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Rosser SPA, Brewer A, Gabriel M, Wong M, Chung J, McLachlan AJ, Nath CE, Keogh SJ, Shaw PJ. Outcomes from hematopoietic stem cell transplantation following treosulfan-based conditioning: A clinical and pharmacokinetic analysis. Pediatr Transplant 2024; 28:e14780. [PMID: 38766999 DOI: 10.1111/petr.14780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 02/01/2024] [Accepted: 04/29/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND The aims of this study are to report our experience with treosulfan-based conditioning regimens for patients with non-malignant hematologic conditions, correlating clinical outcomes at different time points post-transplant with treosulfan exposure (AUC). METHODS This study was a single-center observational study investigating overall survival (OS), disease-free survival (DFS), and event-free survival (EFS) end-points post-transplant. The consequences of treosulfan AUC with respect to toxicity, correction of underlying disease, and long-term chimerism were also explored using pharmacokinetic analysis. RESULTS Forty-six patients received 49 transplants with treosulfan and fludarabine-based conditioning between 2005 and 2023. Twenty-four patients also received thiotepa. Donor chimerism was assessed on either whole blood or sorted cell lines at different time points post-transplant. Thirty-nine patients received treosulfan pharmacokinetic assessment to evaluate cumulative AUC, with five infants receiving real-time assessment to facilitate daily dose adjustment. OS, DFS, and EFS were 87%, 81%, and 69%, respectively. Median follow-up was 32.1 months (range 0.82-160 months) following transplant. Lower EFS was associated with patient age (<1 year; p = .057) and lower cumulative treosulfan dose (<42 g/m2; p = .003). Stable donor chimerism in B-cell, NK-cell, and granulocyte lineages at 1-year post-transplant were more prevalent in patients receiving thiotepa conditioning. Two infants required daily dose adjustment to treosulfan to avoid high AUC. CONCLUSIONS Excellent clinical outcomes and stable chimerism were observed in this patient series. The addition of thiotepa conferred no significant toxicity and trended toward sustained ongoing donor engraftment. Correlating treosulfan AUC with long-term patient outcomes is required.
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Affiliation(s)
- Sebastian P A Rosser
- The Children's Hospital at Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
- Cancer Centre for Children, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
- Department of Biochemistry, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Alice Brewer
- Cancer Centre for Children, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Melissa Gabriel
- Cancer Centre for Children, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Melanie Wong
- Cancer Centre for Children, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Jason Chung
- The Children's Hospital at Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
- Department of Biochemistry, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Andrew J McLachlan
- Sydney Pharmacy School, The University of Sydney, Sydney, New South Wales, Australia
| | - Christa E Nath
- Cancer Centre for Children, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
- Department of Biochemistry, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
- Sydney Pharmacy School, The University of Sydney, Sydney, New South Wales, Australia
| | - Steven J Keogh
- Cancer Centre for Children, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Peter J Shaw
- The Children's Hospital at Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
- Cancer Centre for Children, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
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2
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Uzay A, Gündoğdu Y, Koşan B, Yetiş T, Kartı SS. Treosulfan is a safe and effective alternative to busulfan for conditioning in adult allogeneic HSCT patients: Data from a single center. Cancer Med 2024; 13:e7292. [PMID: 38752476 PMCID: PMC11097247 DOI: 10.1002/cam4.7292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 05/02/2024] [Accepted: 05/05/2024] [Indexed: 05/19/2024] Open
Abstract
INTRODUCTION Type of conditioning regimen impacts the outcome of patients who undergo allogeneic HSCT since graft versus host disease (GVHD), infections, regimen related toxicities (RRT) are important causes of post-transplant mortality. Despite the RRT profile of busulfan, it is frequently used worldwide. Treosulfan has advantages in terms of dose of administration, lower incidence of sinusoidal obstruction syndrome and lower neurotoxicity. We retrospectively investigated outcomes of patients who underwent allogeneic HSCT with treosulfan or busulfan based conditioning regimens in our institution. METHODS Treosulfan was administered to 94 patients while 85 patients received busulfan. Our outcomes were RRT, chronic and acute GVHD, relapse related mortality (RRM), non-relapse mortality, and fungal infection. The clinical follow up data, regarding the primary and secondary endpoints of our study, of the patients who received treosulfan or busulfan based conditioning regimens were statistically analyzed. RESULTS The median follow-up was 14 months for the treosulfan group while it was 11 months for the busulfan group (p = 0.16). RRT was 11.7% and 7.1% for treosulfan and busulfan respectively. The incidence of extensive chronic GVHD was less frequent in the treosulfan group compared to the busulfan group (15.7% vs. 32.1%) (p < 0.001). The incidence of acute GVHD (Grade 3 or higher) was 32.2% in the treosulfan group while it was 31.6% in the busulfan group. The RRM was 17% in the treosulfan group while it was 34% in the busulfan group. The non-relapse mortality was 35.5% and 29.4% in the treosulfan group and in the busulfan group respectively (p = 0.962). CONCLUSION Treosulfan, with a lower RRM, lower chronic GVHD incidence and with a similar RRT profile appears to be a safe alternative to busulfan.
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Affiliation(s)
- Ant Uzay
- School of Medicine, Department of Hematology and Stem Cell TransplantationAcıbadem Mehmet Ali Aydınlar UniversityIstanbulTurkey
| | - Yasemin Gündoğdu
- School of Medicine, Department of Internal MedicineAcıbadem Mehmet Ali Aydınlar UniversityIstanbulTurkey
| | - Barış Koşan
- School of Medicine, Department of Internal MedicineAcıbadem Mehmet Ali Aydınlar UniversityIstanbulTurkey
| | - Tuğba Yetiş
- School of Medicine, Clinical NursingAcıbadem Mehmet Ali Aydınlar UniversityIstanbulTurkey
| | - S. Sami Kartı
- School of Medicine, Department of Hematology and Stem Cell TransplantationAcıbadem Mehmet Ali Aydınlar UniversityIstanbulTurkey
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3
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Wadbudhe AM, Meshram RJ, Tidke SC. Severe Combined Immunodeficiency (SCID) and Its New Treatment Modalities. Cureus 2023; 15:e47759. [PMID: 38022338 PMCID: PMC10676291 DOI: 10.7759/cureus.47759] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 10/26/2023] [Indexed: 12/01/2023] Open
Abstract
Severe combined immunodeficiency (SCID) is a rare condition with very high mortality. SCID is mainly caused by the multiple mutations of genes affecting the entire immune cells. Children with this disease are born with an impaired immune system. The child appears healthy but the consequences of the impaired immune system lead to various secondary infections such as meningeal infections and respiratory infections further leading to consolidation, diarrhea, inflammation of skin and other systemic diseases. Severe combined immunodeficiency is also known as "bubble boy disease" or "living in the bubble" syndrome, as in early days for treatment the physicians decided to completely isolate them until they got the perfect match for the bone marrow transplantation. It is one of the pediatric emergencies and is to be treated as soon as possible. SCID involves multiple genes which leads to makes diagnosis of the disease cumbersome. In early years many infants were diagnosed almost after half a year and in severe conditions which led to the decrease in the survival rate of the children. But now due to advanced newborn screening modalities and other monitoring systems it can be diagnosed as early as within three months of age. The various treatment modalities include hematopoietic stem cell transplantation, gene therapy, enzyme replacement therapy and chemotherapy. This narrative review article describes about the severe combined immunodeficiency and its newer treatment modalities.
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Affiliation(s)
- Akshad M Wadbudhe
- Department of Paediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Revat J Meshram
- Department of Paediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Shivangi C Tidke
- Department of Paediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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4
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Slatter M, Lum SH. Personalized hematopoietic stem cell transplantation for inborn errors of immunity. Front Immunol 2023; 14:1162605. [PMID: 37090739 PMCID: PMC10113466 DOI: 10.3389/fimmu.2023.1162605] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 03/20/2023] [Indexed: 04/08/2023] Open
Abstract
Patients with inborn errors of immunity (IEI) have been transplanted for more than 50 years. Many long-term survivors have ongoing medical issues showing the need for further improvements in how hematopoietic stem cell transplantation (HSCT) is performed if patients in the future are to have a normal quality of life. Precise genetic diagnosis enables early treatment before recurrent infection, autoimmunity and organ impairment occur. Newborn screening for severe combined immunodeficiency (SCID) is established in many countries. For newly described disorders the decision to transplant is not straight-forward. Specific biologic therapies are effective for some diseases and can be used as a bridge to HSCT to improve outcome. Developments in reduced toxicity conditioning and methods of T-cell depletion for mismatched donors have made transplant an option for all eligible patients. Further refinements in conditioning plus precise graft composition and additional cellular therapy are emerging as techniques to personalize the approach to HSCT for each patient.
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Affiliation(s)
- Mary Slatter
- Paediatric Immunology and HSCT, Newcastle University, Newcastle upon Tyne, United Kingdom
- Translational and Clinical Research Institute, Great North Children’s Hospital, Newcastle upon Tyne, United Kingdom
| | - Su Han Lum
- Paediatric Immunology and HSCT, Newcastle University, Newcastle upon Tyne, United Kingdom
- Translational and Clinical Research Institute, Great North Children’s Hospital, Newcastle upon Tyne, United Kingdom
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5
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DeFilipp Z, Hefazi M, Chen YB, Blazar BR. Emerging approaches to improve allogeneic hematopoietic cell transplantation outcomes for nonmalignant diseases. Blood 2022; 139:3583-3593. [PMID: 34614174 PMCID: PMC9728560 DOI: 10.1182/blood.2020009014] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 10/04/2021] [Indexed: 12/14/2022] Open
Abstract
Many congenital or acquired nonmalignant diseases (NMDs) of the hematopoietic system can be potentially cured by allogeneic hematopoietic cell transplantation (HCT) with varying types of donor grafts, degrees of HLA matching, and intensity of conditioning regimens. Unique features that distinguish the use of allogeneic HCT in this population include higher rates of graft failure, immune-mediated cytopenias, and the potential to achieve long-term disease-free survival in a mixed chimerism state. Additionally, in contrast to patients with hematologic malignancies, a priority is to completely avoid graft-versus-host disease in patients with NMD because there is no theoretical beneficial graft-versus-leukemia effect that can accompany graft-versus-host responses. In this review, we discuss the current approach to each of these clinical issues and how emerging novel therapeutics hold promise to advance transplant care for patients with NMDs.
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Affiliation(s)
- Zachariah DeFilipp
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | | | - Yi-Bin Chen
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - Bruce R. Blazar
- Department of Pediatrics, Division of Blood & Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, MN
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6
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王 子, 孟 岩, 窦 颖, 管 贤, 张 璐, 于 洁. [Clinical effect of allogeneic hematopoietic stem cell transplantation in children with hyper-IgM syndrome]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2022; 24:635-642. [PMID: 35762429 PMCID: PMC9250404 DOI: 10.7499/j.issn.1008-8830.2112098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 05/09/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES To evaluate the clinical effect of allogeneic hematopoietic stem cell transplantation (allo-HSCT) in children with hyper-IgM syndrome (HIGM). METHODS A retrospective analysis was performed on the medical data of 17 children with HIGM who received allo-HSCT. The Kaplan Meier method was used for the survival analysis of the children with HIGM after allo-HSCT. RESULTS After allo-HSCT, 16 children were diagnosed with sepsis; 14 tested positive for virus within 100 days after allo-HSCT, among whom 11 were positive for Epstein-Barr virus, 7 were positive for cytomegalovirus, and 2 were positive for JC virus; 9 children were found to have invasive fungal disease. There were 6 children with acute graft-versus-host disease and 3 children with chronic graft-versus-host disease. The median follow-up time was about 2 years, and 3 children died in the early stage after allo-HSCT. The children had an overall survival (OS) rate of 82.35%, an event-free survival (EFS) rate of 70.59%, and a disease-free survival (DFS) rate of 76.47%. The univariate analysis showed that the children receiving HLA-matched allo-HSCT had a significantly higher EFS rate than those receiving HLA-mismatched allo-HSCT (P=0.019) and that the children receiving HLA-matched unrelated allo-HSCT had significantly higher OS, EFS, and DFS rates than those receiving HLA-mismatched unrelated allo-HSCT (P<0.05). Compared with the children with fungal infection after allo-HSCT, the children without fungal infection had significantly higher EFS rate (P=0.02) and DFS rate (P=0.04). CONCLUSIONS Allo-HSCT is an effective treatment method for children with HIGM. HLA-matched allo-HSCT and active prevention and treatment of fungal infection and opportunistic infection may help to improve the prognosis of such children.
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7
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Day JW, Elfeky R, Nicholson B, Goodman R, Pearce R, Fox TA, Worth A, Booth C, Veys P, Carpenter B, Hough R, Gaspar HB, Titman P, Ridout D, Workman S, Hernandes F, Sandford K, Laurence A, Campbell M, Burns SO, Morris EC. Retrospective, Landmark Analysis of Long-term Adult Morbidity Following Allogeneic HSCT for Inborn Errors of Immunity in Infancy and Childhood. J Clin Immunol 2022; 42:1230-1243. [PMID: 35579633 PMCID: PMC9537214 DOI: 10.1007/s10875-022-01278-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 04/22/2022] [Indexed: 11/28/2022]
Abstract
Purpose
Allogeneic hematopoietic stem cell transplant (HSCT) remains the treatment of choice for patients with inborn errors of immunity (IEI). There is little published medical outcome data assessing late medical complications following transition to adult care. We sought to document event-free survival (EFS) in transplanted IEI patients reaching adulthood and describe common late-onset medical complications and factors influencing EFS. Methods In this landmark analysis, 83 adults surviving 5 years or more following prior HSCT in childhood for IEI were recruited. The primary endpoint was event-free survival, defined as time post-first HSCT to graft failure, graft rejection, chronic infection, life-threatening or recurrent infections, malignancy, significant autoimmune disease, moderate to severe GVHD or major organ dysfunction. All events occurring less than 5 years post-HSCT were excluded. Results EFS was 51% for the whole cohort at a median of 20 years post HSCT. Multivariable analysis identified age at transplant and whole blood chimerism as independent predictors of long-term EFS. Year of HSCT, donor, conditioning intensity and underlying diagnosis had no significant impact on EFS. 59 events occurring beyond 5 years post-HSCT were documented in 37 patients (45% cohort). A total of 25 patients (30% cohort) experienced ongoing significant complications requiring active medical intervention at last follow-up. Conclusion Although most patients achieved excellent, durable immune reconstitution with infrequent transplant-related complications, very late complications are common and associated with mixed chimerism post-HSCT. Early intervention to correct mixed chimerism may improve long-term outcomes and adult health following HSCT for IEI in childhood. Supplementary Information The online version contains supplementary material available at 10.1007/s10875-022-01278-6.
