51
|
Effect of increased dose of total body irradiation on graft failure associated with HLA-haploidentical transplantation in patients with severe haemoglobinopathies: a prospective clinical trial. LANCET HAEMATOLOGY 2019; 6:e183-e193. [PMID: 30878319 DOI: 10.1016/s2352-3026(19)30031-6] [Citation(s) in RCA: 91] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 01/21/2019] [Accepted: 01/22/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND Although severe haemoglobinopathies can be cured with allogeneic blood or bone marrow transplantation, availability of matched donors and toxic effects can be problematic. We previously found that non-myeloablative haploidentical related bone marrow transplantation with post-transplantation cyclophosphamide expanded the donor pool while limiting graft-versus-host disease (GVHD). However, graft failure-albeit with full host haemopoietic recovery-occurred in 50% of patients. In this study, we investigated whether increasing total body irradiation from 200 cGy to 400 cGy would improve engraftment while maintaining the safety profile. METHODS This study was done at Johns Hopkins Hospital (Baltimore, MD, USA). Patients aged 2-70 years receiving their first bone marrow transplant were eligible for inclusion in the study. Patients received rabbit-derived intravenous anti-thymocyte globulin 0·5 mg/kg on day -9 and 2 mg/kg on days -8 and -7, intravenous fludarabine 30 mg/m2 on days -6 to -2, intravenous cyclophosphamide 14·5 mg/kg on days -6 and -5, and total body irradiation 400 cGy administered as a single fraction on day -1. We collected unmanipulated bone marrow and infused on day 0. GVHD prophylaxis comprised intravenous cyclophosphamide 50 mg/kg per day on days 3 and 4 after transplantation, oral mycophenolate mofetil 15 mg/kg per dose (maximum 1 g) every 8 h on days 5 to 35, and oral sirolimus to maintain a level of 5-15 ng/dL for at least 1 year starting on day 5. The original planned primary objectives of this phase 2 clinical trial were transplant-related mortality and progression-free survival. However, the coverage decision by the Centers for Medicare and Medicaid Services to only provide payment for allogeneic bone marrow transplantation for patients with sickle cell disease on a clinical trial that had a comparison arm with patients not receiving bone marrow transplantation prompted the closure of this trial to accrual in 2017. Therefore, as we were unable to perform our planned statistical analysis, the primary objective was modified to evaluate engraftment, assessed by chimerism. This trial is registered with ClinicalTrials.gov, number NCT00489281. The study is closed to new participants and this is the primary analysis. FINDINGS Between Sept 24, 2014, and Aug 1, 2017, we enrolled 17 consecutive patients: 12 (71%) with sickle cell disease and 5 (29%) with β-thalassaemia major. The median patient age was 16 years (range 6-31, IQR 7·7-27·5). One (6%) of 17 patients had primary graft failure with recovery of host haemopoiesis. 13 (76%) of 17 patients achieved full donor chimerism and three (18%) had mixed donor-host chimerism. Five (29%) of 17 patients developed grade 2-4 acute GVHD, including four (24%) with maximal grade 2 GVHD and one (6%) with grade 3 GVHD. Chronic GVHD developed in three (18%) patients. As of their last follow-up visit, GVHD had resolved in all patients and no patients were receiving systemic GVHD therapy. All patients remained alive as of Aug 4, 2019, and the median follow-up duration was 705 days (range 355-1294; IQR 398-943). Only one (6%) of the 16 engrafted patients remained transfusion dependent, and 14 (88%) discontinued immunosuppression. INTERPRETATION Increasing total body irradiation to 400 cGy substantially reduced graft failure while maintaining the safety of haploidentical bone marrow transplantation with post-transplantation cyclophosphamide. These results suggest that engraftment after haploidentical bone marrow transplantation for haemoglobinopathies is possible, and primary graft failure-the main problem previously reported-might be addressed by this strategy. Therefore, this curative approach should no longer be restricted to patients with HLA-matched donors. FUNDING Maryland Stem Cell Research Fund and US National Institutes of Health.
Collapse
|
52
|
King AA, McKinstry RC, Wu J, Eapen M, Abel R, Varughese T, Kamani N, Shenoy S. Functional and Radiologic Assessment of the Brain after Reduced-Intensity Unrelated Donor Transplantation for Severe Sickle Cell Disease: Blood and Marrow Transplant Clinical Trials Network Study 0601. Biol Blood Marrow Transplant 2019; 25:e174-e178. [PMID: 30639825 DOI: 10.1016/j.bbmt.2019.01.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 01/01/2019] [Indexed: 02/09/2023]
Abstract
Stroke and cognitive decline are hallmarks of sickle cell disease (SCD). The natural history of SCD predicts progressive loss of 1 IQ point per year attributable to disease-related pathology. Hematopoietic cell transplantation (HCT) is curative by reverting to donor-derived erythropoiesis, but evidence that HCT can positively influence disease-induced cognitive decline is lacking. The Sickle Cell Unrelated Transplant Trial prospectively evaluated cognition and brain magnetic resonance imaging (MRI) findings at 2 years after reduced-intensity conditioning followed by unrelated donor HCT. Thirteen study participants completed pre-HCT and post-HCT assessments of intelligence. The mean age of participants was 12.5 ± 3.3 years (range, 6.7 to 17.4 years). Eleven of the 13 recipients completed imaging studies at baseline and post-HCT. Seven had overt stroke pre-HCT, and 1 had an elevated transcranial Doppler velocity with abnormal MRI. The mean Full-Scale IQ was stable: 90.9 ± 13 at baseline and 91.2 ± 13 post-HCT. The mean Performance IQ was 89.9 ± 13 at baseline versus 90.9 ± 13 post-HCT, and mean Verbal IQ was 93.4 ± 13 at baseline versus 93.2 ± 13 post-HCT, respectively. Six recipients had stable MRI; 2 showed resolution of all areas of infarction. Three had additional infarcts post-HCT noted at the 2-year time point. This is the first report describing stabilization of IQ and central nervous system outcomes after unrelated donor HCT despite previous central nervous system morbidity and post-HCT posterior reversible encephalopathy syndrome. These preliminary results post-HCT suggest that HCT may stabilize the cognitive decline of SCD and should continue to be followed over the long term.
Collapse
Affiliation(s)
- Allison A King
- Dept. of Pediatrics, Division of Hematology and Oncology, Program in Occupational Therapy, Washington University School of Medicine, St. Louis Children's Hospital, St Louis, Missouri.
| | - Robert C McKinstry
- Dept. of Radiology, Section of Neuroradiology, Washington University School of Medicine, St. Louis Children's Hospital, St Louis, Missouri
| | - Juan Wu
- The Emmes Corporation, Rockville, Maryland
| | - Mary Eapen
- Dept. of Medicine, Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Regina Abel
- Program in Occupational Therapy, Washington University School of Medicine, St. Louis Children's Hospital, St Louis, Missouri
| | - Taniya Varughese
- Program in Occupational Therapy, Washington University School of Medicine, St. Louis Children's Hospital, St Louis, Missouri
| | - Naynesh Kamani
- Division of Allergy Immunology, Children's National Medical Center, Washington, DC
| | - Shalini Shenoy
- Dept. of Pediatrics, Division of Hematology and Oncology, Washington University School of Medicine, St. Louis Children's Hospital, St Louis, Missouri
| |
Collapse
|
53
|
Robin M, Raj K, Chevret S, Gauthier J, de Lavallade H, Michonneau D, McLornan D, Peffault de Latour R, Potter V, Kulasekararaj A, Sicre de Fontbrune F, Pagliuca A, Yakoub-Agha I, Socié G, Mufti GJ. Alemtuzumab vs anti-thymocyte globulin in patients transplanted from an unrelated donor after a reduced intensity conditioning. Eur J Haematol 2018; 101:466-474. [PMID: 29714032 DOI: 10.1111/ejh.13085] [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] [Accepted: 04/13/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Relapse and graft-vs-host disease (GVHD) are still the main complications after allogeneic hematopoietic stem cell transplantation, especially in the setting of reduced intensity regimen (RIC) and unrelated donor. We compared here anti-thymocyte globulin (ATG) or alemtuzumab as GVHD prophylaxis in patients with myeloid disease transplanted after RIC and from an unrelated donor. METHOD ATG and alemtuzumab patients have been matched by age, gender, HLA matching, comorbidities and cytogenetics risk (119 patients in each group). RESULTS After matching, we found that ATG decreased the risk of relapse (HR: 0.55, P = .0049) and improved relapse-free survival (RFS, HR: 0.70, P = .042). The improved RFS with ATG was more pronounced in CMV-positive patients but was not influenced by disease risk. Regarding overall survival, GVHD-free relapse-free survival and transplant-related mortality, the risk was similar using ATG or alemtuzumab. CONCLUSION Even if GVHD risk is lowered by alemtuzumab use, it does not translate in better outcome due to higher risk of relapse.
