.024] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 09/30/2016] [Indexed: 11/17/2022]
Abstract
High-dose therapy and autologous stem cell transplantation (ASCT) with thiotepa, busulfan, and cyclophosphamide (TBC) conditioning has emerged as an effective postinduction treatment strategy for patients with primary central nervous system lymphoma (PCNSL) or secondary central nervous system lymphoma (SCNSL), but it is associated with considerable toxicity and transplantation-related mortality (TRM) in the modern era. Forty-three adult patients with chemosensitive PCNSL or SCNSL underwent TBC-conditioned ASCT between 2006 and 2015. Twenty-eight of these patients received pharmacokinetically (PK)-targeted busulfan dosing. The median number of clinically relevant individual grade ≥3 nonhematologic toxicities per patient was 5. We found no association between pretransplantation patient characteristics and the presence of more than 5 grade ≥3 nonhematologic toxicities. Patients with elevated first-dose busulfan area under the curve values did not experience more toxicity. Paradoxically, patients treated with more than 2 regimens before undergoing ASCT had lower first-dose busulfan AUC values. With a median follow-up among survivors of 20 months, 1-year progression-free survival (PFS) and overall survival (OS) from the time of ASCT were 83% and 87%, respectively. Although this study reaffirms the favorable PFS and OS associated with TBC-conditioned ASCT for PCNSL or SCNSL, this treatment strategy carries a large toxicity burden.
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194
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Qazilbash MH, Wieder E, Thall PF, Wang X, Rios R, Lu S, Kanodia S, Ruisaard KE, Giralt SA, Estey EH, Cortes J, Komanduri KV, Clise-Dwyer K, Alatrash G, Ma Q, Champlin RE, Molldrem JJ. PR1 peptide vaccine induces specific immunity with clinical responses in myeloid malignancies. Leukemia 2016; 31:697-704. [PMID: 27654852 PMCID: PMC5332281 DOI: 10.1038/leu.2016.254] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2016] [Revised: 06/27/2016] [Accepted: 07/12/2016] [Indexed: 01/29/2023]
Abstract
PR1, an HLA-A2-restricted peptide derived from both proteinase 3 and neutrophil elastase, is recognized on myeloid leukemia cells by cytotoxic T lymphocytes (CTL) that preferentially kill leukemia and contribute to cytogenetic remission. To evaluate safety, immunogenicity and clinical activity of PR1 vaccination, a phase I/II trial was conducted. Sixty-six HLA-A2+ patients with acute myeloid leukemia (AML: 42), chronic myeloid leukemia (CML: 13) or myelodysplastic syndrome (MDS: 11) received three to six PR1 peptide vaccinations, administered subcutaneously every 3 weeks at dose levels of 0.25, 0.5 or 1.0 mg. Patients were randomized to the 3 dose levels after establishing the safety of the highest dose level. Primary endpoints were safety and immune response, assessed by doubling of PR1/HLA-A2 tetramer-specific CTL, and the secondary endpoint was clinical response. Immune responses were noted in 35 of 66 (53%) patients. Of the 53 evaluable patients with active disease, 12 (24%) had objective clinical responses (complete: 8, partial: 1 and hematological improvement: 3). PR1-specific immune response was seen in 9 of 25 clinical responders vs. 3 of 28 clinical non-responders (p=0.03). In conclusion, PR1 peptide vaccine induces specific immunity that correlates with clinical responses, including molecular remission, in AML, CML and MDS patients.
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Murata K, McCash SI, Carroll B, Lesokhin AM, Hassoun H, Lendvai N, Korde NS, Mailankody S, Landau HJ, Koehne G, Chung DJ, Giralt SA, Ramanathan LV, Landgren O. Treatment of multiple myeloma with monoclonal antibodies and the dilemma of false positive M-spikes in peripheral blood. Clin Biochem 2016; 51:66-71. [PMID: 27664535 DOI: 10.1016/j.clinbiochem.2016.09.015] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 08/28/2016] [Accepted: 09/19/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To characterize the effect of three humanized IgG κ monoclonal antibodies (daratumumab, isatuximab, and elotuzumab) on the interpretation of results generated by protein electrophoresis, immunofixation, free light chain, and heavy/light chain assays performed on human serum. METHODS Healthy volunteer serum and serum from multiple myeloma patients were supplemented with clinically relevant concentrations of each of the three monoclonal antibodies. These specimens then underwent analysis via serum protein electrophoresis, immunofixation, serum free light chain quantification, heavy/light chain quantification, total IgG, and total protein. In addition, serum specimens from patients who had undergone treatment with elotuzumab for multiple myeloma underwent similar analysis. RESULTS Addition of the study drugs to serum from both the healthy donor as well as multiple myeloma patients resulted in a visible and quantifiable M-protein on SPEP and a visible IgGκ band by IFE. Increases were also noted in total IgG, IgGκ, and IgGκ/IgGλ-ratios. Analysis of serum from multiple myeloma patients receiving study drug showed similar findings with an additional IgGκ band and quantifiable M-protein with similar migration patterns in specimens drawn after administration. CONCLUSION The treatment of multiple myeloma patients with monoclonal antibodies results in a visible and quantifiable M-protein that has the potential to falsely indicate poor response to therapy.