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Affiliation(s)
- James W Day
- Department of Immunology, Royal Free London Hospitals NHS Foundation Trust, London, UK.,University College London Hospitals NHS Foundation Trust, London, UK
| | - Reem Elfeky
- Department of Immunology, Royal Free London Hospitals NHS Foundation Trust, London, UK
| | - Bethany Nicholson
- Department of Immunology, Royal Free London Hospitals NHS Foundation Trust, London, UK
| | - Rupert Goodman
- Department of Immunology, Royal Free London Hospitals NHS Foundation Trust, London, UK
| | | | - Thomas A Fox
- University College London Hospitals NHS Foundation Trust, London, UK.,UCL Institute of Immunity & Transplantation, London, UK
| | - Austen Worth
- Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Claire Booth
- Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK.,UCL Great Ormond Street Institute of Child Health, London, UK
| | - Paul Veys
- Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Ben Carpenter
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Rachael Hough
- University College London Hospitals NHS Foundation Trust, London, UK
| | - H Bobby Gaspar
- Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK.,UCL Great Ormond Street Institute of Child Health, London, UK
| | - Penny Titman
- Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Deborah Ridout
- UCL Great Ormond Street Institute of Child Health, London, UK
| | - Sarita Workman
- Department of Immunology, Royal Free London Hospitals NHS Foundation Trust, London, UK
| | - Fernando Hernandes
- Department of Immunology, Royal Free London Hospitals NHS Foundation Trust, London, UK
| | | | - Arian Laurence
- Department of Immunology, Royal Free London Hospitals NHS Foundation Trust, London, UK.,University College London Hospitals NHS Foundation Trust, London, UK
| | - Mari Campbell
- Department of Immunology, Royal Free London Hospitals NHS Foundation Trust, London, UK.,UCL Institute of Immunity & Transplantation, London, UK
| | - Siobhan O Burns
- Department of Immunology, Royal Free London Hospitals NHS Foundation Trust, London, UK.,UCL Institute of Immunity & Transplantation, London, UK
| | - Emma C Morris
- Department of Immunology, Royal Free London Hospitals NHS Foundation Trust, London, UK. .,University College London Hospitals NHS Foundation Trust, London, UK. .,UCL Institute of Immunity & Transplantation, London, UK.
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8
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Umeda K. Unresolved issues in allogeneic hematopoietic cell transplantation for non-malignant diseases. Int J Hematol 2022; 116:41-47. [PMID: 35568772 DOI: 10.1007/s12185-022-03361-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 04/14/2022] [Accepted: 04/19/2022] [Indexed: 11/27/2022]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) can be curative for a variety of non-malignant diseases (NMDs) as well as hematological malignancies. However, there are several fundamental differences between HCT for NMDs and hematological malignancies, which may necessitate the use of alternative HCT strategies. For example, these diseases differ in the intensity of conditioning regimen sufficient to improve disease. In addition, patients with NMDs are at higher risk of graft failure or mixed chimerism following HCT, and gain no or little survival benefit from graft-versus-host disease. Because more than 80% of patients with NMDs become long-term survivors, greater attention has been paid to late adverse effects and decreased of quality of life after HCT. This review addresses several unresolved issues in allogeneic HCT for patients with NMDs, such as (1) stem cell source, (2) conditioning regimen, (3) use of serotherapy or low-dose irradiation, and (4) therapeutic intervention for mixed chimerism. Resolving these issues may improve transplant outcomes in patients with NMDs.
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Affiliation(s)
- Katsutsugu Umeda
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan.
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9
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Lum SH, Greener S, Perez-Heras I, Drozdov D, Payne RP, Watson H, Carruthers K, January R, Nademi Z, Owens S, Williams E, Waugh S, Burton-Fanning S, Leahy TR, Cant A, Abinun M, Flood T, Hambleton S, Gennery AR, Slatter M. T-replete HLA-matched grafts vs T-depleted HLA-mismatched grafts in inborn errors of immunity. Blood Adv 2022; 6:1319-1328. [PMID: 34972212 PMCID: PMC8864655 DOI: 10.1182/bloodadvances.2020004072] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 11/07/2021] [Indexed: 11/28/2022] Open
Abstract
Hematopoietic cell transplantation (HCT) has become standard-of-care for an increasing number of inborn errors of immunity (IEI). This report is the first to compare transplant outcomes according to T-cell-replete (ie, T-replete) HLA-matched grafts using alemtuzumab (n = 117) and T-cell-depleted (ie, T-depleted) HLA-mismatched grafts using T-cell receptor-αβ (TCRαβ)/CD19 depletion (n = 47) in children with IEI who underwent first HCT between 2014 and 2019. All patients received treosulfan-based conditioning except patients with DNA repair disorders. For T-replete grafts, the stem cell source was marrow in 25 (21%) patients, peripheral blood stem cell (PBSC) in 85 (73%), and cord blood in 7 (6%). TCRαβ/CD19 depletion was performed on PBSCs from 45 haploidentical parental donors and 2 mismatched unrelated donors. The 3-year overall survival (OS) and event-free survival for the entire cohort were 85% (77%-90%) and 79% (69%-86%), respectively. Analysis according to age at transplant revealed a comparable 3-year OS between T-replete grafts (88%; 76%-94%) and T-depleted grafts (87%; 64%-96%) in younger patients (aged <5 years at HCT). For older patients (aged >5 years), the OS was significantly lower in T-depleted grafts (55%; 23%-78%) compared with T-replete grafts (87%; 68%-95%) (P = .03). Grade III to IV acute graft-versus-host disease was observed in 8% of T-replete marrow, 7% of T-replete PBSC, 14% of T-replete cord blood, and 2% of T-depleted PBSC (P = .73). Higher incidence of viremia (P < .001) and delayed CD3 reconstitution (P = .003) were observed after T-depleted graft HCT. These data indicate that mismatched donor transplant after TCRαβ/CD19 depletion represents an excellent alternative for younger children with IEI in need of an allograft.
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Affiliation(s)
- Su Han Lum
- Children’s Haematopoietic Stem Cell Transplant Unit, Great North Children’s Hospital, Newcastle upon Tyne Hospital NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Sinéad Greener
- Children’s Haematopoietic Stem Cell Transplant Unit, Great North Children’s Hospital, Newcastle upon Tyne Hospital NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Inigo Perez-Heras
- Children’s Haematopoietic Stem Cell Transplant Unit, Great North Children’s Hospital, Newcastle upon Tyne Hospital NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Daniel Drozdov
- Children’s Haematopoietic Stem Cell Transplant Unit, Great North Children’s Hospital, Newcastle upon Tyne Hospital NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Rebecca P. Payne
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | | | | | - Robert January
- Children’s Haematopoietic Stem Cell Transplant Unit, Great North Children’s Hospital, Newcastle upon Tyne Hospital NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Zohreh Nademi
- Children’s Haematopoietic Stem Cell Transplant Unit, Great North Children’s Hospital, Newcastle upon Tyne Hospital NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Stephen Owens
- Children’s Haematopoietic Stem Cell Transplant Unit, Great North Children’s Hospital, Newcastle upon Tyne Hospital NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Eleri Williams
- Children’s Haematopoietic Stem Cell Transplant Unit, Great North Children’s Hospital, Newcastle upon Tyne Hospital NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Sheila Waugh
- Microbiology and Virology Department, Newcastle upon Tyne Hospital NHS Foundation Trust, Newcastle upon Tyne, United Kingdom; and
| | - Shirelle Burton-Fanning
- Microbiology and Virology Department, Newcastle upon Tyne Hospital NHS Foundation Trust, Newcastle upon Tyne, United Kingdom; and
| | | | - Andrew Cant
- Children’s Haematopoietic Stem Cell Transplant Unit, Great North Children’s Hospital, Newcastle upon Tyne Hospital NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Mario Abinun
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Terry Flood
- Children’s Haematopoietic Stem Cell Transplant Unit, Great North Children’s Hospital, Newcastle upon Tyne Hospital NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Sophie Hambleton
- Children’s Haematopoietic Stem Cell Transplant Unit, Great North Children’s Hospital, Newcastle upon Tyne Hospital NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Andrew R. Gennery
- Children’s Haematopoietic Stem Cell Transplant Unit, Great North Children’s Hospital, Newcastle upon Tyne Hospital NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Mary Slatter
- Children’s Haematopoietic Stem Cell Transplant Unit, Great North Children’s Hospital, Newcastle upon Tyne Hospital NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
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10
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Lüftinger R, Zubarovskaya N, Galimard JE, Cseh A, Salzer E, Locatelli F, Algeri M, Yesilipek A, de la Fuente J, Isgrò A, Alseraihy A, Angelucci E, Smiers FJ, La La Nasa G, Zecca M, Fisgin T, Unal E, Kleinschmidt K, Peters C, Lankester A, Corbacioglu S. Busulfan–fludarabine- or treosulfan–fludarabine-based myeloablative conditioning for children with thalassemia major. Ann Hematol 2022; 101:655-665. [DOI: 10.1007/s00277-021-04732-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 11/26/2021] [Indexed: 11/29/2022]
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11
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Atay D, Akcay A, Akinci B, Yenigurbuz FD, Ovali E, Ozturk G. Co-transplantation of mesenchymal stromal cell and haploidentical hematopoietic stem cell with TCR αβ depletion in children with primary immunodeficiency syndromes. Pediatr Transplant 2021; 25:e14120. [PMID: 34409718 DOI: 10.1111/petr.14120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 08/08/2021] [Accepted: 08/09/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Haploidentical HSCT is a good option for children with PIDs lacking an HLA-matched donor. Co-transplantation of MSCs during haploidentical HSCT in patients with PIDs may enhance engraftment, decrease the risk of GVHD, and ensure stable donor chimerism. METHODS Twenty-seven pediatric patients (median age, 1.4 years; range, .3-10.9) with PIDs undergoing thirty haploidentical HSCT with TCR αβ depletion and co-transplantation of MSCs were enrolled to study. Most patients (73.3%) received myeloablative conditioning consisting of treosulfan or busulfan, fludarabine, and thiotepa. The median duration of follow-up was 14.3 months (range, 1-69 months). RESULTS Acute GVHD occurred in 7 patients (grade I-II n = 5, grade III-IV n = 2). Chronic GVHD was observed in only one patient. Twenty-one patients (70.2%) had 100% donor chimerism in all cell lines including T-cell and B-cell lineages. Primary graft failure was observed in 7 patients (25.9%). The cumulative incidences of TRM were 20% at day 100, and 26.7% at one year and five years. Probabilities of OS were 80% at day 100, and 71.9% at 1 year and 5 years. Infants transplanted younger than 6 months of age had the highest 5-year survival rate (85.7%). CONCLUSION We conclude that use of TCR αβ depleted haploidentical transplantation with MSCs may ensure a rapid engraftment rate, low incidence of significant acute and chronic GVHD, and acceptable post-transplantation morbidity, especially in patients diagnosed with SCID and may be considered in children with PIDs. In younger patients (≤6 months), survival is comparable between HLA-matched graft and CD3+ TCRαβ depleted HLA-mismatched graft recipients.
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Affiliation(s)
- Didem Atay
- Department of Pediatric Hematology/Oncology & Bone Marrow Transplantation Unit, Acıbadem University, Istanbul, Turkey
| | - Arzu Akcay
- Department of Pediatric Hematology/Oncology & Bone Marrow Transplantation Unit, Acıbadem University, Istanbul, Turkey
| | - Burcu Akinci
- Department of Pediatric Hematology/Oncology & Bone Marrow Transplantation Unit, Acıbadem University, Istanbul, Turkey
| | - Fatma Demir Yenigurbuz
- Department of Pediatric Hematology/Oncology & Bone Marrow Transplantation Unit, Acıbadem University, Istanbul, Turkey
| | - Ercument Ovali
- Acibadem Labcell Cellular Therapy Laboratory, Istanbul, Turkey
| | - Gulyuz Ozturk
- Department of Pediatric Hematology/Oncology & Bone Marrow Transplantation Unit, Acıbadem University, Istanbul, Turkey
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12
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Slatter MA, Gennery AR. Treosulfan-based conditioning for inborn errors of immunity. Ther Adv Hematol 2021; 12:20406207211013985. [PMID: 34094045 PMCID: PMC8141989 DOI: 10.1177/20406207211013985] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 04/12/2021] [Indexed: 11/17/2022] Open
Abstract
Inborn errors of immunity (IEI) are inherited disorders that lead to defects in the development and/or function of the immune system. The number of disorders that can be treated by haematopoietic stem-cell transplantation (HSCT) has increased rapidly with the advent of next-generation sequencing. The methods used to transplant children with IEI have improved dramatically over the last 20 years. The introduction of reduced-toxicity conditioning is an important factor in the improved outcome of HSCT. Treosulfan has myeloablative and immunosuppressive properties, enabling engraftment with less toxicity than traditionally used doses of busulfan. It is firmly incorporated into the conditioning guidelines of the Inborn Errors Working Party of the European Society for Blood and Marrow Transplantation. Unlike busulfan, pharmacokinetically guided dosing of treosulfan is not part of routine practice, but data are emerging which indicate that further improvements in outcome may be possible, particularly in infants who have a decreased clearance of treosulfan. It is likely that individualized dosing, not just of treosulfan, but of all agents used in conditioning regimens, will be developed and implemented in the future. This will lead to a reduction in unwanted variability in drug exposure, leading to more predictable and adjustable exposure, and improved outcome of HSCT, with fewer late adverse effects and improved quality of life. Such conditioning regimens can be used as the basis to study the need for additional agents in certain disorders which are difficult to engraft or require high levels of donor chimerism, the dosing of individual cellular components within grafts, and effects of adjuvant cellular or immunotherapy post-transplant. This review documents the establishment of treosulfan worldwide, as a safe and effective agent for conditioning children with IEI prior to HSCT.
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Affiliation(s)
- Mary A Slatter
- Great North Children's Hospital, Clinical Resource Building, Floor 4, Block 2, Queen Victoria Road, Newcastle Upon Tyne NE1 4LP, UK
| | - Andrew R Gennery
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
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13
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Penna S, Villa A, Capo V. Autosomal recessive osteopetrosis: mechanisms and treatments. Dis Model Mech 2021; 14:261835. [PMID: 33970241 PMCID: PMC8188884 DOI: 10.1242/dmm.048940] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Autosomal recessive osteopetrosis (ARO) is a severe inherited bone disease characterized by defective osteoclast resorption or differentiation. Clinical manifestations include dense and brittle bones, anemia and progressive nerve compression, which hamper the quality of patients' lives and cause death in the first 10 years of age. This Review describes the pathogenesis of ARO and highlights the strengths and weaknesses of the current standard of care, namely hematopoietic stem cell transplantation (HSCT). Despite an improvement in the overall survival and outcomes of HSCT, transplant-related morbidity and the pre-existence of neurological symptoms significantly limit the success of HSCT, while the availability of human leukocyte antigen (HLA)-matched donors still remains an open issue. Novel therapeutic approaches are needed for ARO patients, especially for those that cannot benefit from HSCT. Here, we review preclinical and proof-of-concept studies, such as gene therapy, systematic administration of deficient protein, in utero HSCT and gene editing. Summary: Autosomal recessive osteopetrosis is a heterogeneous and rare bone disease for which effective treatments are still lacking for many patients. Here, we review the literature on clinical, preclinical and proof-of-concept studies.