Collapse
Affiliation(s)
- Marie Robin
- Service d'hématologie greffe, Hôpital Saint-Louis, APHP, Paris, France.,INSERM 1131 Université Paris 7, Paris, France
| | - Kavita Raj
- Department of Haematological Medicine, Kings College Hospital and Kings College London, London, UK
| | - Sylvie Chevret
- Service de biostatistique, Hôpital Saint-Louis, APHP, Université Paris 7, Paris, France
| | - Jordan Gauthier
- CHU de Lille, LIRIC INSERM U955, Université Lille2, Paris, France
| | - Hugues de Lavallade
- Department of Haematological Medicine, Kings College Hospital and Kings College London, London, UK
| | - David Michonneau
- Service d'hématologie greffe, Hôpital Saint-Louis, APHP, Paris, France.,INSERM 1160 Université Paris 7, Paris, France
| | - Donal McLornan
- Department of Haematological Medicine, Kings College Hospital and Kings College London, London, UK
| | | | - Victoria Potter
- Department of Haematological Medicine, Kings College Hospital and Kings College London, London, UK
| | - Austin Kulasekararaj
- Department of Haematological Medicine, Kings College Hospital and Kings College London, London, UK
| | | | - Antonio Pagliuca
- Department of Haematological Medicine, Kings College Hospital and Kings College London, London, UK
| | - Ibrahim Yakoub-Agha
- Service de biostatistique, Hôpital Saint-Louis, APHP, Université Paris 7, Paris, France
| | - Gérard Socié
- Service d'hématologie greffe, Hôpital Saint-Louis, APHP, Paris, France.,INSERM 1160 Université Paris 7, Paris, France
| | - Ghulam J Mufti
- Department of Haematological Medicine, Kings College Hospital and Kings College London, London, UK
| |
Collapse
|
54
|
Kapoor S, Little JA, Pecker LH. Advances in the Treatment of Sickle Cell Disease. Mayo Clin Proc 2018; 93:1810-1824. [PMID: 30414734 DOI: 10.1016/j.mayocp.2018.08.001] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 07/08/2018] [Accepted: 08/07/2018] [Indexed: 12/26/2022]
Abstract
Sickle cell disease (SCD) is a monogenic disorder that afflicts approximately 100,000 Americans and millions of people worldwide. It is characterized by hemolytic anemia, vaso-occlusive crises, relentless end-organ injury, and premature death. Currently, red blood cell transfusion and hydroxyurea are the major disease-modifying therapies available for SCD. Hematopoetic stem cell transplant is curative, but barriers to treatment are substantial and include a lack of suitable donors, immunologic transplant rejection, long-term adverse effects, prognostic uncertainty, and poor end-organ function, which is especially problematic for older patients. Gene therapy to correct the βs point mutation is under investigation as another curative modality. Deeper insights into the pathophysiology of SCD have led to the development of novel agents that target cellular adhesion, inflammation, oxidant injury, platelets and/or coagulation, vascular tone, and hemoglobin polymerization. These agents are in preclinical and clinical trials. One such agent, L-glutamine, decreases red blood cell oxidant injury and is recently US Food and Drug Administration approved to prevent acute pain episodes of SCD in patients 5 years of age or older. The purpose of this review is to describe the currently established therapies, barriers to curative therapies, and novel therapeutic agents that can target sickle cell hemoglobin polymerization and/or its downstream sequelae. A PubMed search was conducted for articles published up to May 15, 2018, using the search terms sickle cell disease, novel treatments, hematopoietic stem cell transplantation, and gene therapy. Studies cited include case series, retrospective studies, prospective clinical trials, meta-analyses, online abstracts, and original reviews.
Collapse
Affiliation(s)
- Sargam Kapoor
- Division of Hematology/Oncology, Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH; Division of Hematology/Oncology, Case Western Reserve University, Cleveland, OH
| | - Jane A Little
- Division of Hematology/Oncology, Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH; Division of Hematology/Oncology, Case Western Reserve University, Cleveland, OH
| | - Lydia H Pecker
- Division of Pediatric Hematology, Johns Hopkins University School of Medicine, Baltimore, MD.
| |
Collapse
|
55
|
Haploidentical Bone Marrow Transplantation with Post-Transplantation Cyclophosphamide Plus Thiotepa Improves Donor Engraftment in Patients with Sickle Cell Anemia: Results of an International Learning Collaborative. Biol Blood Marrow Transplant 2018; 25:1197-1209. [PMID: 30500440 DOI: 10.1016/j.bbmt.2018.11.027] [Citation(s) in RCA: 97] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 11/24/2018] [Indexed: 12/19/2022]
Abstract
Curative therapy for individuals with severe sickle cell disease (SCD) who lack an HLA-identical sibling donor has been frustratingly elusive. In with the goal of improving engraftment while minimizing transplantation-related morbidity, a multi-institutional learning collaborative was developed in the context of a Phase II clinical trial of nonmyeloablative, related HLA-haploidentical (haplo) bone marrow transplantation (BMT) with post-transplantation cyclophosphamide. All eligible participants had hemoglobin SS, and 89% (16 of 18) had an identifiable donor. The median patient age was 20.9 years (IQR, 12.1 to 26.0 years), and the most common indication for transplantation was overt stroke (in 69%; 11 of 16). In the first 3 patients, the conditioning regimen consisted of antithymocyte globulin, fludarabine, cyclophosphamide, and low-dose total body irradiation. Graft-versus-host disease (GVHD) prophylaxis included post-transplantation cyclophosphamide, mycophenolate mofetil, and sirolimus. Primary graft rejection occurred in 2 of the 3 patients (67%), which triggered the study-stopping rule. To reduce graft rejection risk, thiotepa was added to the conditioning regimen, and then 15 patients (including 2 with previous graft rejection) underwent haplo-BMT with this thiotepa-augmented conditioning regimen. At a median follow-up of 13.3 months (interquartile range [IQR], 3.8 to 23.1 months), 93% (14 of 15) had >95% stable donor engraftment at 6 months, with 100% overall survival. The median time to neutrophil engraftment (>500) was 22 days (IQR, 19 to 27 days), and that for platelet engraftment (>50 x 109/L) was 28 days (IQR, 27 days to not reached). Two patients had grade III-IV acute GVHD, 1 patient had mild chronic GVHD, and 86% of patients (6 of 7) were off immunosuppression therapy by 1-year post-transplantation. Our data suggest that haplo-BMT with post-transplantation cyclophosphamide and thiotepa improves donor engraftment without significantly increasing morbidity or mortality and could dramatically expand curative options for individuals with SCD.