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Harris B, Morjaria SM, Littmann ER, Geyer AI, Stover DE, Barker JN, Giralt SA, Taur Y, Pamer EG. Gut Microbiota Predict Pulmonary Infiltrates after Allogeneic Hematopoietic Cell Transplantation. Am J Respir Crit Care Med 2016; 194:450-63. [PMID: 26886180 PMCID: PMC5003327 DOI: 10.1164/rccm.201507-1491oc] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 02/16/2016] [Indexed: 12/21/2022] Open
Abstract
RATIONALE Pulmonary complications (PCs) cause significant morbidity and mortality after allogeneic hematopoietic stem cell transplantation (HCT). Shifts in gut microbiota have been linked to HCT outcomes; however, their effect on PCs is unknown. OBJECTIVES To investigate whether changes in gut microbiota are associated with PCs after HCT. METHODS A single-center observational study was performed on 94 patients who underwent HCT from 2009 to 2011 and who were previously enrolled in a protocol for 16S ribosomal RNA sequencing of fecal microbiota. The primary endpoint, PC, was defined by new abnormal parenchymal findings on chest imaging in the setting of respiratory signs and/or symptoms. Outcomes were collected up to 40 months after transplant. Clinical and microbiota risk factors for PCs and mortality were evaluated using survival analysis. MEASUREMENTS AND MAIN RESULTS One hundred twelve PCs occurred in 66 (70.2%) subjects. A high comorbidity index (hazard ratio [HR], 2.30; 95% confidence interval [CI], 1.30-4.00; P = 0.004), fluoroquinolones (HR, 2.29, 95% CI, 1.32-3.98; P = 0.003), low baseline diversity (HR, 2.63; 95% CI, 1.22-5.32; P = 0.015), and γ-proteobacteria domination of fecal microbiota (HR, 2.64; 95% CI, 1.10-5.65; P = 0.031), which included common respiratory pathogens, predicted PCs. In separate analyses, low baseline diversity was associated with PCs that occurred preengraftment (HR, 6.30; 95% CI, 1.42-31.80; P = 0.016), whereas γ-proteobacteria domination predicted PCs postengraftment (HR, 3.68; 95% CI, 1.49-8.21; P = 0.006) and overall mortality (HR, 3.52; 95% CI, 1.28-9.21; P = 0.016). Postengraftment PCs were also independent predictors of death (HR, 2.50; 95% CI, 1.25-5.22; P = 0.009). CONCLUSIONS This is the first study to demonstrate prospective changes in gut microbiota associated with PCs after HCT. Postengraftment PCs and γ-proteobacteria domination were predictive of mortality. This suggests an adverse relationship between the graft and lung, which is perhaps mediated by bacterial composition in the gut. Further study is warranted.
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Spitzer B, Perales MA, Kernan NA, Prockop SE, Zabor EC, Webb N, Castro-Malaspina H, Papadopoulos EB, Young JW, Scaradavou A, Kobos R, Giralt SA, O'Reilly RJ, Boulad F. Second Allogeneic Stem Cell Transplantation for Acute Leukemia Using a Chemotherapy-Only Cytoreduction with Clofarabine, Melphalan, and Thiotepa. Biol Blood Marrow Transplant 2016; 22:1449-1454. [PMID: 27184623 DOI: 10.1016/j.bbmt.2016.05.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 05/02/2016] [Indexed: 01/07/2023]
Abstract
Relapse after allogeneic hematopoietic stem cell transplantation (alloHSCT) remains one of the leading causes of mortality in patients with leukemia. Treatment options in this population remain limited, with concern for both increased toxicity and further relapse. We treated 18 patients with acute leukemia for marrow ± extramedullary relapse after a previous alloHSCT with a myeloablative cytoreductive regimen including clofarabine, melphalan, and thiotepa followed by a second or third transplantation from the same or a different donor. All patients were in remission at the time of the second or third transplantation. All evaluable patients engrafted. The most common toxicity was reversible transaminitis associated with clofarabine. Two patients died from transplantation-related causes. Seven patients relapsed after their second or third transplanation and died of disease. Nine of 18 patients are alive and disease free, with a 3-year 49% probability of overall survival (OS). Patients whose remission duration after initial alloHSCT was >6 months achieved superior outcomes (3-year OS, 74%, 95% confidence interval, 53% to 100%), compared with those relapsing within 6 months (0%) (P < .001). This new cytoreductive regimen has yielded promising results with acceptable toxicity for second or third transplantations in patients with high-risk acute leukemia who relapsed after a prior transplantation, using various graft and donor options. This approach merits further evaluation in collaborative group studies.