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Affiliation(s)
- Sara Penna
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan 20132, Italy.,Translational and Molecular Medicine (DIMET), University of Milano-Bicocca, Monza 20900, Italy
| | - Anna Villa
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan 20132, Italy.,Institute of Genetic and Biomedical Research, Milan Unit, National Research Council, Milan 20090, Italy
| | - Valentina Capo
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan 20132, Italy.,Institute of Genetic and Biomedical Research, Milan Unit, National Research Council, Milan 20090, Italy
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14
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Im HJ, Kang SH. Treosulfan-Based Conditioning Regimen for Hematopoietic Stem Cell Transplantation in Pediatric Patients with Hemophagocytic Lymphohistiocytosis. CLINICAL PEDIATRIC HEMATOLOGY-ONCOLOGY 2021. [DOI: 10.15264/cpho.2021.28.1.28] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Ho Joon Im
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children’s Hospital, Seoul, Korea
| | - Sung Han Kang
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children’s Hospital, Seoul, Korea
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15
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Kraft MT, Mehyar LS, Prince BT, Reshmi SC, Abraham RS, Abu-Arja R. Immune Reconstitution after Hematopoietic Stem Cell Transplantation in Immunodeficiency-Centromeric Instability-Facial Anomalies Syndrome Type 1. J Clin Immunol 2021; 41:1089-1094. [PMID: 33544358 PMCID: PMC7862860 DOI: 10.1007/s10875-021-00984-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 01/27/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Monica T Kraft
- Division of Allergy and Immunology, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Lubna S Mehyar
- Division of Pediatric Hematology, Oncology and Bone Marrow Transplant, Ruby Memorial Hospital, Morgantown, WV, USA.,Department of Pediatrics, West Virginia University, Morgantown, WV, USA
| | - Benjamin T Prince
- Division of Allergy and Immunology, Nationwide Children's Hospital, Columbus, OH, USA. .,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA.
| | - Shalini C Reshmi
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA.,Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pathology, The Ohio State University, Columbus, OH, USA
| | - Roshini S Abraham
- Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Rolla Abu-Arja
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA.,Division of Pediatric Hematology, Oncology and Bone Marrow Transplant, Nationwide Children's Hospital, Columbus, OH, USA
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16
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Infections in Patients with Chronic Granulomatous Disease Treated with Tumor Necrosis Factor Alpha Blockers for Inflammatory Complications. J Clin Immunol 2020; 41:185-193. [PMID: 33150502 DOI: 10.1007/s10875-020-00901-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 10/25/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Management of inflammatory complications of chronic granulomatous disease (CGD) is challenging. The aim of this study was to assess safety, with a focus on infections, and effectiveness of tumor necrosis factor alpha (TNF-α) blockers in CGD patients. METHODS A retrospective, single-center cohort study of CGD patients treated by anti-TNF-α agents at Necker-Enfants Malades University Hospital (Paris, France) and registered at the French National Reference Center for Primary Immunodeficiencies (CEREDIH). RESULTS Between 2006 and 2019, 14 (X-linked: n = 10, 71.4%; autosomal-recessive: n = 4, 28.6%) CGD patients with gastrointestinal (n = 12, 85.7%), pulmonary (n = 10, 71.4%), cutaneous (n = 3, 21.4%), and/or genitourinary (n = 2, 14.3%) inflammatory manifestations received one or more doses of infliximab because of steroid-dependent (n = 7, 50%), refractory (n = 4, 28.6%) inflammatory disease or as first-line drug (n = 2, 14.3%; missing data, n = 1). All patients received adequate antimicrobial prophylaxis. Infliximab achieved complete (n = 2, 14.3%) or partial (n = 9, 64.3%) response in 11 (78.6%) patients. Seven (50%) patients were switched to adalimumab. During anti-TNF-α treatment, 11 infections (pneumonia, adenitis, invasive candidiasis, each n = 2; intra-abdominal abscess, bacteremic salmonellosis, Pseudomonas aeruginosa-related folliculitis, cat-scratch disease, proven pulmonary mucormycosis, each n = 1) occurred in 7 (50%) patients. All infectious complications had a favorable outcome. Anti-TNF-α treatment was definitively stopped because of infection in two patients. Nine (64.3%) patients finally underwent hematopoietic stem cell transplantation. No death occurred during follow-up. CONCLUSIONS Anti-TNF-α treatment could improve the outcome of severe inflammatory complications in CGD patients, but increases their risk of infections. We suggest that anti-TNF-α treatment might be of short-term benefit in selected CGD patients with severe inflammatory complications awaiting hematopoietic stem cell transplantation.
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17
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Richards S, Gennery AR, Davies EG, Wong M, Shaw PJ, Peake J, Fraser C, Gray P, Brothers S, Sinclair J, Prestidge T, Preece K, Quinn P, Ramachandran S, Loh R, McLean-Tooke A, Mitchell R, Cole T. Diagnosis and management of severe combined immunodeficiency in Australia and New Zealand. J Paediatr Child Health 2020; 56:1508-1513. [PMID: 33099818 DOI: 10.1111/jpc.15158] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 08/06/2020] [Indexed: 01/06/2023]
Abstract
This consensus document outlines the recommendations from the Australasian Society of Clinical Immunology and Allergy Transplantation and Primary Immunodeficiency group for the diagnosis and management of patients with severe combined immunodeficiency. It also provides a proposed framework for the early investigation, management and supportive care prior to haematopoietic stem cell transplantation.
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Affiliation(s)
- Stephanie Richards
- Department of Allergy and Immunology, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Andrew R Gennery
- Paediatric Immunology and Haematopoietic Stem Cell Transplantation, Great North Children's Hospital, Newcastle upon Tyne, United Kingdom.,Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - E Graham Davies
- Department of Immunology, Great Ormond Street Hospital, London, United Kingdom.,UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Melanie Wong
- Department of Allergy and Immunology, Children's Hospital Westmead, Sydney, New South Wales, Australia
| | - Peter J Shaw
- Bone Marrow Transplant Unit, Children's Hospital Westmead, Sydney, New South Wales, Australia.,Discipline of Child and Adolescent Health, University of Sydney, Sydney, New South Wales, Australia
| | - Jane Peake
- Department of Allergy and Immunology, Queensland Children's Hospital, Brisbane, Queensland, Australia.,Discipline of Paediatrics and Child Health, School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Chris Fraser
- Oncology Service, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Paul Gray
- Department of Immunology, Sydney Children's Hospital, Sydney, New South Wales, Australia.,School of Women and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Shannon Brothers
- Department of Immunology and Allergy, Starship Children's Hospital, Auckland, New Zealand.,Newborn Metabolic Screening, Specialist Chemical Pathology Department, LabPlus, Auckland City Hospital, Auckland, New Zealand
| | - Jan Sinclair
- Department of Immunology and Allergy, Starship Children's Hospital, Auckland, New Zealand
| | - Tim Prestidge
- Blood and Cancer Centre, Starship Children's Hospital, Auckland, New Zealand
| | - Kahn Preece
- Allergy and Immunology Department, John Hunter Children's Hospital, Newcastle, New South Wales, Australia
| | - Patrick Quinn
- Department of Allergy and Clinical Immunology, Women and Children's Hospital, Adelaide, South Australia, Australia.,Discipline of Paediatrics, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Shanti Ramachandran
- Department of Paediatric and Adolescent Oncology and Haematology, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Richard Loh
- Immunology Department, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Andrew McLean-Tooke
- Immunology Department, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Richard Mitchell
- School of Women and Children's Health, University of New South Wales, Sydney, New South Wales, Australia.,Kids Cancer Centre, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Theresa Cole
- Department of Allergy and Immunology, The Royal Children's Hospital, Melbourne, Victoria, Australia
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18
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Ali S, Wall DA, Ali M, Chiang KY, Naqvi A, Weitzman S, Gassas A, Gibson P, Brager R, Fernandez CV, Crooks B, Schechter T, Krueger J. Effect of different conditioning regimens on survival and engraftment for children with hemophagocytic lymphohistiocytosis undergoing allogeneic hematopoeitic stem cell transplantation: A single institution experience. Pediatr Blood Cancer 2020; 67:e28477. [PMID: 33740322 DOI: 10.1002/pbc.28477] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 05/09/2020] [Accepted: 05/18/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH), a rare hyperinflammatory immuneregulatory disorder, is a challenge in hematopoietic stem cell transplantation (HSCT) because of the high rate of mixed chimerism, relapse, and graft failure (GF) unless intensive myeloablative regimens are used. However, historically conventional myeloablative regimens (conv MA) are associated with high toxicity and mortality. PROCEDURE We retrospectively compared transplant outcomes between three preparative regimens of varying intensities: Conv MA (n = 15), reduced-intensity conditioning (RIC, n = 12), and a treosulfan-based reduced-toxicity conditioning (RTC, n = 9). RESULTS Patients in the RIC cohort had a higher incidence of mixed donor chimerism and five patients (42%) developed secondary GF (P = .002) compared to the other two regimens. There was a higher incidence of veno-occlusive disease and intensive care unit (ICU) admissions in the Conv MA cohort. With the RTC regimen, there was a similar 2-year overall survival (89, 73, and 83%; P = .87), but improved compound EFS (lack of relapse, GF, second transplant or additional donor cell infusions, or death; 89, 73, and 42%, P = .041) in RTC, Conv MA, and RIC regimen, respectively. CONCLUSIONS The intensity of the preparative regimen has a significant impact on outcome of HSCT for HLH. The newly described treosulfan-based RTC provides for a stable graft with a reasonable toxicity profile.
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Affiliation(s)
- Salah Ali
- Division of Hematology/Oncology/BMT, Sheffield Childrens NHS Foundation Trust, Sheffield, UK
| | - Donna A Wall
- Division of Hematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Muhammad Ali
- Division of Hematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Kuang-Yueh Chiang
- Division of Hematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Ahmed Naqvi
- Division of Hematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Sheila Weitzman
- Division of Hematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Adam Gassas
- Pediatric Bone Marrow Transplant, University Hospitals Bristol, Bristol, UK
| | - Paul Gibson
- Pediatric Hematology/Oncology, Children's Hospital, London Health Sciences Centre, London, Ontario, Canada
| | - Rae Brager
- Division of Rheumatology, Department of Pediatrics, McMaster University Medical Centre, Hamilton, Ontario, Canada
| | - Conrad V Fernandez
- Department of Pediatrics, IWK Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Bruce Crooks
- Department of Pediatrics, IWK Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Tal Schechter
- Division of Hematology/Oncology/BMT, Sheffield Childrens NHS Foundation Trust, Sheffield, UK.,Division of Hematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Joerg Krueger
- Division of Hematology/Oncology/BMT, Sheffield Childrens NHS Foundation Trust, Sheffield, UK.,Division of Hematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
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19
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Huttunen P, Taskinen M, Vettenranta K. Acute toxicity and outcome among pediatric allogeneic hematopoietic transplant patients conditioned with treosulfan-based regimens. Pediatr Hematol Oncol 2020; 37:355-364. [PMID: 32166994 DOI: 10.1080/08880018.2020.1738604] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Treosulfan-based regimens constitute a feasible and increasingly used, but still myeloablative, conditioning in pediatric allogeneic hematopoietic stem cell transplantation (HSCT). We retrospectively analyzed the acute toxicity and outcome of all consecutive (2004-2015) pediatric HSCT patients prepared for HSCT with treosulfan in a single-center setting. We included HSCTs performed for both nonmalignant (n = 23) and malignant diseases (n = 11). The controls were patients with nonmalignant diseases or hematological malignancies conditioned with cyclophosphamide (Cy)-total body irradiation (TBI)-based (39 patients) or busulfan-based regimens (11 patients). The major toxicities of the treosulfan-based regimens were limited to oral mucosa and skin. 50% of the patients needed IV morphine for severe mucositis compared to 31% in patients conditioned with Cy-TBI (P = 0.02). Other toxicities were rare. The disease-free survival (DFS) of patients transplanted for nonmalignant disorders was 88.9 ± 7.5% at 2 years. The event-free survival (EFS) at 2 years in this small cohort for those with a malignant disease and a treosulfan-based conditioning was 54.5 ± 1.5%. We conclude that a treosulfan-based conditioning regimen gives excellent DFS in pediatric HSCT performed for a nonmalignant disorder but with substantial mucosal toxicity. In a malignant disorder a treosulfan-based regimen looks promising but larger, preferably randomized, studies are needed to prove efficacy.
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Affiliation(s)
- Pasi Huttunen
- Division of Hematology-Oncology and Stem Cell Transplantation, New Children´s Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Mervi Taskinen
- Division of Hematology-Oncology and Stem Cell Transplantation, New Children´s Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Kim Vettenranta
- Division of Hematology-Oncology and Stem Cell Transplantation, New Children´s Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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20
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Mitchell R. Hematopoietic Stem Cell Transplantation Beyond Severe Combined Immunodeficiency: Seeking a Cure for Primary Immunodeficiency. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 7:776-785. [PMID: 30832892 DOI: 10.1016/j.jaip.2018.12.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 12/12/2018] [Accepted: 12/13/2018] [Indexed: 12/27/2022]
Abstract
Hematopoietic stem cell transplantation (HSCT) can provide definitive therapy for patients with primary immunodeficiency disease (PIDD). Modern HSCT techniques and supportive care have significantly improved outcomes for patients with PIDD. This review examines current HSCT practice for PIDD other than severe combined immunodeficiency, and explores indications, risks, and long-term outcomes for this group of challenging diseases.
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Affiliation(s)
- Richard Mitchell
- Kids Cancer Centre, Sydney Children's Hospital, Randwick, New South Wales, Australia; School of Women and Children's Health, University of New South Wales, Sydney, New South Wales, Australia.
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21
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Jamee M, Zaki-Dizaji M, Lo B, Abolhassani H, Aghamahdi F, Mosavian M, Nademi Z, Mohammadi H, Jadidi-Niaragh F, Rojas M, Anaya JM, Azizi G. Clinical, Immunological, and Genetic Features in Patients with Immune Dysregulation, Polyendocrinopathy, Enteropathy, X-linked (IPEX) and IPEX-like Syndrome. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2747-2760.e7. [PMID: 32428713 DOI: 10.1016/j.jaip.2020.04.070] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 04/06/2020] [Accepted: 04/15/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Immune dysregulation, polyendocrinopathy, enteropathy, X-linked (IPEX) syndrome is a rare inborn error of immunity caused by mutations in the forkhead box P3 (FOXP3) gene. OBJECTIVE In this study, we conducted a systematic review of patients with IPEX and IPEX-like syndrome to delineate differences in these 2 major groups. METHODS The literature search was performed in PubMed, Web of Science, and Scopus databases, and demographic, clinical, immunologic, and molecular data were compared between the IPEX and IPEX-like groups. RESULTS A total of 459 patients were reported in 148 eligible articles. Major clinical differences between patients with IPEX and IPEX-like syndrome were observed in rates of pneumonia (11% vs 31%, P < .001), bronchiectasis (0.3% vs 14%, P < .001), diarrhea (56% vs 42%, P = .020), and organomegaly (10% vs 23%, P = .001), respectively. Eosinophilia (95% vs 100%), low regulatory T-cell count (68% vs 50%), and elevated IgE (87% vs 61%) were the most prominent laboratory findings in patients with IPEX and IPEX-like syndrome, respectively. In the IPEX group, a lower mortality rate was observed among patients receiving hematopoietic stem cell transplantation (HSCT) (24%) compared with other patients (43%), P = .008; however, in the IPEX-like group, it was not significant (P = .189). CONCLUSIONS Patients with IPEX syndrome generally suffer from enteropathy, autoimmunity, dermatitis, eosinophilia, and elevated serum IgE. Despite similarities in their clinical presentations, patients with IPEX-like syndrome are more likely to present common variable immunodeficiency-like phenotype such as respiratory tract infections, bronchiectasis, and organomegaly. HSCT is currently the only curative therapy for both IPEX and IPEX-like syndrome and may result in favorable outcome.