Collapse
|
56
|
Thanarajasingam G, Minasian LM, Baron F, Cavalli F, De Claro RA, Dueck AC, El-Galaly TC, Everest N, Geissler J, Gisselbrecht C, Gribben J, Horowitz M, Ivy SP, Jacobson CA, Keating A, Kluetz PG, Krauss A, Kwong YL, Little RF, Mahon FX, Matasar MJ, Mateos MV, McCullough K, Miller RS, Mohty M, Moreau P, Morton LM, Nagai S, Rule S, Sloan J, Sonneveld P, Thompson CA, Tzogani K, van Leeuwen FE, Velikova G, Villa D, Wingard JR, Wintrich S, Seymour JF, Habermann TM. Beyond maximum grade: modernising the assessment and reporting of adverse events in haematological malignancies. Lancet Haematol 2018; 5:e563-e598. [PMID: 29907552 PMCID: PMC6261436 DOI: 10.1016/s2352-3026(18)30051-6] [Citation(s) in RCA: 97] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Revised: 03/28/2018] [Accepted: 03/29/2018] [Indexed: 02/06/2023]
Abstract
Tremendous progress in treatment and outcomes has been achieved across the whole range of haematological malignancies in the past two decades. Although cure rates for aggressive malignancies have increased, nowhere has progress been more impactful than in the management of typically incurable forms of haematological cancer. Population-based data have shown that 5-year survival for patients with chronic myelogenous and chronic lymphocytic leukaemia, indolent B-cell lymphomas, and multiple myeloma has improved markedly. This improvement is a result of substantial changes in disease management strategies in these malignancies. Several haematological malignancies are now chronic diseases that are treated with continuously administered therapies that have unique side-effects over time. In this Commission, an international panel of clinicians, clinical investigators, methodologists, regulators, and patient advocates representing a broad range of academic and clinical cancer expertise examine adverse events in haematological malignancies. The issues pertaining to assessment of adverse events examined here are relevant to a range of malignancies and have been, to date, underexplored in the context of haematology. The aim of this Commission is to improve toxicity assessment in clinical trials in haematological malignancies by critically examining the current process of adverse event assessment, highlighting the need to incorporate patient-reported outcomes, addressing issues unique to stem-cell transplantation and survivorship, appraising challenges in regulatory approval, and evaluating toxicity in real-world patients. We have identified a range of priority issues in these areas and defined potential solutions to challenges associated with adverse event assessment in the current treatment landscape of haematological malignancies.
Collapse
Affiliation(s)
| | - Lori M Minasian
- National Cancer Institute, National Institutes of Health, Department of Health & Human Services, Bethesda, MD, USA
| | - Frederic Baron
- Division of Haematology, University of Liege, Liege, Belgium
| | - Franco Cavalli
- Oncology Institute of Southern Switzerland, Bellinzona, Switzlerand
| | - R Angelo De Claro
- Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Amylou C Dueck
- Department of Health Sciences Research, Mayo Clinic, Scottsdale, AZ, USA
| | - Tarec C El-Galaly
- Department of Haematology, Aalborg University Hospital, Aalborg Denmark
| | - Neil Everest
- Haematology Clinical Evaluation Unit, Therapeutic Goods Administration, Department of Health, Symondston, ACT, Australia
| | - Jan Geissler
- Leukaemia Patient Advocates Foundation, Bern, Switzerland
| | - Christian Gisselbrecht
- Haemato-Oncology Department, Hopital Saint-Louis, Paris Diderot University VII, Paris, France
| | - John Gribben
- Centre for Haemato-Oncology, Barts Cancer Institute, London, UK
| | - Mary Horowitz
- Division of Haematology and Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - S Percy Ivy
- National Cancer Institute, National Institutes of Health, Department of Health & Human Services, Bethesda, MD, USA
| | - Caron A Jacobson
- Division of Haematologic Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Armand Keating
- Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Paul G Kluetz
- Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Aviva Krauss
- Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Yok Lam Kwong
- Department of Haematology and Haematologic Oncology, University of Hong Kong, Hong Kong, China
| | - Richard F Little
- National Cancer Institute, National Institutes of Health, Department of Health & Human Services, Bethesda, MD, USA
| | | | - Matthew J Matasar
- Lymphoma and Adult BMT Services, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | | | - Robert S Miller
- CancerLinQ, American Society of Clinical Oncology, Alexandria, VA, USA
| | - Mohamad Mohty
- Haematology and Cellular Therapy Department, Saint-Antoine Hospital, University Pierre & Marie Curie, Paris, France
| | | | - Lindsay M Morton
- National Cancer Institute, National Institutes of Health, Department of Health & Human Services, Bethesda, MD, USA
| | - Sumimasa Nagai
- University of Tokyo, Tokyo, Japan; Pharmaceuticals and Medical Devices Agency, Tokyo, Japan
| | - Simon Rule
- Plymouth University Medical School, Plymouth, UK
| | - Jeff Sloan
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Pieter Sonneveld
- Department of Haematology, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | | | | | | | - Galina Velikova
- Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
| | - Diego Villa
- Division of Medical Oncology, British Columbia Cancer Agency, University of British Columbia, Vancouver, BC, Canada
| | - John R Wingard
- Division of Haematology & Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Sophie Wintrich
- Myelodysplastic Syndrome (MDS) Alliance and MDS UK Patient Support Group, London, UK
| | - John F Seymour
- Department of Haematology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Royal Melbourne Hospital, Melbourne, VIC, Australia; University of Melbourne, Melbourne, VIC, Australia
| | | |
Collapse
|
57
|
Hulbert ML, Shenoy S. Hematopoietic stem cell transplantation for sickle cell disease: Progress and challenges. Pediatr Blood Cancer 2018; 65:e27263. [PMID: 29797658 DOI: 10.1002/pbc.27263] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 05/04/2018] [Accepted: 05/07/2018] [Indexed: 02/06/2023]
Abstract
Sickle cell disease (SCD) presents challenges to hematopoietic stem cell transplantation (HSCT), including donor availability and morbidity with age/disease severity. However, severe SCD causes irreversible organ damage that HSCT can mitigate. This benefit must be balanced against preparative regimen toxicity, graft-versus-host disease, and mortality risk. We review efforts to balance HSCT complications with the promise of cure, and knowledge gaps that warrant further investigation. We highlight the burden of SCD, HSCT risks and benefits, and SCD families' approach to this balance. We emphasize the necessity for information exchange to ensure a joint decision-making process between providers and patients.
Collapse
Affiliation(s)
- Monica L Hulbert
- Division of Pediatric Hematology/Oncology, Washington University in St. Louis, St. Louis, Missouri
| | - Shalini Shenoy
- Division of Pediatric Hematology/Oncology, Washington University in St. Louis, St. Louis, Missouri
| |
Collapse
|
58
|
Leonard A, Tisdale J. Stem cell transplantation in sickle cell disease: therapeutic potential and challenges faced. Expert Rev Hematol 2018; 11:547-565. [PMID: 29883237 PMCID: PMC8459571 DOI: 10.1080/17474086.2018.1486703] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 06/06/2018] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Sickle cell disease (SCD) is the most common inherited hemoglobinopathy worldwide, and is a life-limiting disease with limited therapeutic options to reduce disease severity. Despite being a monogenic disorder, the clinical phenotypes of SCD are variable, with few reliable predictors of disease severity easily identifying patients where the benefits of curative therapy outweigh the risks. Allogeneic hematopoietic stem cell transplantation (HSCT) is the only curative option, though significant advances in gene therapy raise the promise for additional curative methods. Areas covered: Allogeneic transplantation in SCD has evolved and improved over the last two decades, now offering a standard of care curative option using a human leukocyte antigen (HLA)-matched sibling donor. Many of the seminal transplantation studies are reviewed here, demonstrating how initial failures and successes have influenced and led to current HSCT strategies. Such strategies aim to overcome setbacks and limitations, and focus on conditioning regimens, immune suppression methods, the use alternative donor sources, and gene therapy approaches. Expert commentary: SCD is a curable disease. Each dedicated effort to refine transplantation methods, expand the donor pool, and bring gene therapy models to fruition will make enormous impacts reducing disease burden and improving outcomes and quality of life for patients with SCD.