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Huang YT, Neofytos D, Foldi J, Kim SJ, Maloy M, Chung D, Castro-Malaspina H, Giralt SA, Papadopoulos E, Perales MA, Jakubowski AA, Papanicolaou GA. Cytomegalovirus Infection after CD34(+)-Selected Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2016; 22:1480-1486. [PMID: 27178374 DOI: 10.1016/j.bbmt.2016.05.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Accepted: 05/03/2016] [Indexed: 11/16/2022]
Abstract
The effectiveness of preemptive treatment (PET) for cytomegalovirus (CMV) in recipients of ex vivo T cell-depleted (TCD) hematopoietic cell transplantation (HCT) by CD34(+) selection is not well defined. We analyzed 213 adults who received TCD-HCT at our institution from June 2010 through May 2014. Patients were monitored by a CMV quantitative PCR assay if recipient (R) or donor (D) were CMV seropositive. CMV viremia occurred early (median, 27 days after HCT) in 91 of 213 (42.7%) patients for a 180-day cumulative incidence of 84.5%, 61.8%, and 0 for R+/D+, R+/D-, and R-/D+ patients, respectively. CMV disease occurred in 5% of patients. In Cox regression analysis, R+/D+ status was associated with increased risk for CMV viremia compared with R+/D- (hazard ratio [HR], 1.79, 95% confidence interval [CI], 1.16 to 2.76, P = .01), whereas matched unrelated donor allograft was associated with decreased risk (HR, .62; 95% CI, .39 to .97, P = .04). Of 91 patients with CMV viremia, 52 (57%) had persistent viremia (>28 days duration). Time lag from detection of CMV viremia to PET was associated with incremental risk for persistent viremia (HR, 1.09; 95% CI, 1.01 to 1.18; P = .03). Overall, 166 of 213 (77.9%) patients were alive 1 year after HCT, with no difference between patients with and without CMV viremia or among the different CMV serostatus pairs (P = not significant). CMV viremia occurred in 70% of R + TCD-HCT. Delay in PET initiation was associated with persistent viremia. With PET, CMV R/D serostatus did not adversely impact survival in TCD-HCT on 1-year survival in the present cohort.
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199
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Malek E, de Lima M, Letterio JJ, Kim BG, Finke JH, Driscoll JJ, Giralt SA. Myeloid-derived suppressor cells: The green light for myeloma immune escape. Blood Rev 2016; 30:341-8. [PMID: 27132116 DOI: 10.1016/j.blre.2016.04.002] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 03/28/2016] [Accepted: 04/01/2016] [Indexed: 01/04/2023]
Abstract
Myeloid-derived suppressor cells (MDSCs) are a heterogeneous, immature myeloid cell population with the ability to suppress innate and adaptive immune responses that promote tumor growth. MDSCs are increased in patients with multiple myeloma (MM) and have bidirectional interaction with tumors within the MM microenvironment. MM-MDSCs promote MM tumor growth and induce immune suppression; conversely, MM cells induce MDSC development and survival. Although the role of MDSCs in infections, inflammatory diseases and solid tumors has been extensively characterized, their tumor-promoting and immune-suppressive role in MM and the MM microenvironment is only beginning to emerge. The presence and activation of MDSCs in MM patients has been well documented; however, the direct actions and functional consequences of MDSCs on cancer cells is poorly defined. Immunosuppressive MDSCs play an important role in tumor progression primarily because of their capability to promote immune-escape, angiogenesis, drug resistance and metastasis. However, their role in the bone marrow (BM), the primary MM site, is poorly understood. MM remains an incurable malignancy, and it is likely that the BM microenvironment protects MM against chemotherapy agents and the host immune system. A growing body of evidence suggests that host immune cells with a suppressive phenotype contribute to a myeloma immunosuppressive network. Among the known suppressor cells, MDSCs and T regulatory cells (Tregs) have been found to be significantly increased in myeloma patients and their levels correlate with disease stage and clinical outcome. Furthermore, it has been shown that MDSC can mediate suppression of myeloma-specific T-cell responses through the induction of T-cell anergy and Treg development in the MM microenvironment. Here, we review clinical correlations and the preclinical proof-of-principle data on the role of MDSCs in myeloma immunotolerance and highlight the mechanistically relevant MDSC-targeted compounds and their potential utility in a new approach for anti-myeloma therapy.
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Kosuri S, Hilden P, Devlin SM, Yoo Y, Lauer E, Peled JU, Avecilla S, Castro-Malaspina H, Dahi P, Giralt SA, Gyurkocza B, Jakubowski AA, Meagher R, Papadopoulos E, Perales MA, Reich L, Sauter CS, Scaradavou A, Shaffer B, Tamari R, van den Brink MR, Young JW, Ponce DM, Barker JN. High Progression-Free Survival (PFS) in Adult Double Unit Cord Blood (dCB) Transplant Recipients with High Risk Disease after a Novel Intermediate Intensity Conditioning Regimen. Biol Blood Marrow Transplant 2016. [DOI: 10.1016/j.bbmt.2015.11.370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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