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Affiliation(s)
- Mahnaz Jamee
- Student Research Committee, Alborz University of Medical Sciences, Karaj, Iran; Alborz Office of USERN, Universal Scientific Education and Research Network (USERN), Alborz University of Medical Sciences, Karaj, Iran
| | - Majid Zaki-Dizaji
- Legal Medicine Research Center, Legal Medicine Organization, Tehran, Iran
| | - Bernice Lo
- Sidra Medicine, Division of Translational Medicine, Research Branch, Doha, Qatar
| | - Hassan Abolhassani
- Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran; Division of Clinical Immunology, Department of Laboratory Medicine, Karolinska Institute at Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Fatemeh Aghamahdi
- Non-communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran
| | - Mehdi Mosavian
- Non-communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran
| | - Zohreh Nademi
- Children's Bone Marrow Transplant Unit, Great North Children's Hospital, Newcastle, United Kingdom
| | - Hamed Mohammadi
- Non-communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran
| | | | - Manuel Rojas
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
| | - Juan-Manuel Anaya
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
| | - Gholamreza Azizi
- Non-communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran.
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22
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Anti-Müllerian hormone and Inhibin B after stem cell transplant in childhood: a comparison of myeloablative, reduced intensity and treosulfan-based chemotherapy regimens. Bone Marrow Transplant 2020; 55:1985-1995. [DOI: 10.1038/s41409-020-0866-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 03/06/2020] [Accepted: 03/09/2020] [Indexed: 12/20/2022]
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23
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Mismatched related vs matched unrelated donors in TCRαβ/CD19-depleted HSCT for primary immunodeficiencies. Blood 2020; 134:1755-1763. [PMID: 31558465 DOI: 10.1182/blood.2019001757] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Accepted: 08/28/2019] [Indexed: 11/20/2022] Open
Abstract
TCRαβ+/CD19+ graft depletion effectively prevents graft-versus-host disease (GVHD). In the current study, we compared the outcomes of hematopoietic stem cell transplantation (HSCT) with TCRαβ+/CD19+ depletion from matched unrelated donors (MUDs) and mismatched related donors (MMRDs) in patients with primary immunodeficiency (PID). A total of 98 pediatric patients with various PIDs underwent HSCT with TCRαβ+/CD19+ graft depletion from MUDs (n = 75) and MMRDs (n = 23). All patients received a fludarabine-/treosulfan-based conditioning regimen, with 73 also receiving a second alkylating agent. For GVHD prophylaxis, all but 2 received serotherapy (antithymocyte globulin) before HSCT and a short course of posttransplant immunosuppression. Neutrophil and platelet engraftment in both the MUD and MMRD groups occurred on days 14 and 13, respectively. The incidence of secondary graft failure was 0.16 and 0.17 (P = .85), respectively. The cumulative incidence of acute GVHD grade 2 to 4 was 0.17 in the MUD group and 0.22 in the MMRD group (P = .7). The incidence of cytomegalovirus (CMV) viremia was 0.5 in the MUD group and 0.6 in the MMRD group (P = .35). The frequency of CMV disease was high (17%), and the most common manifestation was retinitis. The kinetics of immune recovery was similar in both groups. The overall survival was 0.86 in the MUD group and 0.87 in the MMRD group (P = .95). In our experience, there was no difference in the outcomes of HSCT performed from MUD and MMRD. Hence, given the immediate availability of donors, in the absence of HLA-identical siblings, HSCT with TCRαβ+/CD19+ graft depletion from MMRDs can be considered as the first choice in patients with PID.
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Vellaichamy Swaminathan V, Uppuluri R, Patel S, Melarcode Ramanan K, Ravichandran N, Jayakumar I, Vaidhyanathan L, Raj R. Treosulfan-based reduced toxicity hematopoietic stem cell transplantation in X-linked agammaglobulinemia: A cost-effective alternative to long-term immunoglobulin replacement in developing countries. Pediatr Transplant 2020; 24:e13625. [PMID: 31821668 DOI: 10.1111/petr.13625] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 10/16/2019] [Accepted: 11/07/2019] [Indexed: 01/07/2023]
Abstract
X-linked agammaglobulinemia (XLA) is a primary antibody disorder due to a mutation in the Bruton tyrosine kinase gene that requires lifelong immunoglobulin replacement resulting in a significant economic burden and treatment abandonment. Hematopoietic stem cell transplantation (HSCT) offers an alternative option for complete cure. In our series, two children with XLA underwent successful HSCT using a myeloablative conditioning with thiotepa, treosulfan, and fludarabine from a matched sibling donor. The second child had rejected his first graft following a busulfan-based regimen with resultant autologous reconstitution. At 6 months post-HSCT, serum IgG were normal, off IVIG, and had no infections. Both children after a median follow-up of 20 months have 100% chimerism. Treosulfan-based reduced toxicity myeloablative HSCT has encouraging results with a positive impact on the socioeconomics in developing countries.
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Affiliation(s)
| | - Ramya Uppuluri
- Department of Pediatric Hematology, Oncology, Blood and Marrow Transplantation, Apollo Hospitals, Chennai, India
| | - Shivani Patel
- Department of Pediatric Hematology, Oncology, Blood and Marrow Transplantation, Apollo Hospitals, Chennai, India
| | - Kesavan Melarcode Ramanan
- Department of Pediatric Hematology, Oncology, Blood and Marrow Transplantation, Apollo Hospitals, Chennai, India
| | - Nikila Ravichandran
- Department of Pediatric Hematology, Oncology, Blood and Marrow Transplantation, Apollo Hospitals, Chennai, India
| | - Indira Jayakumar
- Department of Pediatric Critical Care, Apollo Hospitals, Chennai, India
| | | | - Revathi Raj
- Department of Pediatric Hematology, Oncology, Blood and Marrow Transplantation, Apollo Hospitals, Chennai, India
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25
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Beelen DW, Trenschel R, Stelljes M, Groth C, Masszi T, Reményi P, Wagner-Drouet EM, Hauptrock B, Dreger P, Luft T, Bethge W, Vogel W, Ciceri F, Peccatori J, Stölzel F, Schetelig J, Junghanß C, Grosse-Thie C, Michallet M, Labussiere-Wallet H, Schaefer-Eckart K, Dressler S, Grigoleit GU, Mielke S, Scheid C, Holtick U, Patriarca F, Medeot M, Rambaldi A, Micò MC, Niederwieser D, Franke GN, Hilgendorf I, Winkelmann NR, Russo D, Socié G, Peffault de Latour R, Holler E, Wolff D, Glass B, Casper J, Wulf G, Menzel H, Basara N, Bieniaszewska M, Stuhler G, Verbeek M, Grass S, Iori AP, Finke J, Benedetti F, Pichlmeier U, Hemmelmann C, Tribanek M, Klein A, Mylius HA, Baumgart J, Dzierzak-Mietla M, Markiewicz M. Treosulfan or busulfan plus fludarabine as conditioning treatment before allogeneic haemopoietic stem cell transplantation for older patients with acute myeloid leukaemia or myelodysplastic syndrome (MC-FludT.14/L): a randomised, non-inferiority, phase 3 trial. LANCET HAEMATOLOGY 2020; 7:e28-e39. [DOI: 10.1016/s2352-3026(19)30157-7] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 07/15/2019] [Accepted: 07/16/2019] [Indexed: 01/10/2023]
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26
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Hempel G. Pharmacotherapy in Children and Adolescents: Oncology. Handb Exp Pharmacol 2020; 261:415-440. [PMID: 31792677 DOI: 10.1007/164_2019_306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Pharmacotherapy in paediatric oncology is a difficult task. It is challenging to determine the optimal dose in children of different age groups. In addition, anticancer drugs display severe side effects reducing the quality of life. Late effects like secondary tumours and cardiotoxicity can be apparent years after treatment and must be taken into account when planning treatment schedules. Classical cytoreducing agents are still of great importance in treating children with leukaemia and solid tumours. In addition, drugs developed by rational drug design (targeted drugs) are a very important part of many treatment protocols, and newer drugs are emerging in several types of cancer. Unfortunately, there is only limited experience with newer drugs in children, because new drugs are mostly developed for adults. Complicated therapy regimens require a solid knowledge of the pharmacology of the drugs applied. This chapter attempts to introduce some pharmacological knowledge for the most important anticancer drugs in children with a focus on side effects and age-specific considerations.
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Affiliation(s)
- Georg Hempel
- Westfälische Wilhelms-Universität Münster, Institut für Pharmazeutische und Medizinische Chemie, Klinische Pharmazie, Münster, Germany.
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Dimitrova D, Gea-Banacloche J, Steinberg SM, Sadler JL, Hicks SN, Carroll E, Wilder JS, Parta M, Skeffington L, Hughes TE, Blau JE, Broadney MM, Rose JJ, Hsu AP, Fletcher R, Nunes NS, Yan XY, Telford WG, Kapoor V, Cohen JI, Freeman AF, Garabedian E, Holland SM, Lisco A, Malech HL, Notarangelo LD, Sereti I, Shah NN, Uzel G, Zerbe CS, Fowler DH, Gress RE, Kanakry CG, Kanakry JA. Prospective Study of a Novel, Radiation-Free, Reduced-Intensity Bone Marrow Transplantation Platform for Primary Immunodeficiency Diseases. Biol Blood Marrow Transplant 2020; 26:94-106. [PMID: 31493539 PMCID: PMC6942248 DOI: 10.1016/j.bbmt.2019.08.018] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 08/28/2019] [Accepted: 08/28/2019] [Indexed: 12/20/2022]
Abstract
Allogeneic blood or marrow transplantation (BMT) is a potentially curative therapy for patients with primary immunodeficiency (PID). Safe and effective reduced-intensity conditioning (RIC) approaches that are associated with low toxicity, use alternative donors, and afford good immune reconstitution are needed to advance the field. Twenty PID patients, ranging in age from 4 to 58 years, were treated on a prospective clinical trial of a novel, radiation-free and serotherapy-free RIC, T-cell-replete BMT approach using pentostatin, low-dose cyclophosphamide, and busulfan for conditioning with post-transplantation cyclophosphamide-based graft-versus-host-disease (GVHD) prophylaxis. This was a high-risk cohort with a median hematopoietic cell transplantation comorbidity index of 3. With median follow-up of survivors of 1.9 years, 1-year overall survival was 90% and grade III to IV acute GVHD-free, graft-failure-free survival was 80% at day +180. Graft failure incidence was 10%. Split chimerism was frequently observed at early post-BMT timepoints, with a lower percentage of donor T cells, which gradually increased by day +60. The cumulative incidences of grade II to IV and grade III to IV acute GVHD (aGVHD) were 15% and 5%, respectively. All aGVHD was steroid responsive. No patients developed chronic GVHD. Few significant organ toxicities were observed. Evidence of phenotype reversal was observed for all engrafted patients, even those with significantly mixed chimerism (n = 2) or with unknown underlying genetic defect (n = 3). All 6 patients with pre-BMT malignancies or lymphoproliferative disorders remain in remission. Most patients have discontinued immunoglobulin replacement. All survivors are off immunosuppression for GVHD prophylaxis or treatment. This novel RIC BMT approach for patients with PID has yielded promising results, even for high-risk patients.
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Affiliation(s)
- Dimana Dimitrova
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | | | - Seth M Steinberg
- Biostatistics and Data Management Section, National Cancer Institute, Center for Cancer Research, National Institutes of Health, Bethesda, Maryland
| | - Jennifer L Sadler
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Stephanie N Hicks
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Ellen Carroll
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Jennifer S Wilder
- Clinical Research Directorate/Clinical Monitoring Research Program, Frederick National Laboratory for Cancer Research sponsored by the National Cancer Institute, Bethesda, Maryland
| | - Mark Parta
- Clinical Research Directorate/Clinical Monitoring Research Program, Frederick National Laboratory for Cancer Research sponsored by the National Cancer Institute, Bethesda, Maryland
| | - Lauren Skeffington
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Thomas E Hughes
- National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Jenny E Blau
- Metabolic Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Miranda M Broadney
- Section on Growth and Obesity, Program in Endocrinology, Metabolism and Genetics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Jeremy J Rose
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Amy P Hsu
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, Maryland
| | - Rochelle Fletcher
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Natalia S Nunes
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Xiao-Yi Yan
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - William G Telford
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Veena Kapoor
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Jeffrey I Cohen
- Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Alexandra F Freeman
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, Maryland
| | - Elizabeth Garabedian
- Genetics and Molecular Biology Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland
| | - Steven M Holland
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, Maryland
| | - Andrea Lisco
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Harry L Malech
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, Maryland
| | - Luigi D Notarangelo
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, Maryland
| | - Irini Sereti
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Nirali N Shah
- Pediatric Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Gulbu Uzel
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, Maryland
| | - Christa S Zerbe
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, Maryland
| | - Daniel H Fowler
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Ronald E Gress
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Christopher G Kanakry
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Jennifer A Kanakry
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland.
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28
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Lum SH, Hoenig M, Gennery AR, Slatter MA. Conditioning Regimens for Hematopoietic Cell Transplantation in Primary Immunodeficiency. Curr Allergy Asthma Rep 2019; 19:52. [PMID: 31741098 PMCID: PMC6861349 DOI: 10.1007/s11882-019-0883-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW Hematopoietic cell transplantation (HCT) is an established curative treatment for children with primary immunodeficiencies. This article reviews the latest developments in conditioning regimens for primary immunodeficiency (PID). It focuses on data regarding transplant outcomes according to newer reduced toxicity conditioning regimens used in HCT for PID. RECENT FINDINGS Conventional myeloablative conditioning regimens are associated with significant acute toxicities, transplant-related mortality, and late effects such as infertility. Reduced toxicity conditioning regimens have had significant positive impacts on HCT outcome, and there are now well-established strategies in children with PID. Treosulfan has emerged as a promising preparative agent. Use of a peripheral stem cell source has been shown to be associated with better donor chimerism in patients receiving reduced toxicity conditioning. Minimal conditioning regimens using monoclonal antibodies are in clinical trials with promising results thus far. Reduced toxicity conditioning has emerged as standard of care for PID and has resulted in improved transplant survival for patients with significant comorbidities.
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Affiliation(s)
- S H Lum
- Children's Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital, Newcastle upon Tyne Hospital NHS Foundation Trust, Newcastle upon Tyne, UK
| | - M Hoenig
- Department of Pediatrics, University Medical Center Ulm, Ulm, Germany
| | - A R Gennery
- Children's Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital, Newcastle upon Tyne Hospital NHS Foundation Trust, Newcastle upon Tyne, UK
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - M A Slatter
- Children's Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital, Newcastle upon Tyne Hospital NHS Foundation Trust, Newcastle upon Tyne, UK.
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.