Collapse
Affiliation(s)
- Alexis Leonard
- Molecular and Clinical Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of
Health, Bethesda, MD, USA
- Center for Cancer and Blood Disorders, Children’s National Health System, Washington, DC, USA
| | - John Tisdale
- Molecular and Clinical Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of
Health, Bethesda, MD, USA
| |
Collapse
|
59
|
Shenoy S, Walters MC, Ngwube A, Soni S, Jacobsohn D, Chaudhury S, Grimley M, Chan K, Haight A, Kasow KA, Parikh S, Andreansky M, Connelly J, Delgado D, Godder K, Hale G, Nieder M, Pulsipher MA, Trachtenberg F, Neufeld E, Kwiatkowski JL, Thompson AA. Unrelated Donor Transplantation in Children with Thalassemia using Reduced-Intensity Conditioning: The URTH Trial. Biol Blood Marrow Transplant 2018; 24:1216-1222. [PMID: 29374585 PMCID: PMC5993578 DOI: 10.1016/j.bbmt.2018.01.023] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Accepted: 01/18/2018] [Indexed: 01/19/2023]
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) can cure transfusion-dependent thalassemia (TDT). In a multicenter trial we investigated the efficacy of reduced-intensity conditioning (RIC) before unrelated donor (URD) HSCT in children with TDT. Thirty-three children, ages 1 to 17 years, received bone marrow (BM) or umbilical cord blood (UCB) allografts. Median time to neutrophil engraftment was 13 days (range, 10 to 25) and 24 days (range, 18 to 49) and platelet engraftment 23 days (range, 12 to 46) and 50 days (range, 31 to 234) after BM and UCB allografts, respectively. With a median follow-up of 58 months (range, 7 to 79), overall and thalassemia-free survival was 82% (95% CI, .64% to .92%) and 79% (95% CI, .6% to .9%), respectively. The cumulative incidence of grades II to IV acute graft-versus-host disease (GVHD) after BM and UCB allografts was 24% and 44%; the 2-year cumulative incidence of chronic extensive GVHD was 29% and 21%, respectively; 71% of BM and 91% of UCB recipients discontinued systemic immunosuppression by 2 years. Six patients who had Pesaro risk class 2 (n = 5) and class 3 (n = 1) died of GVHD (n = 3), viral pneumonitis (n = 2) and pulmonary hemorrhage (n = 1). Outcomes after this RIC compared favorably with URD HSCT outcomes for TDT and supported engraftment in 32 of 33 patients. Efforts to reduce GVHD and infectious complications are being pursued further.
Collapse
Affiliation(s)
- Shalini Shenoy
- Department of Pediatrics, St. Louis Children's Hospital, Washington University, St. Louis, Missouri.
| | - Mark C Walters
- Department of Pediatrics, UCSF Benioff Children's Hospital, Oakland, California
| | - Alex Ngwube
- Department of Pediatrics, Phoenix Children's Hospital, Phoenix, Arizona
| | - Sandeep Soni
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California
| | - David Jacobsohn
- Department of Pediatrics, Children's National Medical Center, Washington, DC
| | - Sonali Chaudhury
- Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois
| | - Michael Grimley
- Department of Pediatrics, Texas Transplant Institute, San Antonio, Texas
| | - Kawah Chan
- Department of Pediatrics, Texas Transplant Institute, San Antonio, Texas
| | - Ann Haight
- Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | - Kimberley A Kasow
- Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina
| | - Suhag Parikh
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Martin Andreansky
- Department of Pediatrics, University of Miami, Holtz Children's Hospital, Miami, Florida
| | - Jim Connelly
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - David Delgado
- Department of Pediatrics, Riley Children's Hospital, Indianapolis, Indiana
| | - Kamar Godder
- Department of Pediatrics, Nicklaus Children's Hospital, Miami, Florida
| | - Gregory Hale
- Department of Pediatrics, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Michael Nieder
- Department of Pediatrics, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Michael A Pulsipher
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California
| | - Felicia Trachtenberg
- Department of Pediatrics, New England Research Institutes, Boston, Massachusetts
| | - Ellis Neufeld
- Department of Pediatrics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Janet L Kwiatkowski
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alexis A Thompson
- Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois
| |
Collapse
|
60
|
Abstract
Sickle cell disease (SCD) complications begin with the polymerization of sickle hemoglobin (HbS). Thus, SCD therapies are focused on preventing HbS production or reducing the circulating amount of HbS. Hydroxyurea treatment has become more widespread, whereas the number of evidence-based indications for erythrocyte transfusion is small. Hematopoietic stem cell transplant is a curative option for SCD but less than 25% of patients have a suitable donor. This article focuses on supportive and preventive care improvements and the benefits of hydroxyurea. Indications for erythrocyte transfusion, hematopoietic stem cell transplant, and gene therapy trials are also summarized.
Collapse
Affiliation(s)
- Emily Riehm Meier
- Sickle Cell Research, Indiana Hemophilia and Thrombosis Center, 8326 Naab Road, Indianapolis, IN 46260, USA.
| |
Collapse
|
61
|
Sarri G, Bhor M, Abogunrin S, Farmer C, Nandal S, Halloway R, Revicki DA. Systematic literature review and assessment of patient-reported outcome instruments in sickle cell disease. Health Qual Life Outcomes 2018; 16:99. [PMID: 29784054 PMCID: PMC5963009 DOI: 10.1186/s12955-018-0930-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Accepted: 05/10/2018] [Indexed: 12/15/2022] Open
Abstract
Background Sickle cell disease (SCD) is a chronic condition associated with high mortality and morbidity. It is characterized by acute clinical symptoms such as painful vaso-occlusive crises, which can impair health-related quality of life (HRQL). This study was conducted to identify validated patient-reported outcome (PRO) instruments for use in future trials of potential treatments for SCD. Methods A systematic literature review (SLR) was performed using MEDLINE and EMBASE to identify United States (US)-based studies published in English between 1997 and 2017 that reported on validated PRO instruments used in randomized controlled trials and real-world settings. The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist was used to assess the quality of PRO instruments. Results The SLR included 21 studies assessing the psychometric properties of 24 PRO instruments. Fifteen of those instruments were developed and validated for adults and 10 for children (one instrument was used in both children and young adults aged up to 21 years). Only five of the 15 adult instruments and three of the 10 pediatric instruments were developed specifically for SCD. For most instruments, there were few or no data on validation conducted in SCD development cohorts. Of the 24 PRO instruments identified, 16 had strong internal reliability (Cronbach’s α ≥0.80). There was often insufficient information to assess the content validity, construct validity, responsiveness, or test-retest reliability of the instruments identified for both child and adult populations. No validated PRO instruments measuring caregiver burden in SCD were identified. Conclusions The evidence on the psychometric properties of PRO instruments was limited. However, the results of this SLR provide key information on such tools to help inform the design of future clinical trials for patients with SCD in the US. Electronic supplementary material The online version of this article (10.1186/s12955-018-0930-y) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Grammati Sarri
- Evidera, Metro Building, 6th Floor, 1 Butterwick, London, W6 8DL, UK.