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29
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Universal donor strategy for primary immunodeficiency. Blood 2019; 134:1688-1689. [PMID: 31725867 DOI: 10.1182/blood.2019003222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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30
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Successful haploidentical transplantation with post-transplant cyclophosphamide for activated phosphoinositide 3-kinase δ syndrome. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:1034-1037.e1. [DOI: 10.1016/j.jaip.2018.05.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 04/22/2018] [Accepted: 05/18/2018] [Indexed: 11/23/2022]
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31
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Ferrua F, Galimberti S, Courteille V, Slatter MA, Booth C, Moshous D, Neven B, Blanche S, Cavazzana M, Laberko A, Shcherbina A, Balashov D, Soncini E, Porta F, Al-Mousa H, Al-Saud B, Al-Dhekri H, Arnaout R, Formankova R, Bertrand Y, Lange A, Smart J, Wolska-Kusnierz B, Aquino VM, Dvorak CC, Fasth A, Fouyssac F, Heilmann C, Hoenig M, Schuetz C, Kelečić J, Bredius RGM, Lankester AC, Lindemans CA, Suarez F, Sullivan KE, Albert MH, Kałwak K, Barlogis V, Bhatia M, Bordon V, Czogala W, Alonso L, Dogu F, Gozdzik J, Ikinciogullari A, Kriván G, Ljungman P, Meyts I, Mustillo P, Smith AR, Speckmann C, Sundin M, Keogh SJ, Shaw PJ, Boelens JJ, Schulz AS, Sedlacek P, Veys P, Mahlaoui N, Janda A, Davies EG, Fischer A, Cowan MJ, Gennery AR. Hematopoietic stem cell transplantation for CD40 ligand deficiency: Results from an EBMT/ESID-IEWP-SCETIDE-PIDTC study. J Allergy Clin Immunol 2019; 143:2238-2253. [PMID: 30660643 DOI: 10.1016/j.jaci.2018.12.1010] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 12/20/2018] [Accepted: 12/31/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND CD40 ligand (CD40L) deficiency, an X-linked primary immunodeficiency, causes recurrent sinopulmonary, Pneumocystis and Cryptosporidium species infections. Long-term survival with supportive therapy is poor. Currently, the only curative treatment is hematopoietic stem cell transplantation (HSCT). OBJECTIVE We performed an international collaborative study to improve patients' management, aiming to individualize risk factors and determine optimal HSCT characteristics. METHODS We retrospectively collected data on 130 patients who underwent HSCT for CD40L deficiency between 1993-2015. We analyzed outcome and variables' relevance with respect to survival and cure. RESULTS Overall survival (OS), event-free survival (EFS), and disease-free survival (DFS) were 78.2%, 58.1%, and 72.3% 5 years after HSCT. Results were better in transplantations performed in 2000 or later and in children less than 10 years old at the time of HSCT. Pre-existing organ damage negatively influenced outcome. Sclerosing cholangitis was the most important risk factor. After 2000, superior OS was achieved with matched donors. Use of myeloablative regimens and HSCT at 2 years or less from diagnosis associated with higher OS and DFS. EFS was best with matched sibling donors, myeloablative conditioning (MAC), and bone marrow-derived stem cells. Most rejections occurred after reduced-intensity or nonmyeloablative conditioning, which associated with poor donor cell engraftment. Mortality occurred mainly early after HSCT, predominantly from infections. Among survivors who ceased immunoglobulin replacement, T-lymphocyte chimerism was 50% or greater donor in 85.2%. CONCLUSION HSCT is curative in patients with CD40L deficiency, with improved outcome if performed before organ damage development. MAC is associated with better OS, EFS, and DFS. Prospective studies are required to compare the risks of HSCT with those of lifelong supportive therapy.
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Affiliation(s)
- Francesca Ferrua
- Department of Pediatric Immunology and HSCT, Great North Children's Hospital, Newcastle upon Tyne, United Kingdom; San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), Pediatric Immunohematology and Bone Marrow Transplantation Unit, San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.
| | - Stefania Galimberti
- Center of Biostatistics for Clinical Epidemiology, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Virginie Courteille
- Paris Descartes-Sorbonne Paris Cité University, Imagine Institute, Paris, France; French National Reference Center for Primary Immune Deficiencies (CEREDIH), Necker Enfants Malades University Hospital, AP-HP, Paris, France
| | - Mary Anne Slatter
- Department of Pediatric Immunology and HSCT, Great North Children's Hospital, Newcastle upon Tyne, United Kingdom; Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Claire Booth
- Department of Pediatric Immunology, Great Ormond Street Hospital, London, United Kingdom
| | - Despina Moshous
- Paris Descartes-Sorbonne Paris Cité University, Imagine Institute, Paris, France; Pediatric Hematology-Immunology and Rheumatology Unit, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France; French National Reference Center for Primary Immune Deficiencies (CEREDIH), Necker Enfants Malades University Hospital, AP-HP, Paris, France
| | - Benedicte Neven
- Paris Descartes-Sorbonne Paris Cité University, Imagine Institute, Paris, France; Pediatric Hematology-Immunology and Rheumatology Unit, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France; French National Reference Center for Primary Immune Deficiencies (CEREDIH), Necker Enfants Malades University Hospital, AP-HP, Paris, France
| | - Stephane Blanche
- Paris Descartes-Sorbonne Paris Cité University, Imagine Institute, Paris, France; Pediatric Hematology-Immunology and Rheumatology Unit, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France; French National Reference Center for Primary Immune Deficiencies (CEREDIH), Necker Enfants Malades University Hospital, AP-HP, Paris, France
| | - Marina Cavazzana
- Paris Descartes-Sorbonne Paris Cité University, Imagine Institute, Paris, France; Biotherapy Department, Necker Children's Hospital, AP-HP, Paris, France; Biotherapy Clinical Investigation Center, Groupe Hospitalier Universitaire Ouest, AP-HP, INSERM, Paris, France; INSERM UMR 1163, Laboratory of Human Lymphohematopoiesis, Paris, France
| | - Alexandra Laberko
- Dmitry Rogachev Federal Research Centre of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Anna Shcherbina
- Dmitry Rogachev Federal Research Centre of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Dmitry Balashov
- Dmitry Rogachev Federal Research Centre of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Elena Soncini
- Pediatric Oncology-Hematology and BMT Unit, Spedali Civili di Brescia, Brescia, Italy
| | - Fulvio Porta
- Pediatric Oncology-Hematology and BMT Unit, Spedali Civili di Brescia, Brescia, Italy
| | - Hamoud Al-Mousa
- Department of Pediatrics, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Bandar Al-Saud
- Department of Pediatrics, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Hasan Al-Dhekri
- Department of Pediatrics, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Rand Arnaout
- Department of Pediatrics, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Renata Formankova
- Department of Pediatric Hematology and Oncology, University Hospital Motol Prague, Prague, Czech Republic
| | - Yves Bertrand
- Institut d'Hematologie et d'Oncologie Pediatrique, Hospices Civils de Lyon, Lyon, France
| | - Andrzej Lange
- L. Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, Wrocław, Poland; Lower Silesian Center for Cellular Transplantation & National Bone Marrow Donor Registry, Wrocław, Poland
| | - Joanne Smart
- Department of Allergy and Immunology, Royal Children's Hospital, Melbourne, Australia
| | | | - Victor M Aquino
- Department of Pediatrics, University of Texas Southwestern Medical Center Dallas, Dallas, Tex
| | - Christopher C Dvorak
- Division of Pediatric Allergy, Immunology & Bone Marrow Transplantation, University of California, San Francisco, Calif
| | - Anders Fasth
- Department of Pediatrics, Sahlgrenska Academy at University of Gothenburg and Queen Silvia Children's Hospital, Gothenburg, Sweden
| | - Fanny Fouyssac
- Pediatric Oncology and Hematology Unit, Children Hospital, University Hospital Nancy, Vandoeuvre-les-Nancy, France; French National Reference Center for Primary Immune Deficiencies (CEREDIH), Necker Enfants Malades University Hospital, AP-HP, Paris, France
| | | | - Manfred Hoenig
- Department of Pediatrics, University Medical Center Ulm, Ulm, Germany
| | - Catharina Schuetz
- Department of Pediatrics, University Medical Center Ulm, Ulm, Germany
| | - Jadranka Kelečić
- Department of Pediatrics, Division of Allergology, Clinical Immunology, Respiratory Diseases and Rheumatology, University Hospital Center Zagreb, Zagreb, Croatia
| | - Robbert G M Bredius
- Department of Pediatrics/Willem-Alexander Children's hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Arjan C Lankester
- Department of Pediatrics/Willem-Alexander Children's hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Caroline A Lindemans
- Department of Pediatrics, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands; Princess Maxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Felipe Suarez
- Hématologie Adulte, Hôpital Necker, AP-HP, Paris, France; French National Reference Center for Primary Immune Deficiencies (CEREDIH), Necker Enfants Malades University Hospital, AP-HP, Paris, France
| | - Kathleen E Sullivan
- Division of Allergy Immunology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Michael H Albert
- Pediatric Hematology/Oncology, Dr. von Hauner University Children's Hospital, Munich, Germany
| | - Krzysztof Kałwak
- Department of Pediatric Hematology and Oncology, Wroclaw Medical University, Wrocław, Poland
| | - Vincent Barlogis
- Service d'hématologie pédiatrique, Hôpital de la Timone Enfants, Marseille, France; French National Reference Center for Primary Immune Deficiencies (CEREDIH), Necker Enfants Malades University Hospital, AP-HP, Paris, France
| | - Monica Bhatia
- Pediatric Stem Cell Transplantation, Columbia University College of Physicians and Surgeons, New York, NY
| | - Victoria Bordon
- Pediatric Hematology-Oncology and Stem Cell Transplantation, Ghent University Hospital, Ghent, Belgium
| | | | - Laura Alonso
- Pediatric Hematology and Oncology Department, Hospital Universitario MaternoInfantil Vall d'Hebron, Barcelona, Spain
| | - Figen Dogu
- Department of Pediatric Immunology and Allergy, Ankara University School of Medicine, Ankara, Turkey
| | - Jolanta Gozdzik
- Department of Clinical Immunology and Transplantology, Jagiellonian University, Medical Collage, Transplantation Center, University Children's Hospital, Cracow, Poland
| | - Aydan Ikinciogullari
- Department of Pediatric Immunology-Allergy and BMT Unit, Ankara University Medical School, Ankara, Turkey
| | - Gergely Kriván
- Department of Pediatric Hematology and Stem Cell Transplantation United St. István and St László Hospital, Budapest, Hungary
| | - Per Ljungman
- Department of Hematology, Karolinska University Hospital, Stockholm, Sweden
| | - Isabelle Meyts
- Department of Pediatrics, University Hospitals Leuven, Division of Pediatric Immunology, Department of Immunology and Microbiology, Catholic University Leuven, Leuven, Belgium
| | | | - Angela R Smith
- Pediatric Blood and Marrow Transplant, University of Minnesota, Minneapolis, Minn
| | - Carsten Speckmann
- Center for Chronic Immunodeficiency, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Mikael Sundin
- Division of Pediatrics, CLINTEC, Karolinska Institutet, Stockholm, Sweden; Pediatric Blood Disorders, Immunodeficiency and SCT, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Steven John Keogh
- Cancer Centre for Children, Children's Hospital at Westmead, Sydney, Australia
| | - Peter John Shaw
- Cancer Centre for Children, Children's Hospital at Westmead, Sydney, Australia; University of Sydney Medical Program, Sydney, Australia
| | - Jaap Jan Boelens
- Department of Pediatrics, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands; Princess Maxima Center for Pediatric Oncology, Utrecht, The Netherlands; Department of Pediatrics, Memorial Sloan Kettering Cancer Center, BMT and Cell Therapies Program, New York, NY; Laboratory for Translational Immunology, Tumor-immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ansgar S Schulz
- Department of Pediatrics, University Medical Center Ulm, Ulm, Germany
| | - Petr Sedlacek
- Department of Pediatric Hematology and Oncology, University Hospital Motol Prague, Prague, Czech Republic
| | - Paul Veys
- Department of BMT, Great Ormond Street Hospital for Children NHS Trust, London, United Kingdom
| | - Nizar Mahlaoui
- Paris Descartes-Sorbonne Paris Cité University, Imagine Institute, Paris, France; Pediatric Hematology-Immunology and Rheumatology Unit, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France; French National Reference Center for Primary Immune Deficiencies (CEREDIH), Necker Enfants Malades University Hospital, AP-HP, Paris, France; INSERM UMR 1163, Laboratory of Human Genetics of Infectious Diseases, Necker Branch, Paris, France
| | - Ales Janda
- Center for Pediatrics and Center for Chronic Immunodeficiency, Medical Center, University of Freiburg, Freiburg, Germany
| | - E Graham Davies
- Department of Pediatric Immunology, Great Ormond Street Hospital, London, United Kingdom
| | - Alain Fischer
- Paris Descartes-Sorbonne Paris Cité University, Imagine Institute, Paris, France; Pediatric Hematology-Immunology and Rheumatology Unit, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France; French National Reference Center for Primary Immune Deficiencies (CEREDIH), Necker Enfants Malades University Hospital, AP-HP, Paris, France; College de France, Paris, France
| | - Morton J Cowan
- Division of Pediatric Allergy, Immunology & Bone Marrow Transplantation, University of California, San Francisco, Calif
| | - Andrew Richard Gennery
- Department of Pediatric Immunology and HSCT, Great North Children's Hospital, Newcastle upon Tyne, United Kingdom; Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
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Shaw P, Shizuru J, Hoenig M, Veys P. Conditioning Perspectives for Primary Immunodeficiency Stem Cell Transplants. Front Pediatr 2019; 7:434. [PMID: 31781522 PMCID: PMC6851055 DOI: 10.3389/fped.2019.00434] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 10/07/2019] [Indexed: 01/10/2023] Open
Abstract
The majority of children undergoing Hematopoietic Stem cell Transplantation (HSCT) require conditioning therapy to make space and prevent rejection of the donor stem cells. The exception is certain children with Severe Combined immune deficiency, who have limited or no ability to reject the donor graft. Transplant conditioning is associated with significant morbidity and mortality from both direct toxic effects of chemotherapy as well as opportunistic infections associated with profound immunosuppression. The ultimate goal of transplant practice is to achieve sufficient engraftment of donor cells to correct the underlying disease with minimal short- and long-term toxicity to the recipient. Traditional combinations, such as busulfan and cyclophosphamide, achieve a high rate of full donor engraftment, but are associated with significant acute transplant-related-mortality and late effects such as infertility. Less "intensive" approaches, such as combinations of treosulfan or melphalan with fludarabine, are less toxic, but may be associated with rejection or low level chimerism requiring the need for re-transplantation. The major benefit of these novel approaches, however, which we hope will be realized in the decades to come, may be the preservation of fertility. Future approaches look to replace chemotherapy with non-toxic antibody conditioning. The lessons learnt in refining conditioning for HSCT are likely to be equally applicable to gene therapy protocols for the same diseases.
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Affiliation(s)
- Peter Shaw
- Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Judith Shizuru
- Departments of Medicine and Pediatrics, Stanford University, Stanford, CA, United States
| | - Manfred Hoenig
- Klinik für Kinder- und Jugendmedizin, Universitätsklinikum Ulm, Ulm, Germany
| | - Paul Veys
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
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Castagnoli R, Delmonte OM, Calzoni E, Notarangelo LD. Hematopoietic Stem Cell Transplantation in Primary Immunodeficiency Diseases: Current Status and Future Perspectives. Front Pediatr 2019; 7:295. [PMID: 31440487 PMCID: PMC6694735 DOI: 10.3389/fped.2019.00295] [Citation(s) in RCA: 110] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 07/03/2019] [Indexed: 12/29/2022] Open
Abstract
Primary immunodeficiencies (PID) are disorders that for the most part result from mutations in genes involved in immune host defense and immunoregulation. These conditions are characterized by various combinations of recurrent infections, autoimmunity, lymphoproliferation, inflammatory manifestations, atopy, and malignancy. Most PID are due to genetic defects that are intrinsic to hematopoietic cells. Therefore, replacement of mutant cells by healthy donor hematopoietic stem cells (HSC) represents a rational therapeutic approach. Full or partial ablation of the recipient's marrow with chemotherapy is often used to allow stable engraftment of donor-derived HSCs, and serotherapy may be added to the conditioning regimen to reduce the risks of graft rejection and graft versus host disease (GVHD). Initially, hematopoietic stem cell transplantation (HSCT) was attempted in patients with severe combined immunodeficiency (SCID) as the only available curative treatment. It was a challenging procedure, associated with elevated rates of morbidity and mortality. Overtime, outcome of HSCT for PID has significantly improved due to availability of high-resolution HLA typing, increased use of alternative donors and new stem cell sources, development of less toxic, reduced-intensity conditioning (RIC) regimens, and cellular engineering techniques for graft manipulation. Early identification of infants affected by SCID, prior to infectious complication, through newborn screening (NBS) programs and prompt genetic diagnosis with Next Generation Sequencing (NGS) techniques, have also ameliorated the outcome of HSCT. In addition, HSCT has been applied to treat a broader range of PID, including disorders of immune dysregulation. Yet, the broad spectrum of clinical and immunological phenotypes associated with PID makes it difficult to define a universal transplant regimen. As such, integration of knowledge between immunologists and transplant specialists is necessary for the development of innovative transplant protocols and to monitor their results during follow-up. Despite the improved outcome observed after HSCT, patients with severe forms of PID still face significant challenges of short and long-term transplant-related complications. To address this issue, novel HSCT strategies are being implemented aiming to improve both survival and long-term quality of life. This article will discuss the current status and latest developments in HSCT for PID, and present data regarding approach and outcome of HSCT in recently described PID, including disorders associated with immune dysregulation.
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Affiliation(s)
- Riccardo Castagnoli
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States.,Department of Pediatrics, Foundation IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Ottavia Maria Delmonte
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Enrica Calzoni
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States.,Department of Molecular and Translational Medicine, A. Nocivelli Institute for Molecular Medicine, University of Brescia, Brescia, Italy
| | - Luigi Daniele Notarangelo
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
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Immune Reconstitution Therapy for Immunodeficiency. Clin Immunol 2019. [DOI: 10.1016/b978-0-7020-6896-6.00082-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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El-Serafi I, Loy O, Zhao Y, Oerther S, Mattsson J. Pre-formulation investigations for establishing a protocol for treosulfan handling and activation. Pharm Dev Technol 2018; 24:639-648. [PMID: 30474459 DOI: 10.1080/10837450.2018.1551903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Treosulfan is an alkylating agent that is used for the treatment of ovarian cancer and for conditioning prior to stem cell transplantation. It is a prodrug that is activated non-enzymatically to two active epoxides. OBJECTIVES To optimize a protocol for both in vivo samples handling and in vitro drug preparation. Treosulfan stability was tested in biological fluids at different conditions as well as for its cytotoxicity on cell lines. RESULTS Plasma samples can be safely frozen for a short period up to 8 h, however; for longer periods, samples should be acidified. Urine samples and cell culture media can be safely frozen regardless their pH. For in vitro investigations, incubation of treosulfan at 37 °C for 24 h activated 100% of the drug. Whole blood acidification should be avoided for the risk of hemolysis. Finally; treosulfan cytotoxicity on HL-60 cells has increased following pre-incubation for 24 h at 37 °C compared to K562 cell line. CONCLUSION The stability profiling of treosulfan provided a valuable reference for handling of biological samples for both in vivo and in vitro studies. These results can be utilized for further investigations concerning the drug kinetics and dynamics in addition to the development of new pharmaceutical formulations.
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Affiliation(s)
- Ibrahim El-Serafi
- a Department of Laboratory Medicine , Karolinska Institutet , Stockholm , Sweden.,b Department of Clinical and Experimental Medicine , Linköping University , Linköping , Sweden.,c Department of Biochemistry, Faculty of Medicine , Port-Said University, Port-Said , Egypt
| | - Orlaith Loy
- a Department of Laboratory Medicine , Karolinska Institutet , Stockholm , Sweden
| | - Ying Zhao
- a Department of Laboratory Medicine , Karolinska Institutet , Stockholm , Sweden
| | - Sandra Oerther
- a Department of Laboratory Medicine , Karolinska Institutet , Stockholm , Sweden
| | - Jonas Mattsson
- d Department of Oncology and Pathology , Karolinska Institutet , Stockholm , Sweden.,e Department of Hematology , Oslo University Hospital , Oslo , Norway
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36
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Haskoloğlu Ş, Köstel Bal S, İslamoğlu C, Altun D, Kendirli T, Doğu EF, İkincioğulları A. Outcome of treosulfan-based reduced-toxicity conditioning regimens for HSCT in high-risk patients with primary immune deficiencies. Pediatr Transplant 2018; 22:e13266. [PMID: 29992714 DOI: 10.1111/petr.13266] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 06/18/2018] [Indexed: 11/28/2022]
Abstract
INTRODUCTION HSCT is the curative therapeutic option in PIDs. Due to the increase in survival rates, reduced-toxicity conditioning regimens with treosulfan have become another alternative. The purpose of this retrospective study was to analyze the outcome of treosulfan-based conditioning before HSCT for patients with PID. METHOD A total of 15 patients that received a treosulfan-based conditioning regimen for HSCT were recruited. Type of diagnosis, donor and stem cell source, pretransplant organ damage, infections, engraftment, chimerism, and transplant-related toxicities were analyzed. RESULTS At a median follow-up time of 32 months, the overall survival was 86.7%. Following HSCT, 14 of 15 patients had engraftment, with 86.7% of the cohort having full-donor chimerism. The most common toxicity was seen on the skin (53.3%). Acute GVHD and chronic GVHD were documented in 53% and 20% of the study population, respectively. Although the cohort consisted of patients with pretransplant liver damage, SOS manifestations were documented in 20%. CONCLUSION Treosulfan-based conditioning regimens before HSCT are associated with lower toxicity compared to myeloablative regimens, are safe, and have high engraftment rates with full-donor chimerism in patients having PID, regardless of the specified genetic diagnosis and donor type.
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Affiliation(s)
- Şule Haskoloğlu
- Department of Pediatric Allergy and Immunology, Ankara University School of Medicine, Ankara, Turkey
| | - Sevgi Köstel Bal
- Department of Pediatric Allergy and Immunology, Ankara University School of Medicine, Ankara, Turkey
| | - Candan İslamoğlu
- Department of Pediatric Allergy and Immunology, Ankara University School of Medicine, Ankara, Turkey
| | - Demet Altun
- Department of Pediatrics, Ufuk University School of Medicine, Ankara, Turkey
| | - Tanıl Kendirli
- Department of Pediatric Intensive Care, Ankara University School of Medicine, Ankara, Turkey
| | - Esin Figen Doğu
- Department of Pediatric Allergy and Immunology, Ankara University School of Medicine, Ankara, Turkey
| | - Aydan İkincioğulları
- Department of Pediatric Allergy and Immunology, Ankara University School of Medicine, Ankara, Turkey
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Shamriz O, Chandrakasan S. Update on Advances in Hematopoietic Cell Transplantation for Primary Immunodeficiency Disorders. Immunol Allergy Clin North Am 2018; 39:113-128. [PMID: 30466768 DOI: 10.1016/j.iac.2018.08.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Hematopoietic stem cell transplantation (HSCT) in patients with primary immunodeficiency disorders (PIDDs) is being increasingly used as a curative option. Understanding the critical components, such as disease's nature and activity and pre-HSCT and post-HSCT patient care is key to a successful outcome. HSCT should be tailored to the underlying PIDD, as different PIDDs, such as severe combined immune deficiency, Treg dysfunction, and phagocytic disorders, have different transplant approaches. Therefore, successful HSCT in patients with PIDDs requires teamwork between immunologists and transplant physicians. In this article, the authors elaborate on various aspects of PIDD-HSCT and highlight recent advances.
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Affiliation(s)
- Oded Shamriz
- Division of Bone Marrow Transplant, Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University School of Medicine, 2015 Uppergate Drive, ECC Room 418, Atlanta, GA 30030, USA; Pediatric Division, Hadassah-Hebrew University Medical Center, Ein-Kerem, POB 12000, Jerusalem, Israel 91120
| | - Shanmuganathan Chandrakasan
- Division of Bone Marrow Transplant, Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University School of Medicine, 2015 Uppergate Drive, ECC Room 418, Atlanta, GA 30030, USA.
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38
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Allen CE, Marsh R, Dawson P, Bollard CM, Shenoy S, Roehrs P, Hanna R, Burroughs L, Kean L, Talano JA, Schultz KR, Pai SY, Baker KS, Andolina JR, Stenger EO, Connelly J, Ramirez A, Bryant C, Eapen M, Pulsipher MA. Reduced-intensity conditioning for hematopoietic cell transplant for HLH and primary immune deficiencies. Blood 2018; 132:1438-1451. [PMID: 29997222 PMCID: PMC6161764 DOI: 10.1182/blood-2018-01-828277] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 07/01/2018] [Indexed: 12/27/2022] Open
Abstract
Allogeneic hematopoietic cell transplantation (HCT) with myeloablative conditioning for disorders associated with excessive inflammation such as hemophagocytic lymphohistiocytosis (HLH) is associated with early mortality. A multicenter prospective phase 2 trial of reduced-intensity conditioning with melphalan, fludarabine, and intermediate-timing alemtuzumab was conducted for HLA matched or single HLA locus mismatched related or unrelated donor HCT in a largely pediatric cohort. Graft-versus-host disease (GVHD) prophylaxis was cyclosporine with methylprednisolone. The primary end point was 1-year overall survival (OS). Thirty-four patients with HLH and 12 with other primary immune deficiencies were transplanted. With a median follow-up of 20 months, the 1-year OS for transplanted patients was 80.4% (90% confidence interval [CI], 68.6%-88.2%). Five additional deaths by 16 months yielded an 18-month OS probability of 66.7% (90% CI, 52.9%-77.3%). Two patients experienced primary graft failure, and 18 patients either experienced a secondary graft failure or required a second intervention (mostly donor lymphocyte infusion [DLI]). At 1 year, the proportion of patients alive with sustained engraftment without DLI or second HCT was 39.1% (95% CI, 25.2%-54.6%), and that of being alive and engrafted (with or without DLI) was 60.9% (95% CI, 45.4 %-74.9%). The day 100 incidence of grade II to IV acute GVHD was 17.4% (95% CI, 8.1%-29.7%), and 1-year incidence of chronic GVHD was 26.7% (95% CI, 14.6%-40.4%). Although the trial demonstrated low early mortality, the majority of surviving patients required DLI or second HCT. These results demonstrate a need for future approaches that maintain low early mortality with improved sustained engraftment. The trial was registered at Clinical Trials.gov (NCT 01998633).
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Affiliation(s)
- Carl E Allen
- Texas Children's Cancer Center, Texas Children's Hospital, Houston, TX
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Rebecca Marsh
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | | | - Catherine M Bollard
- Center for Cancer and Immunology Research, Children's National Health System and Department of Pediatrics, The George Washington University, Washington, DC
| | - Shalini Shenoy
- Division of Pediatric Hematology-Oncology, Washington University School of Medicine, St. Louis, MO
| | - Philip Roehrs
- Levine Children's Hospital, Carolinas HealthCare System, Charlotte, NC
| | - Rabi Hanna
- Department of Pediatric Hematology and Oncology and BMT, Cleveland Clinic, Cleveland, OH
| | - Lauri Burroughs
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, WA
| | - Leslie Kean
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, WA
- Clinical Research Division, Fred Hutchinson Cancer Research Center, University of Washington School of Medicine, Seattle, WA
- Seattle Children's Hospital, Seattle, WA
| | - Julie-An Talano
- Department of Pediatric Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - Kirk R Schultz
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Sung-Yun Pai
- Division of Pediatric Hematology-Oncology, Boston Children's Hospital and Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - K Scott Baker
- Clinical Research Division, Fred Hutchinson Cancer Research Center, University of Washington School of Medicine, Seattle, WA
- Seattle Children's Hospital, Seattle, WA
| | - Jeffrey R Andolina
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY
| | - Elizabeth O Stenger
- Aflac Center and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Atlanta, GA
| | - James Connelly
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, University of Michigan, Ann Arbor, MI
| | | | | | - Mary Eapen
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI; and
| | - Michael A Pulsipher
- Division of Hematology, Oncology and Blood & Marrow Transplantation, Children's Hospital Los Angeles, Los Angeles, CA
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39
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Hematopoietic Stem Cell Transplantation for Primary Immunodeficiency Disorders: Experience from a Referral Center in India. Indian Pediatr 2018. [DOI: 10.1007/s13312-018-1354-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Shadur B, Zaidman I, NaserEddin A, Lokshin E, Hussein F, Oron HC, Avni B, Grisariu S, Stepensky P. Successful hematopoietic stem cell transplantation for osteopetrosis using reduced intensity conditioning. Pediatr Blood Cancer 2018; 65:e27010. [PMID: 29469225 DOI: 10.1002/pbc.27010] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 01/03/2018] [Accepted: 01/18/2018] [Indexed: 11/05/2022]
Abstract
BACKGROUND Infantile malignant osteopetrosis (IMO) is an autosomal recessive condition characterized by defective osteoclast activity, with hematopoietic bone marrow transplant being the only available cure. Over the past several years, new conditioning regimes and donor options have emerged, thus extending the possibility of cure to a greater number of patients and improving the outcomes of bone marrow transplant. Here we detail the outcomes of bone marrow transplant in a cohort of 31 patients treated with a combination of fludarabine, treosulphan, thiotepa, and antithymocyte globulin. PROCEDURES Thirty-one patients with IMO who underwent hematopoietic stem cell transplantation with fludarabine, treosulphan, thiotepa, and antithymocyte globulin at our center from 2012 to 2017 are retrospectively reviewed in this study. Twenty-six patients were transplanted from 10/10 matched donors (13 from siblings, 11 from unrelated, and two from extended family donors), four from 9/10 matched unrelated donors, and one from a 9/10 matched family donor. RESULTS Overall survival was 100% with a median follow-up of 363 days (range 74-1891). There were 12 cases of acute graft versus host disease (GvHD) (38.7%), no cases of veno-occlusive disease, and eight cases of hypercalcemia (25.8%). Almost 80% of patients suffered viral reactivations with two cases of Epstein-Barr-virus-driven post-transplant lymphoproliferative disease. All cases of GvHD and viral reactivation were successfully treated. CONCLUSIONS We conclude that transplantation in children with IMO using fludarabine, treosulphan, thiotepa, and antithymocyte globulin is safe and effective and should be performed as early as possible following diagnosis, prior to the development of severe disease sequelae.