| | - Menaka Bhor
- Novartis, One Health Plaza, East Hanover, NJ, 07936-1080, USA
| | - Seye Abogunrin
- Evidera, Metro Building, 6th Floor, 1 Butterwick, London, W6 8DL, UK
| | - Caroline Farmer
- Evidera, Metro Building, 6th Floor, 1 Butterwick, London, W6 8DL, UK
| | - Savita Nandal
- Novartis, One Health Plaza, East Hanover, NJ, 07936-1080, USA
| | - Rashid Halloway
- Novartis, One Health Plaza, East Hanover, NJ, 07936-1080, USA
| | - Dennis A Revicki
- Evidera, 7101 Wisconsin Ave, Suite 1400, Bethesda, MD, 20814, USA
| |
Collapse
|
62
|
Damlaj M, Alaskar A, Ghazi S, Alahmari B, Alhejazi A, Al-Zahrani M. Peripheral hematopoietic stem cell mobilization utilizing growth factors in donors with sickle cell trait is safe and effective. Bone Marrow Transplant 2018; 53:1366-1368. [PMID: 29743574 DOI: 10.1038/s41409-018-0208-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 03/30/2018] [Accepted: 04/03/2018] [Indexed: 11/09/2022]
Affiliation(s)
- Moussab Damlaj
- Department of Oncology, King Abdulaziz Medical City, Riyadh, Saudi Arabia. .,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia. .,King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
| | - Ahmed Alaskar
- Department of Oncology, King Abdulaziz Medical City, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Samer Ghazi
- Department of Oncology, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Bader Alahmari
- Department of Oncology, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Ayman Alhejazi
- Department of Oncology, King Abdulaziz Medical City, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Mohsen Al-Zahrani
- Department of Oncology, King Abdulaziz Medical City, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| |
Collapse
|
63
|
Esrick EB, Bauer DE. Genetic therapies for sickle cell disease. Semin Hematol 2018; 55:76-86. [PMID: 29958563 DOI: 10.1053/j.seminhematol.2018.04.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 04/30/2018] [Indexed: 12/20/2022]
Abstract
After decades with few novel therapeutic options for sickle cell disease (SCD), autologous hematopoietic stem cell (HSC) based genetic therapies including lentiviral gene therapy (GT), and genome editing (GE) now appear imminent. Lentiviral GT has advanced considerably in the past decade with promising clinical trial results in multiple disorders. For β-hemoglobinopathies, GT strategies of gene addition and fetal hemoglobin induction through BCL11A regulation are both being evaluated in open clinical trials. GE techniques offer the possibility of a nonviral curative approach, either through sickle hemoglobin mutation repair or fetal hemoglobin elevation. Although GE currently remains at the preclinical stage, multiple clinical trials will likely open soon. In addition to reviewing current strategies for GT and GE, this review highlights important next steps toward optimization of these therapies. All autologous cell-based genetic therapies rely on safely obtaining an adequate yield of autologous HSCs for genetic modification and transplantation. HSC collection is uniquely challenging in SCD. Peripheral mobilization with plerixafor has recently emerged as a promising approach. The acute and long-term toxicities associated with myeloablative conditioning are risks that may not be acceptable to a significant number of SCD patients, highlighting the need for novel conditioning regimens. Finally, increasing availability of autologous genetic therapies will require comprehensive and collaborative discussions regarding cost and access for SCD patients, at individual centers and worldwide.
Collapse
Affiliation(s)
- Erica B Esrick
- Division of Hematology/Oncology, Boston Children's Hospital, Boston, MA; Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Daniel E Bauer
- Division of Hematology/Oncology, Boston Children's Hospital, Boston, MA; Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA.
| |
Collapse
|
64
|
Hematopoietic stem cell transplantation for adult sickle cell disease in the era of universal donor availibility. Bone Marrow Transplant 2018; 53:1390-1400. [DOI: 10.1038/s41409-018-0193-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 02/13/2018] [Accepted: 03/28/2018] [Indexed: 12/13/2022]
|
65
|
Joseph JJ, Abraham AA, Fitzhugh CD. When there is no match, the game is not over: Alternative donor options for hematopoietic stem cell transplantation in sickle cell disease. Semin Hematol 2018; 55:94-101. [PMID: 29958565 DOI: 10.1053/j.seminhematol.2018.04.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 04/18/2018] [Indexed: 12/31/2022]
Abstract
Many patients with sickle cell disease experience severe morbidity and early mortality. The only curative option remains hematopoietic stem cell transplantation. Although HLA-matched sibling transplantation has been very successful for adults and children, the vast majority of patients with sickle cell disease do not have an HLA-matched sibling. Alternative donor options include haploidentical, unrelated umbilical cord blood, and matched unrelated donor transplantation. This report summarizes major alternative donor transplantation studies reported to date and ongoing and upcoming clinical trials. We conclude that when there is no HLA-match, all these approaches should be systematically considered before ruling out the option of hematopoietic stem cell transplantation.
Collapse
Affiliation(s)
- Jacinth J Joseph
- Sickle Cell Branch, National Heart, Lung, and Blood Institute, Bethesda, MD; Department of Hematology, Washington Hospital Center/Georgetown University, Washington, DC
| | - Allistair A Abraham
- Division of Blood and Marrow Transplantation, Children's National Health System, Washington, DC
| | - Courtney D Fitzhugh
- Sickle Cell Branch, National Heart, Lung, and Blood Institute, Bethesda, MD.
| |
Collapse
|
66
|
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.
Collapse
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
| |
Collapse
|
67
|
Abstract
BACKGROUND Sickle cell disease causes significant morbidity and mortality and affects the economic and healthcare status of many countries. Yet historically, the disease has not had commensurate outlays of funds that have been aimed at research and development of drugs and treatment procedures for other diseases. METHODS This review examines several treatment modalities and new drugs developed since the late 1990s that have been used to improve outcomes for patients with sickle cell disease. RESULTS Targeted therapies based upon the pathophysiologic mechanisms of sickle cell disease that result in organ dysfunction and painful episodes include hydroxyurea, L-glutamine, crizanlizumab, and other drugs that are currently on the market or are on the verge of becoming available. These agents have the potential to improve survival and quality of life for individuals with sickle cell disease. Also discussed is stem cell transplantation that, to date, is the only curative approach for this disease, as well as the current status of gene therapy. CONCLUSION These examples demonstrate how the current knowledge of sickle cell disease pathophysiology and treatment approaches intersect. Although interest in sickle cell research has blossomed, many more clinical trials need to be initiated and subjected to more strenuous examination and analysis than have been used in the past.
Collapse
Affiliation(s)
- Renée V. Gardner
- Department of Pediatrics, Louisiana State University Health Sciences Center, Children’s Hospital of New Orleans, New Orleans, LA
| |
Collapse
|
68
|
Kassim AA, Sharma D. Hematopoietic stem cell transplantation for sickle cell disease: The changing landscape. Hematol Oncol Stem Cell Ther 2017. [DOI: 10.1016/j.hemonc.2017.05.008] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
|
69
|
Abstract
PURPOSE OF REVIEW As the safety and availability of allogeneic hematopoietic stem cell transplantation (HSCT) have improved, this procedure is becoming a viable option for nonmalignant conditions such as sickle cell disease (SCD). There are very few treatment options available for SCD, and even with optimal care SCD patients still suffer from a myriad of comorbidities to multiple organ systems and have a decreased life span. In this review, we will summarize results from trials of HSCT for children or adults with SCD using a variety of graft sources as well as conditioning and graft-versus-host disease prophylaxis regimens, and discuss the unique challenges that arise in these patients. RECENT FINDINGS AlloHSCT for SCD has been performed on small numbers of patients at multiple centers around the world using several different transplant platforms, and early outcomes are encouraging. Overall survival is excellent, although graft failure remains a challenge. SUMMARY As alloHSCT becomes safer and more widely available, the procedure should be considered for patients with severe disease phenotypes in whom the potential benefits of transplantation outweigh the complications from the disease. AlloHSCT has been shown to reverse or at least halt the progression of end-organ damage secondary to SCD. More research is needed to understand the mechanisms underlying graft failure in SCD recipients, as well as to understand the biopsychosocial underpinnings of persistent pain in the posttransplant period to maximize the benefit from the transplant procedure.
Collapse
|
70
|
Rangarajan HG, Abu-Arja R, Pai V, Guilcher GMT, Soni S. Outcomes of Unrelated Donor Stem Cell Transplantion with Post-Transplant Cyclophosphamide for Graft-versus-Host Disease Prophylaxis in Patients with Severe Sickle Cell Disease. Biol Blood Marrow Transplant 2017; 24:413-417. [PMID: 29061531 DOI: 10.1016/j.bbmt.2017.10.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 10/15/2017] [Indexed: 10/18/2022]
Abstract
Unrelated donor (URD) hematopoietic cell transplantation (HCT) in children with sickle cell disease (SCD) is associated with a high incidence of rejection and graft-versus-host disease (GVHD). We report on the first 4 patients with severe SCD who underwent URD HCT using a novel myeloablative and immunosuppressive regimen composed of busulfan, fludarabine, and antithymocyte globulin with a single dose of post-transplant cyclophosphamide along with tacrolimus and mycophenolate mofetil for GVHD prophylaxis. Three patients engrafted and remain disease-free after a median follow-up period of 2.5 years. One patient had primary graft failure attributed to low stem cell content of the graft. Of interest, none of the engrafted patients developed acute or chronic GVHD. This preparative regimen along with the use of post-transplant cyclophosphamide offers a promising approach for unrelated donor transplants in patients with SCD and needs further corroboration in larger number of patients.
Collapse
Affiliation(s)
- Hemalatha G Rangarajan
- Division of Pediatric Hematology, Oncology and Bone Marrow Transplant, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatrics, The Ohio State University, Columbus, Ohio
| | - Rolla Abu-Arja
- Division of Pediatric Hematology, Oncology and Bone Marrow Transplant, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatrics, The Ohio State University, Columbus, Ohio
| | - Vinita Pai
- Division of Pediatric Hematology, Oncology and Bone Marrow Transplant, Nationwide Children's Hospital, Columbus, Ohio; Department of Pharmacy, Nationwide Children's Hospital, Columbus, Ohio
| | - Gregory M T Guilcher
- Section of Pediatric Oncology and Blood and Marrow Transplant, Alberta Children's Hospital, Departments of Oncology and Pediatrics, University of Calgary Faculty of Medicine, Calgary, Alberta, Canada
| | - Sandeep Soni
- Division of Stem Cell Transplant and Regenerative Medicine, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California.
| |
Collapse
|
71
|
Bauer DE, Brendel C, Fitzhugh CD. Curative approaches for sickle cell disease: A review of allogeneic and autologous strategies. Blood Cells Mol Dis 2017; 67:155-168. [PMID: 28893518 DOI: 10.1016/j.bcmd.2017.08.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 08/31/2017] [Indexed: 02/05/2023]
Abstract
Despite sickle cell disease (SCD) first being reported >100years ago and molecularly characterized >50years ago, patients continue to experience severe morbidity and early mortality. Although there have been substantial clinical advances with immunizations, penicillin prophylaxis, hydroxyurea treatment, and transfusion therapy, the only cure that can be offered is hematopoietic stem cell transplantation (HSCT). In this work, we summarize the various allogeneic curative approaches reported to date and discuss open and upcoming clinical research protocols. Then we consider gene therapy and gene editing strategies that may enable cure based on autologous HSCs.
Collapse
Affiliation(s)
- Daniel E Bauer
- Division of Hematology/Oncology, Boston Children's Hospital, Department of Pediatric Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02115, United States; Harvard Stem Cell Institute, Department of Pediatrics, Harvard Medical School, Boston, MA 02115, United States.
| | - Christian Brendel
- Gene Therapy Program, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA 02115, United States
| | - Courtney D Fitzhugh
- Sickle Cell Branch, National Heart, Lung, and Blood Institute, Bethesda, MD 20892, United States.
| |
Collapse
|
72
|
Unrelated Umbilical Cord Blood Transplantation for Sickle Cell Disease Following Reduced-Intensity Conditioning: Results of a Phase I Trial. Biol Blood Marrow Transplant 2017; 23:1587-1592. [DOI: 10.1016/j.bbmt.2017.05.027] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 05/28/2017] [Indexed: 01/08/2023]
|
73
|
da Silva-Malta MCF, Rodrigues PS, Zuccherato LW, de Souza FCB, Domingues EMFL, Souza VR, Tarazona-Santos E, Martins ML. Human leukocyte antigen distribution and genomic ancestry in Brazilian patients with sickle cell disease. HLA 2017; 90:211-218. [DOI: 10.1111/tan.13102] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 06/13/2017] [Accepted: 07/18/2017] [Indexed: 12/11/2022]
Affiliation(s)
- M. C. F. da Silva-Malta
- Fundação Centro de Hematologia e Hemoterapia de Minas Gerais - Hemominas; Belo Horizonte Brazil
| | - P. S. Rodrigues
- Fundação Centro de Hematologia e Hemoterapia de Minas Gerais - Hemominas; Belo Horizonte Brazil
| | - L. W. Zuccherato
- Departamento de Biologia Geral, Instituto de Ciências Biológicas; Universidade Federal de Minas Gerais; Belo Horizonte Brazil
| | - F. C. B. de Souza
- Fundação Centro de Hematologia e Hemoterapia de Minas Gerais - Hemominas; Belo Horizonte Brazil
| | - E. M. F. L. Domingues
- Fundação Centro de Hematologia e Hemoterapia de Minas Gerais - Hemominas; Belo Horizonte Brazil
| | - V. R. Souza
- Fundação Centro de Hematologia e Hemoterapia de Minas Gerais - Hemominas; Belo Horizonte Brazil
| | - E. Tarazona-Santos
- Departamento de Biologia Geral, Instituto de Ciências Biológicas; Universidade Federal de Minas Gerais; Belo Horizonte Brazil
| | - M. L. Martins
- Fundação Centro de Hematologia e Hemoterapia de Minas Gerais - Hemominas; Belo Horizonte Brazil
| |
Collapse
|
74
|
Ware RE, de Montalembert M, Tshilolo L, Abboud MR. Sickle cell disease. Lancet 2017; 390:311-323. [PMID: 28159390 DOI: 10.1016/s0140-6736(17)30193-9] [Citation(s) in RCA: 560] [Impact Index Per Article: 80.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 11/11/2016] [Accepted: 11/18/2016] [Indexed: 01/08/2023]
Abstract
Sickle cell disease is a common and life-threatening haematological disorder that affects millions of people worldwide. Abnormal sickle-shaped erythrocytes disrupt blood flow in small vessels, and this vaso-occlusion leads to distal tissue ischaemia and inflammation, with symptoms defining the acute painful sickle-cell crisis. Repeated sickling and ongoing haemolytic anaemia, even when subclinical, lead to parenchymal injury and chronic organ damage, causing substantial morbidity and early mortality. Currently available treatments are limited to transfusions and hydroxycarbamide, although stem cell transplantation might be a potentially curative therapy. Several new therapeutic options are in development, including gene therapy and gene editing. Recent advances include systematic universal screening for stroke risk, improved management of iron overload using oral chelators and non-invasive MRI measurements, and point-of-care diagnostic devices. Controversies include the role of haemolysis in sickle cell disease pathophysiology, optimal management of pregnancy, and strategies to prevent cerebrovascular disease.