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Affiliation(s)
- Bella Shadur
- Department of Bone Marrow Transplantation and Cancer Immunotherapy, Hadassah University Medical Center, Jerusalem, Israel.,Immunology Division, Garvan Institute of Medical Research, Sydney, Australia.,Graduate Research School, The University of New South Wales, Sydney, Australia
| | - Irina Zaidman
- Department of Bone Marrow Transplantation and Cancer Immunotherapy, Hadassah University Medical Center, Jerusalem, Israel
| | - Adeeb NaserEddin
- Department of Bone Marrow Transplantation and Cancer Immunotherapy, Hadassah University Medical Center, Jerusalem, Israel
| | - Elana Lokshin
- Department of Bone Marrow Transplantation and Cancer Immunotherapy, Hadassah University Medical Center, Jerusalem, Israel
| | - Fatma Hussein
- Department of Bone Marrow Transplantation and Cancer Immunotherapy, Hadassah University Medical Center, Jerusalem, Israel
| | - Hodaya Cohen Oron
- Department of Bone Marrow Transplantation and Cancer Immunotherapy, Hadassah University Medical Center, Jerusalem, Israel
| | - Batia Avni
- Department of Bone Marrow Transplantation and Cancer Immunotherapy, Hadassah University Medical Center, Jerusalem, Israel
| | - Sigal Grisariu
- Department of Bone Marrow Transplantation and Cancer Immunotherapy, Hadassah University Medical Center, Jerusalem, Israel
| | - Polina Stepensky
- Department of Bone Marrow Transplantation and Cancer Immunotherapy, Hadassah University Medical Center, Jerusalem, Israel
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Connelly JA, Marsh R, Parikh S, Talano JA. Allogeneic Hematopoietic Cell Transplantation for Chronic Granulomatous Disease: Controversies and State of the Art. J Pediatric Infect Dis Soc 2018; 7:S31-S39. [PMID: 29746680 PMCID: PMC5946867 DOI: 10.1093/jpids/piy015] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Chronic granulomatous disease (CGD) is a congenital disorder characterized by recurrent life-threatening bacterial and fungal infections and development of severe inflammation secondary to a congenital defect in 1 of the 5 phagocyte oxidase (phox) subunits of the nicotinamide adenine dinucleotide phosphate (NADPH) oxidase complex. Hematopoietic cell transplant (HCT) is a curative treatment for patients with CGD that provides donor neutrophils with functional NADPH and superoxide anion production. Many characteristics of CGD, including preexisting infection and inflammation and the potential for cure with mixed-donor chimerism, influence the transplant approach and patient outcome. Because of the dangers of short-term death, graft-versus-host disease, and late effects from chemotherapy, HCT historically has been reserved for patients with high-risk disease and a matched donor. However, as advances in CGD and HCT treatments have evolved, recommendations on transplant eligibility also must be amended, but the development of modern guidelines has proven difficult. In this review, we provide an overview of HCT in patients with CGD, including the debate over HCT indications in them, the unique aspects of CGD that can complicate HCT, and a summary of transplant outcomes.
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Affiliation(s)
- James A Connelly
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rebecca Marsh
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital, Ohio
| | - Suhag Parikh
- Division of Pediatric Blood and Marrow Transplantation, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Julie-An Talano
- Division of Hematology/Oncology/Blood and Marrow Transplant, Department of Pediatrics, Medical College of Wisconsin and Children’s Hospital of Wisconsin, Milwaukee,Correspondence: J. A. Connelly, MD, Division of Pediatric Hematology/Oncology, Vanderbilt University Medical Center, 397 PRB, 2220 Pierce Ave, Nashville, TN 37232-6310 ()
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Danielak D, Kasprzyk A, Wróbel T, Wachowiak J, Kałwak K, Główka F. Relationship between exposure to treosulfan and its monoepoxytransformer - An insight from population pharmacokinetic study in pediatric patients before hematopoietic stem cell transplantation. Eur J Pharm Sci 2018; 120:1-9. [PMID: 29705215 DOI: 10.1016/j.ejps.2018.04.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 04/09/2018] [Accepted: 04/23/2018] [Indexed: 11/27/2022]
Abstract
Treosulfan (TREO), a structural analog of busulfan, is currently studied as a myeloablative agent in conditioning regimens before hematopoietic stem cell transplantation in pediatric patients. High exposure to TREO (>1650 mg∗h/mL) might be related to early toxicity, especially skin toxicity and mucositis. The aim of the present study was to investigate a potential relationship between exposure to TREO and its monoepoxytransformer (S,S-EBDM), as well as variability of the pharmacokinetics of these entities by means of a population pharmacokinetic approach with a non-linear mixed-effects analysis. The study included data from 14 children with malignant and non-malignant diseases treated with TREO in daily doses 10-14 g/m2. The parent-metabolite population pharmacokinetic model was developed in NONMEM 7.3 software. Upon the constructed model, an extensive simulation was performed to assess the correlation between exposure to TREO and S,S-EBDM. It was found that TREO and S,S-EBDM pharmacokinetics was best described with 2-compartmental and 1-compartmental linear models, respectively. The vast majority (>65%) of TREO was transformed to S,S-EBDM. Overall, a considerable interpatient variability of pharmacokinetic parameters was observed, especially the clearance of S,S-EBDM. A weak correlation was found between the exposure to TREO and S,S-EBDM (r = 0.1681, p < 0.0001). Also, patients with an exposure to TREO above 1650 mg∗h/mL were most likely to have also a high exposure to S,S-EBDM (35.38 μM∗h vs. 43.14 μM∗h, p < 0.0001). In summary, a parent-metabolite population pharmacokinetic model for TREO and S,S-EBDM was developed for the first time. It was shown that there is a weak correlation between exposure to TREO and S,S-EBDM. Therefore therapeutic drug monitoring of not only prodrug but also its active epoxide might be needed.
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Affiliation(s)
- Dorota Danielak
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Święcickiego 6 St, 60-781 Poznań, Poland.
| | - Anna Kasprzyk
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Święcickiego 6 St, 60-781 Poznań, Poland
| | - Tomasz Wróbel
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Święcickiego 6 St, 60-781 Poznań, Poland
| | - Jacek Wachowiak
- Department of Pediatric Hematology, Oncology and Transplantology, Poznan University of Medical Sciences, 27/33 Szpitalna St, 60-572 Poznań, Poland.
| | - Krzysztof Kałwak
- Department of Pediatric Hematology, Oncology and Bone Marrow Transplantation, Wroclaw Medical University, 44 Bujwida St, 50-368 Wroclaw, Poland
| | - Franciszek Główka
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Święcickiego 6 St, 60-781 Poznań, Poland.
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Laberko A, Gennery AR. Clinical considerations in the hematopoietic stem cell transplant management of primary immunodeficiencies. Expert Rev Clin Immunol 2018; 14:297-306. [PMID: 29589971 DOI: 10.1080/1744666x.2018.1459189] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Primary immunodeficiencies (PID) are genetic immune disorders causing increased predisposition to infections and autoimmunity. The only curative procedure is hematopoietic stem cell transplantation (HSCT), results from which have improved dramatically since 2000. Complications remain a serious issue, especially in HLA non-identical transplantation. In PID patients, persistent infection and autoimmunity with end-organ damage cause particular problems with approach to transplantation. This article examines these, emphasising approach to management and consequences. Areas covered: It is challenging to know which patients should be offered HSCT. As new diseases are discovered, data are required to determine natural history, and HSCT outcomes. Treatment of adults can be challenging, although HSCT outcomes are encouraging. New methods of T-lymphocyte depletion show results comparable to those of matched sibling donor transplants. New cellular therapies to treat viral infections show promising results, and immunomodulatory methods are successful in treating acute graft-versus-host disease. Expert commentary: New T-lymphocyte depletion methods are a paradigm shift in approach to HSCT for PID. In combination with new cellular approaches to treating viral infection, immunomodulatory approaches to acute graft-versus-host disease and better understanding of endothelial activation syndromes, survival approaches 90%. Widespread introduction of newborn screening for severe combined immunodeficiencies will improve survival further.
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Affiliation(s)
- Alexandra Laberko
- a Immunology and Hematopoietic Stem Cell Transplantation Department , Dmitry Rogachev National Center for Pediatric Hematology, Oncology and Immunology , Moscow , Russia
| | - Andrew R Gennery
- b Primary Immunodeficiency Group, Institute of Cellular Medicine , Newcastle University , Newcastle upon Tyne , UK.,c Paediatric Immunology + HSCT , Great North Children's Hospital , Newcastle upon Tyne , UK
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Guilcher GMT, Shah R, Shenoy S. Principles of alemtuzumab immunoablation in hematopoietic cell transplantation for non-malignant diseases in children: A review. Pediatr Transplant 2018; 22. [PMID: 29352515 DOI: 10.1111/petr.13142] [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: 12/29/2017] [Indexed: 12/19/2022]
Abstract
Alemtuzumab is a humanized mAb targeted to CD52. Alemtuzumab is highly immunosuppressive with the ability to deplete T and B cells (in addition to other immune cell lines). A growing understanding of the PKs, dosing, and timing of administration of alemtuzumab has allowed for the study of its use as a conditioning agent for allogeneic HCT. The highly immunosuppressive properties of the drug are particularly appealing in the setting of non-malignant HCT, where GVHD provides no clinical benefit and relapse of malignancy is not applicable. In addition, the degree of immune suppression achieved with alemtuzumab has allowed for a reduction in the intensity of myeloablative cytotoxic agents included in some HCT conditioning regimens, allowing for fewer acute and late toxicities. This review paper will provide a comprehensive summary of the mechanism of action, PKs, dosing, and timing of alemtuzumab, a brief description of its use in various allogeneic HCT protocols for non-malignant conditions and a summary of the data regarding its use for GVHD therapy. The goal of this review was to provide an understanding as to how alemtuzumab might be safely incorporated into HCT conditioning regimens for children with non-malignant disease, allowing for expanded access to curative HCT therapy.
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Affiliation(s)
- Gregory M T Guilcher
- Section of Paediatric Oncology/BMT, Departments of Oncology and Paediatrics, University of Calgary, Calgary, AB, Canada
| | - Ravi Shah
- Department of Paediatric Haematology/BMT, Great Ormond Street Hospital, NHS Foundation Trust, London, UK
| | - Shalini Shenoy
- Division of Pediatric Hematology/Oncology, Washington University School of Medicine, St. Louis, MO, USA
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Fox TA, Chakraverty R, Burns S, Carpenter B, Thomson K, Lowe D, Fielding A, Peggs K, Kottaridis P, Uttenthal B, Bigley V, Buckland M, Grandage V, Denovan S, Grace S, Dahlstrom J, Workman S, Symes A, Mackinnon S, Hough R, Morris E. Successful outcome following allogeneic hematopoietic stem cell transplantation in adults with primary immunodeficiency. Blood 2018; 131:917-931. [PMID: 29279357 PMCID: PMC6225386 DOI: 10.1182/blood-2017-09-807487] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 12/14/2017] [Indexed: 12/14/2022] Open
Abstract
The primary immunodeficiencies (PIDs), rare inherited diseases characterized by severe dysfunction of immunity, have been successfully treated by allogeneic hematopoietic stem cell transplantation (Allo-HSCT) in childhood. Controversy exists regarding optimal timing and use of Allo-HSCT in adults, due to lack of experience and previous poor outcomes. Twenty-nine consecutive adult patients, with a mean age at transplant of 24 years (range, 17-50 years), underwent Allo-HSCT. Reduced-intensity conditioning (RIC) included fludarabine (Flu)/melphalan/alemtuzumab (n = 20), Flu/busulfan (Bu)/alemtuzumab (n = 8), and Flu/Bu/antithymocyte globulin (n = 1). Stem cell donors were matched unrelated donors or mismatched unrelated donors (n = 18) and matched related donors (n = 11). Overall survival (OS), event-free survival, transplant-related mortality (TRM), acute and chronic graft-versus-host disease incidence and severity, time to engraftment, lineage-specific chimerism, immune reconstitution, and discontinuation of immunoglobulin replacement therapy were recorded. OS at 3 years for the whole cohort was 85.2%. The rarer PID patients without chronic granulomatous disease (CGD) achieved an OS at 3 years of 88.9% (n = 18), compared with 81.8% for CGD patients (n = 11). TRM was low with only 4 deaths observed at a median follow-up of 3.5 years. There were no cases of early or late rejection. In all surviving patients, either stable mixed chimerism or full donor chimerism were observed. At last follow-up, 87% of the surviving patients had no evidence of persistent or recurrent infections. Allo-HSCT is safe and effective in young adult patients with severe PID and should be considered the treatment of choice where an appropriate donor is available.
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Affiliation(s)
- Thomas A Fox
- Institute of Immunity and Transplantation, University College London (UCL), London, United Kingdom
- Bone Marrow Transplant (BMT) Programme, UCL Hospital National Health Service Foundation Trust (NHS FT), London, United Kingdom
| | - Ronjon Chakraverty
- Bone Marrow Transplant (BMT) Programme, UCL Hospital National Health Service Foundation Trust (NHS FT), London, United Kingdom
- Department of Haematology, Royal Free London NHS FT, London, United Kingdom
- Department of Haematology, Cancer Institute, UCL, London, United Kingdom
| | - Siobhan Burns
- Institute of Immunity and Transplantation, University College London (UCL), London, United Kingdom
- Bone Marrow Transplant (BMT) Programme, UCL Hospital National Health Service Foundation Trust (NHS FT), London, United Kingdom
- Department of Haematology, Royal Free London NHS FT, London, United Kingdom
| | - Benjamin Carpenter
- Bone Marrow Transplant (BMT) Programme, UCL Hospital National Health Service Foundation Trust (NHS FT), London, United Kingdom
- Teenage and Young Adult BMT Programme, UCL Hospital NHS FT, London, United Kingdom
| | - Kirsty Thomson
- Bone Marrow Transplant (BMT) Programme, UCL Hospital National Health Service Foundation Trust (NHS FT), London, United Kingdom
- Department of Haematology, Cancer Institute, UCL, London, United Kingdom
| | - David Lowe
- Institute of Immunity and Transplantation, University College London (UCL), London, United Kingdom
- Department of Immunology, Royal Free London NHS FT, London, United Kingdom
| | - Adele Fielding
- Bone Marrow Transplant (BMT) Programme, UCL Hospital National Health Service Foundation Trust (NHS FT), London, United Kingdom
- Department of Haematology, Royal Free London NHS FT, London, United Kingdom
- Department of Haematology, Cancer Institute, UCL, London, United Kingdom
| | - Karl Peggs
- Bone Marrow Transplant (BMT) Programme, UCL Hospital National Health Service Foundation Trust (NHS FT), London, United Kingdom
- Department of Haematology, Cancer Institute, UCL, London, United Kingdom
| | - Panagiotis Kottaridis
- Bone Marrow Transplant (BMT) Programme, UCL Hospital National Health Service Foundation Trust (NHS FT), London, United Kingdom
- Department of Haematology, Royal Free London NHS FT, London, United Kingdom
| | - Benjamin Uttenthal
- Department of Haematology, Addenbrookes' Hospital, Cambridge, United Kingdom; and
| | - Venetia Bigley
- Institute of Cellular Medicine, Newcastle University, Newcastle, United Kingdom
| | - Matthew Buckland
- Institute of Immunity and Transplantation, University College London (UCL), London, United Kingdom
- Department of Immunology, Royal Free London NHS FT, London, United Kingdom
| | - Victoria Grandage
- Teenage and Young Adult BMT Programme, UCL Hospital NHS FT, London, United Kingdom
| | - Shari Denovan
- Bone Marrow Transplant (BMT) Programme, UCL Hospital National Health Service Foundation Trust (NHS FT), London, United Kingdom
- Department of Haematology, Royal Free London NHS FT, London, United Kingdom
- Teenage and Young Adult BMT Programme, UCL Hospital NHS FT, London, United Kingdom
| | - Sarah Grace
- Bone Marrow Transplant (BMT) Programme, UCL Hospital National Health Service Foundation Trust (NHS FT), London, United Kingdom
- Department of Haematology, Royal Free London NHS FT, London, United Kingdom
- Teenage and Young Adult BMT Programme, UCL Hospital NHS FT, London, United Kingdom
| | - Julia Dahlstrom
- Bone Marrow Transplant (BMT) Programme, UCL Hospital National Health Service Foundation Trust (NHS FT), London, United Kingdom
- Teenage and Young Adult BMT Programme, UCL Hospital NHS FT, London, United Kingdom
| | - Sarita Workman
- Department of Immunology, Royal Free London NHS FT, London, United Kingdom
| | - Andrew Symes
- Department of Immunology, Royal Free London NHS FT, London, United Kingdom
| | - Stephen Mackinnon
- Bone Marrow Transplant (BMT) Programme, UCL Hospital National Health Service Foundation Trust (NHS FT), London, United Kingdom
- Department of Haematology, Royal Free London NHS FT, London, United Kingdom
- Department of Haematology, Cancer Institute, UCL, London, United Kingdom
| | - Rachael Hough
- Teenage and Young Adult BMT Programme, UCL Hospital NHS FT, London, United Kingdom
| | - Emma Morris
- Institute of Immunity and Transplantation, University College London (UCL), London, United Kingdom
- Bone Marrow Transplant (BMT) Programme, UCL Hospital National Health Service Foundation Trust (NHS FT), London, United Kingdom
- Department of Immunology, Royal Free London NHS FT, London, United Kingdom
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46
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Mohanan E, Panetta JC, Lakshmi KM, Edison ES, Korula A, Na F, Abraham A, Viswabandya A, George B, Mathews V, Srivastava A, Balasubramanian P. Pharmacokinetics and Pharmacodynamics of Treosulfan in Patients With Thalassemia Major Undergoing Allogeneic Hematopoietic Stem Cell Transplantation. Clin Pharmacol Ther 2018; 104:575-583. [PMID: 29247522 DOI: 10.1002/cpt.988] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 12/05/2017] [Accepted: 12/11/2017] [Indexed: 12/28/2022]
Abstract
A treosulfan (Treo)-based conditioning regimen prior to hematopoietic stem cell transplantation (HSCT) has been successfully used in treating hematological malignant and nonmalignant diseases. We report Treo pharmacokinetics (PK) in patients with thalassemia major undergoing HSCT (n = 87), receiving Treo at a dose of 14 g/m2 /day. Median Treo AUC and clearance (CL) was 1,326 mg*h/L and 10.8 L/h/m2 , respectively. There was wide interindividual variability in Treo AUC and CL (64 and 68%) which was not explained by any of the variables tested. None of the Treo PK parameters were significantly associated with graft rejection or toxicity; however, Treo CL <7.97 L/h/m2 was significantly associated with poor overall (hazard ratio (HR) 2.7, confidence interval (CI) (1.09-6.76), P = 0.032) and event-free survival (HR 2.4, CI (0.98-5.73), P = 0.055). Further studies in a larger cohort are warranted to identify the factors explaining the variation in Treo PK as well as to establish a therapeutic range of Treo for targeted dose adjustment to improve HSCT outcome.
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Affiliation(s)
| | - John C Panetta
- St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | | | | | - Anu Korula
- Christian Medical College, Vellore, India
| | - Fouzia Na
- Christian Medical College, Vellore, India
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47
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Slatter MA, Rao K, Abd Hamid IJ, Nademi Z, Chiesa R, Elfeky R, Pearce MS, Amrolia P, Worth A, Flood T, Abinun M, Hambleton S, Qasim W, Gaspar HB, Cant AJ, Gennery AR, Veys P. Treosulfan and Fludarabine Conditioning for Hematopoietic Stem Cell Transplantation in Children with Primary Immunodeficiency: UK Experience. Biol Blood Marrow Transplant 2017; 24:529-536. [PMID: 29155317 DOI: 10.1016/j.bbmt.2017.11.009] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 11/08/2017] [Indexed: 11/17/2022]
Abstract
We previously published results for 70 children who received conditioning with treosulfan and cyclophosphamide (n = 30) or fludarabine (n = 40) before undergoing hematopoietic stem cell transplantation (HSCT) for primary immunodeficiency (PID). Toxicity was lower and T cell chimerism was better in the patients receiving fludarabine, but cohort numbers were relatively small and follow-up was short. Here we report outcomes of 160 children who received homogeneous conditioning with treosulfan, fludarabine, and, in most cases, alemtuzumab (n = 124). The median age at transplantation was 1.36 years (range, .09 to 18.25 years). Donors included 73 matched unrelated, 54 1 to 3 antigen-mismatched unrelated, 12 matched sibling, 17 other matched family, and 4 haploidentical donors. Stem cell source was peripheral blood stem cells (PBSCs) in 70, bone marrow in 49, and cord blood in 41. Median duration of follow-up was 4.3 years (range, .8 to 9.4 years). Overall survival was 83%. No patients had veno-occlusive disease. Seventy-four patients (46%) had acute GVHD, but only 14 (9%) greater than grade II. Four patients underwent successful retransplantation for graft loss or poor immune reconstitution. Another patient experienced graft rejection and died. There was no association between T cell chimerism >95% and stem cell source, but a significant association was seen between myeloid chimerism >95% and use of PBSCs without an increased risk of significant GVHD compared with other sources. All 11 patients with severe combined immunodeficiency diagnosed at birth were alive at up to 8.7 years of follow-up. Long-term studies are needed to determine late gonadotoxic effects, and pharmacokinetic studies are needed to identify whether specific targeting is advantageous. The combination of treosulfan, fludarabine, and alemtuzumab is associated with excellent results in HSCT for PID.
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Affiliation(s)
- Mary A Slatter
- Department of Paediatric Immunology, Newcastle upon Tyne Hospital NHS Foundation Trust, Newcastle upon Tyne, United Kingdom.
| | - Kanchan Rao
- Great Ormond Street Hospital NHS Trust, London, United Kingdom
| | - Intan Juliana Abd Hamid
- Department of Paediatric Immunology, Newcastle upon Tyne Hospital NHS Foundation Trust, Newcastle upon Tyne, United Kingdom; Regenerative Medicine Cluster, Advanced Medical and Dental Institute, Universiti Sains Malaysia, Bertam, Malaysia
| | - Zohreh Nademi
- Department of Paediatric Immunology, Newcastle upon Tyne Hospital NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Robert Chiesa
- Great Ormond Street Hospital NHS Trust, London, United Kingdom
| | - Reem Elfeky
- Great Ormond Street Hospital NHS Trust, London, United Kingdom
| | - Mark S Pearce
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Persis Amrolia
- Great Ormond Street Hospital NHS Trust, London, United Kingdom
| | - Austen Worth
- Great Ormond Street Hospital NHS Trust, London, United Kingdom
| | - Terence Flood
- Department of Paediatric Immunology, Newcastle upon Tyne Hospital NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Mario Abinun
- Department of Paediatric Immunology, Newcastle upon Tyne Hospital NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Sophie Hambleton
- Department of Paediatric Immunology, Newcastle upon Tyne Hospital NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Waseem Qasim
- Great Ormond Street Hospital NHS Trust, London, United Kingdom
| | - Hubert B Gaspar
- Great Ormond Street Hospital NHS Trust, London, United Kingdom
| | - Andrew J Cant
- Department of Paediatric Immunology, Newcastle upon Tyne Hospital NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Andrew R Gennery
- Department of Paediatric Immunology, Newcastle upon Tyne Hospital NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Paul Veys
- Great Ormond Street Hospital NHS Trust, London, United Kingdom
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48
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Heimall J, Cowan MJ. Long term outcomes of severe combined immunodeficiency: therapy implications. Expert Rev Clin Immunol 2017; 13:1029-1040. [PMID: 28918671 PMCID: PMC6019104 DOI: 10.1080/1744666x.2017.1381558] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 09/15/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Newborn screening has led to a better understanding of the prevalence of Severe Combined Immunodeficiency (SCID) overall and in terms of specific genotypes. Survival has improved following hematopoietic stem cell transplantation (HCT) with the best outcomes seen following use of a matched sibling donor. However, questions remain regarding the optimal alternative donor source, appropriate use of conditioning and the impact of these decisions on immune reconstitution and other late morbidities. Areas covered: The currently available literature reporting late effects after HCT for SCID and use of alternative therapies including enzyme replacement, alternative donors and gene therapy are reviewed. A literature search was performed on Pubmed and ClinicalTrials.gov using key words 'Severe Combined Immunodeficiency', 'SCID', 'hematopoietic stem cell transplant', 'conditioning', 'gene therapy', 'SCID newborn screening', 'TREC' and 'late effects'. Expert commentary: Newborn screening has dramatically changed the clinical presentation of newborn SCID. While the majority of patients with SCID survive HCT, data regarding late effects in these patients is limited and additional studies focused on genotype specific late effects are needed. Prospective studies aimed at minimizing the use of alkylating agents and reducing late effects beyond survival are needed. Gene therapy is being developed and will likely become a more commonly used treatment that will require separate consideration of survival and late effects.
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Affiliation(s)
- Jennifer Heimall
- Allergy/Immunology Attending Physician, Perelman School of Medicine, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Morton J. Cowan
- Allergy Immunology and Blood and Marrow Transplant Division, University of California San Francisco, Benioff Children’s Hospital, San Francisco, CA, USA
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49
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Successful Reduced Intensity Conditioning Alternate Donor Stem Cell Transplant for Wiskott-Aldrich Syndrome. J Pediatr Hematol Oncol 2017; 39:e493-e496. [PMID: 28859032 DOI: 10.1097/mph.0000000000000959] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
There are very few reports of reduced intensity conditioning (RIC) hematopoietic stem cell transplant (HSCT) with alternate donor for Wiskott-Aldrich syndrome (WAS) and there is no report of RIC with posttransplant cyclophosphamide (PTCy) in WAS. There is only 1 report of T cell receptor αβ and CD19-depleted haploidentical HSCT for WAS. Here we report successful outcome in 3 children with WAS who underwent successful RIC alternate donor HSCT of whom 2 (matched unrelated donor and T-cell replete haploidentical) received PTCy and 1 underwent T cell receptor αβ and CD19-depleted haploidentical HSCT. We modified conditioning used by Luznik for haploidentical HSCT by adding thiotepa 8 mg/kg and Campath or rabbit antithymoglobulin for 2 cases who received PTCy. In third case we gave fludarabine, thiotepa, and treosulfan-based conditioning. The mean duration of follow-up for these patients was 23.6 months posttransplant (range, 21 to 26 mo). All 3 patients are transfusion independent. Acute graft versus host disease (GVHD) grade I occurred in 1 and none had chronic GVHD. Chimerism of all 3 was fully donor (>95% donor) at D+30 and D+100 posttransplant. All are alive, healthy, and doing well. Our 3 cases highlight that with newer conditioning and GVHD prophylaxis approach alternate donor HSCT in WAS can become a safe and effective treatment option.
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50
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Gössling KL, Schipp C, Fischer U, Babor F, Koch G, Schuster FR, Dietzel-Dahmen J, Wieczorek D, Borkhardt A, Meisel R, Kuhlen M. Hematopoietic Stem Cell Transplantation in an Infant with Immunodeficiency, Centromeric Instability, and Facial Anomaly Syndrome. Front Immunol 2017; 8:773. [PMID: 28713390 PMCID: PMC5491950 DOI: 10.3389/fimmu.2017.00773] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Accepted: 06/19/2017] [Indexed: 12/19/2022] Open
Abstract
Immunodeficiency, centromeric instability, and facial anomaly (ICF) syndrome is a rare autosomal recessive genetic condition with severe immunodeficiency, which leads to lethal infections if not recognized and treated in early childhood. Up-to-date treatment regimens consist of prophylactic and supportive treatment of the recurrent infections. Here, we report the case of a 1-year-old boy of Moroccan consanguineous parents, who was diagnosed at 4 months of age with ICF syndrome with a homozygous missense mutation in the DNMT3B gene. He was initially admitted to the hospital with recurrent pulmonary infections from the opportunistic pathogen Pneumocystis jirovecii (PJ). Further immunological workup revealed agammaglobulinemia in the presence of B cells. After successful recovery from the PJ pneumonia, he underwent hematopoietic stem cell transplantation (HSCT) from the HLA-matched healthy sister using a chemotherapeutic conditioning regimen consisting of treosulfan, fludarabine, and thiotepa. Other than acute chemotherapy-associated side effects, no serious adverse events occurred. Six months after HSCT immune-reconstitution, he had a stable chimerism with 2.9% autologous portion in the peripheral blood and a normal differential blood cell count, including all immunoglobulin subtypes. This is one of the first cases of successful HSCT in ICF syndrome. Early diagnosis and subsequent HSCT can prevent severe opportunistic infections and cure the immunodeficiency. Centromeric instability and facial anomaly remain unaffected. Although the long-term patient outcome and the neurological development remain to be seen, this curative therapy for immunodeficiency improves life expectancy and quality of life. This case is meant to raise physicians awareness for ICF syndrome and highlight the consideration for HSCT in ICF syndrome early on.
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Affiliation(s)
- Katharina L Gössling
- Medical Faculty, Department of Pediatric Oncology, Hematology and Clinical Immunology, University of Düsseldorf, Düsseldorf, Germany
| | - Cyrill Schipp
- Medical Faculty, Department of Pediatric Oncology, Hematology and Clinical Immunology, University of Düsseldorf, Düsseldorf, Germany
| | - Ute Fischer
- Medical Faculty, Department of Pediatric Oncology, Hematology and Clinical Immunology, University of Düsseldorf, Düsseldorf, Germany
| | - Florian Babor
- Medical Faculty, Department of Pediatric Oncology, Hematology and Clinical Immunology, University of Düsseldorf, Düsseldorf, Germany
| | - Gerhard Koch
- Department of Pediatrics, Allgemeines Krankenhaus Hagen, Hagen, Germany
| | - Friedhelm R Schuster
- Medical Faculty, Department of Pediatric Oncology, Hematology and Clinical Immunology, University of Düsseldorf, Düsseldorf, Germany
| | - Jutta Dietzel-Dahmen
- Medical Faculty, Department of Human Genetics, University of Düsseldorf, Düsseldorf, Germany
| | - Dagmar Wieczorek
- Medical Faculty, Department of Human Genetics, University of Düsseldorf, Düsseldorf, Germany
| | - Arndt Borkhardt
- Medical Faculty, Department of Pediatric Oncology, Hematology and Clinical Immunology, University of Düsseldorf, Düsseldorf, Germany
| | - Roland Meisel
- Medical Faculty, Department of Pediatric Oncology, Hematology and Clinical Immunology, University of Düsseldorf, Düsseldorf, Germany
| | - Michaela Kuhlen
- Medical Faculty, Department of Pediatric Oncology, Hematology and Clinical Immunology, University of Düsseldorf, Düsseldorf, Germany
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