Collapse
Affiliation(s)
- Russell E Ware
- Division of Hematology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
| | | | - Léon Tshilolo
- Centre Hospitalier Monkole, Kinshasa, Democratic Republic of Congo
| | - Miguel R Abboud
- Department of Pediatrics, American University of Beirut, Beirut, Lebanon
| |
Collapse
|
75
|
Alternative donor hematopoietic stem cell transplantation for sickle cell disease. Blood Adv 2017; 1:1215-1223. [PMID: 29296761 DOI: 10.1182/bloodadvances.2017005462] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 05/15/2017] [Indexed: 11/20/2022] Open
Abstract
Most patients who could be cured of sickle cell disease (SCD) with stem cell transplantation do not have a matched sibling donor. Successful use of alternative donors, including mismatched family members, could provide a donor for almost all patients with SCD. The use of a reduced-intensity conditioning regimen may decrease late adverse effects. Ten patients with symptomatic SCD underwent CD34+ cell-selected, T-cell-depleted peripheral blood stem cell transplantation from a mismatched family member or unrelated donor. A reduced-intensity conditioning regimen including melphalan, thiotepa, fludarabine, and rabbit anti-thymocyte globulin was used. Patients were screened for a companion study for immune reconstitution that included a donor lymphocyte infusion given 30-42 days after transplant with intravenous methotrexate as graft-versus-host disease (GVHD) prophylaxis. Seven eligible patients were treated on the companion study. Nine of 10 patients are alive with a median follow-up of 49 months (range, 14-60 months). Surviving patients have stable donor hematopoietic engraftment (mean donor chimerism, 99.1% ± 0.7%). There were no sickle cell complications after transplant. Two patients had grade II-IV acute GVHD. One patient had chronic GVHD. Epstein-Barr virus-related posttransplant lymphoproliferative disorder (PTLD) occurred in 3 patients, and 1 patient died as a consequence of treatment of PTLD. Two-year overall survival was 90%, and event-free survival was 80%. A reduced-intensity conditioning regimen followed by CD34+ cell-selected, T-cell-depleted alternative donor peripheral blood stem cell transplantation achieved primary engraftment in all patients with a low incidence of GVHD, although PTLD was problematic. This trial was registered at clinicaltrials.gov as #NCT00968864.
Collapse
|
76
|
Bernaudin F, Kuentz M. [Is transplantation an alternative to the transfusional impasse in sickle cell disease?]. Transfus Clin Biol 2017. [PMID: 28648733 DOI: 10.1016/j.tracli.2017.06.007] [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: 11/28/2022]
Abstract
Sickle cell disease is the most frequent genetic disease in France, concerning 400 newborns each year. The management of these Afro-Caribbean patients requires frequent transfusions from Caucasian donors. Due to important erythroid antigenic differences between Caucasian and African, the prevalence of allo-immunization is high in this population with a risk of transfusional impasse. Allogeneic stem cell transplantation is the only curative treatment for this disease and the replacement of red cells and lymphocytes of the sickle cell patient by those of the donor can also resolve the transfusional impasse. However, a close consultation between physicians from the blood bank and transplantation unit will be required for the choice of conditioning regimen and GvH prophylaxis in order to ensure the transition from a mixed chimerism to the full donor curative graft.
Collapse
Affiliation(s)
- F Bernaudin
- Centre de référence de la drépanocytose, centre hospitalier intercommunal de Créteil (CHIC), 40, avenue de Verdun, 94010 Créteil, France; Société francophone de greffe de moelle et de thérapie cellulaire, 8, rue Jean-Walter, 59000 Lille, France.
| | - M Kuentz
- Société francophone de greffe de moelle et de thérapie cellulaire, 8, rue Jean-Walter, 59000 Lille, France
| |
Collapse
|
77
|
Durable Chimerism and Long-Term Survival after Unrelated Umbilical Cord Blood Transplantation for Pediatric Hemophagocytic Lymphohistiocytosis: A Single-Center Experience. Biol Blood Marrow Transplant 2017. [PMID: 28647558 DOI: 10.1016/j.bbmt.2017.06.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening disorder of immune dysregulation characterized by fever, hepatosplenomegaly, cytopenias, central nervous system disease, increased inflammatory markers, and hemophagocytosis. Currently, allogeneic hematopoietic stem cell transplantation is the only curative approach for patients with HLH, with reported survival ranging from 50% to 70% with myeloablative conditioning (MAC) regimens. However, donor availability and transplantation-related mortality associated with conventional MAC are major barriers to success. Unrelated umbilical cord blood transplantation (UCBT) provides a readily available alternative donor source for patients lacking matched related donors. Accordingly, we report the results of UCBT in 14 children treated between 1998 and 2016. All children received standard HLH chemotherapy before UCBT. The median age at diagnosis was 2.7 months (range, .8 to 10.4) and at transplantation was 7.5 months (range, 3.8 to 17). Ten patients received MAC with busulfan/cyclophosphamide/etoposide /antithymocyte globulin (ATG) (n = 5), busulfan/cyclophosphamide /ATG (n = 4), or busulfan /melphalan/ATG (n = 1). Four patients received reduced-toxicity conditioning (RTC) with alemtuzumab/fludarabine/melphalan/hydroxyurea ± thiotepa. Cord blood units were mismatched at either 1 (n = 9) or 2 (n = 5) loci and delivered a median total nucleated cell dose of 11.9 × 107/kg (range, 4.6 to 27.9) and CD34+ dose of 3.1 × 105/kg (range, 1.1 to 6.8). The cumulative incidence of neutrophil engraftment by day 42 was 78.6% (95% confidence interval [CI], 42.9% to 93.4%) with a median of 19 days (range, 13 to 27), and that for platelet (50,000) engraftment by day 100 was 64.3% (95% CI, 28.2% to 85.7%) with a median of 51 days (range, 31 to 94). Six patients developed either grade II (n = 5) or grade IV (n = 1) acute graft-versus-host disease (GVHD); no extensive chronic GVHD was seen. Ten patients (71.4%) are alive and well at a median of 11.2 years after transplantation (range, .85 to 18.25), 9 of whom maintain sustained full donor chimerism after a single UCBT, whereas 1 patient with autologous recovery after first UCBT with RTC has achieved full donor chimerism after a second UCBT with MAC. This series demonstrates that, in combination with standard HLH therapy, UCBT after MAC or RTC conditioning can provide long-term survival with durable complete donor chimerism comparable to that of conventional donors. UCBT should be considered for patients with HLH lacking a fully matched related or unrelated adult donor.
Collapse
|
78
|
Pasha R, Elmoazzen H, Pineault N. Development and testing of a stepwise thaw and dilute protocol for cryopreserved umbilical cord blood units. Transfusion 2017; 57:1744-1754. [DOI: 10.1111/trf.14136] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 03/08/2017] [Accepted: 03/13/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Roya Pasha
- Canadian Blood Services, Centre for Innovation
| | - Heidi Elmoazzen
- Cord Blood Bank and Stem Cell Manufacturing; Canadian Blood Services
| | - Nicolas Pineault
- Canadian Blood Services, Centre for Innovation
- Department of Biochemistry, Microbiology and Immunology Department; University of Ottawa; Ottawa Ontario Canada
| |
Collapse
|
79
|
Reduced toxicity, myeloablative HLA-haploidentical hematopoietic stem cell transplantation with post-transplantation cyclophosphamide for sickle cell disease. Ann Hematol 2017; 96:1373-1377. [DOI: 10.1007/s00277-017-3030-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 05/23/2017] [Indexed: 01/08/2023]
|
80
|
Bidirectional immune tolerance in nonmyeloablative MHC-mismatched BMT for murine β-thalassemia. Blood 2017; 129:3017-3030. [PMID: 28351935 DOI: 10.1182/blood-2016-03-704387] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 02/28/2017] [Indexed: 12/20/2022] Open
Abstract
Nonmyeloablative conditioning using total lymphoid irradiation (TLI) and rabbit antithymocyte serum (ATS) (the murine preclinical equivalent of antithymocyte globulin [ATG]) facilitates immune tolerance after bone marrow transplantation (BMT) across major histocompatibility complex (MHC) disparities and may be a useful strategy for nonmalignant disorders. We previously reported that donor effector T-cell function and graft-versus-host disease (GVHD) are regulated via recipient invariant natural killer T-cell (iNKT) interleukin-4-driven expansion of donor Foxp3+ naturally occurring regulatory T cells (Tregs). This occurs via recipient iNKT- and STAT6-dependent expansion of recipient myeloid dendritic cells (MDCs) that induce contact-dependent expansion of donor Treg through PD-1/PD ligand signaling. After TLI/ATS + BMT, Gr-1lowCD11c+ MDCs and Gr-1highCD11cneg myeloid-derived suppressor cells (MDSCs) were enriched in GVHD target organs. We now report that the recovery of both recipient MDSCs (P < .01) and MDCs (P < .01) is significantly increased when the alkylator cyclophosphamide (CTX) is added to TLI/ATS conditioning. In a BALB/c → B6 lethal GVHD model, adoptive transfer of MDSCs from TLI/ATS/CTX-conditioned recipients is associated with significantly improved GVHD colitis and survival (P < .001), conversion of MDSCs to PD ligand-expressing MDCs, and increased donor naturally occurring Treg recovery (P < .01) compared with control treatment. Using BALB/c donors and β-thalassemic HW-80 recipients, we found significantly improved rates of engraftment and GVHD following TLI/ATS/CTX compared with TLI/ATS, lethal or sublethal total body irradiation/ATS/CTX, or CTX/ATS conditioning. These data provide preclinical support for trials of TLI/ATG/alkylator regimens for MHC-mismatched BMT for hemoglobinopathies. The data also delineate innate immune mechanisms by which TLI/ATS/CTX conditioning may augment transplantation tolerance.
Collapse
|
81
|
Stenger EO, Chinnadurai R, Yuan S, Garcia M, Arafat D, Gibson G, Krishnamurti L, Galipeau J. Bone Marrow-Derived Mesenchymal Stromal Cells from Patients with Sickle Cell Disease Display Intact Functionality. Biol Blood Marrow Transplant 2017; 23:736-745. [PMID: 28132869 DOI: 10.1016/j.bbmt.2017.01.081] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 01/24/2017] [Indexed: 12/31/2022]
Abstract
Hematopoietic cell transplantation (HCT) is the only cure for sickle cell disease (SCD), but engraftment remains challenging in patients lacking matched donors. Infusion of mesenchymal stromal cells (MSCs) at the time of HCT may promote hematopoiesis and ameliorate graft-versus-host disease. Experimental murine models suggest MSC major histocompatibility complex compatibility with recipient impacts their in vivo function, suggesting autologous MSCs could be superior to third-party MSCs for promoting HCT engraftment. Here we tested whether bone marrow (BM)-derived MSCs from SCD subjects have comparable functionality compared with MSCs from healthy volunteers. SCD MSC doubling time and surface marker phenotype did not differ significantly from non-SCD. Third-party and autologous (SCD) T cell proliferation was suppressed in a dose-dependent manner by all MSCs. SCD MSCs comparably expressed indoleamine-2,3-dioxygenase, which based on transwell and blocking experiments appeared to be the dominant immunomodulatory pathway. The expression of key genes involved in hematopoietic stem cell (HSC)-MSC interactions was minimally altered between SCD and non-SCD MSCs. Expression was, however, altered by IFN-γ stimulation, particularly CXCL14, CXCL26, CX3CL1, CKITL, and JAG1, indicating the potential to augment MSC expression by cytokine stimulation. These data demonstrate the feasibility of expanding BM-derived MSCs from SCD patients that phenotypically and functionally do not differ per International Society of Cell Therapy essential criteria from non-SCD MSCs, supporting initial evaluation (primarily for safety) of autologous MSCs to enhance haploidentical HSC engraftment in SCD.
Collapse
Affiliation(s)
- Elizabeth O Stenger
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia.
| | - Raghavan Chinnadurai
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Shala Yuan
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Marco Garcia
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Dalia Arafat
- School of Biology, Georgia Institute of Technology, Atlanta, Georgia
| | - Greg Gibson
- School of Biology, Georgia Institute of Technology, Atlanta, Georgia
| | - Lakshmanan Krishnamurti
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia
| | - Jacques Galipeau
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia; Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| |
Collapse
|
82
|
Özdoğu H, Boğa C. Hematopoietic Stem Cell Transplantation in Adult Sickle Cell Disease: Problems and Solutions. Turk J Haematol 2017; 32:195-205. [PMID: 25912490 PMCID: PMC4563194 DOI: 10.4274/tjh.2014.0311] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Sickle cell disease-related organ injuries cannot be prevented despite hydroxyurea use, infection prophylaxis, and supportive therapies. As a consequence, disease-related mortality reaches 14% in adolescents and young adults. Hematopoietic stem cell transplantation is a unique curative therapeutic approach for sickle cell disease. Myeloablative allogeneic hematopoietic stem cell transplantation is curative for children with sickle cell disease. Current data indicate that long-term disease-free survival is about 90% and overall survival about 95% after transplantation. However, it is toxic in adults due to organ injuries. In addition, this curative treatment approach has several limitations, such as difficulties to find donors, transplant-related mortality, graft loss, graft-versus-host disease (GVHD), and infertility. Engraftment effectivity and toxicity for transplantations performed with nonmyeloablative reduced-intensity regimens in adults are being investigated in phase 1/2 trials at many centers. Preliminary data indicate that GVHD could be prevented with transplantations performed using reduced-intensity regimens. It is necessary to develop novel regimens to prevent graft loss and reduce the risk of GVHD.
Collapse
|
83
|
Fitzhugh CD, Abraham A, Hsieh MM. Alternative Donor/Unrelated Donor Transplants for the β-Thalassemia and Sickle Cell Disease. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2017; 1013:123-153. [PMID: 29127679 DOI: 10.1007/978-1-4939-7299-9_5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Considerable progress with respect to donor source has been achieved in allogeneic stem cell transplant for patients with hemoglobin disorders, with matched sibling donors in the 1980s, matched unrelated donors and cord blood sources in the 1990s, and haploidentical donors in the 2000s. Many studies have solidified hematopoietic progenitors from matched sibling marrow, cord blood, or mobilized peripheral blood as the best source-with the lowest graft rejection and graft versus host disease (GvHD), and highest disease-free survival rates. For patients without HLA-matched sibling donors, but who are otherwise eligible for transplant, fully allelic matched unrelated donor (8/8 HLA-A, B, C, DRB1) appears to be the next best option, though an ongoing study in patients with sickle cell disease will provide data that are currently lacking. There are high GvHD rates and low engraftment rates in some of the unrelated cord transplant studies. Haploidentical donors have emerged in the last decade to have less GvHD; however, improvements are needed to increase the engraftment rate. Thus the decision to use unrelated cord blood units or haploidentical donors may depend on the institutional expertise; there is no clear preferred choice over the other. Active research is ongoing in expanding cord blood progenitor cells to overcome the limitation of cell dose, including the options of small molecule inhibitor compounds added to ex vivo culture or co-culture with supportive cell lines. There are inconsistent data from using 7/8 or lower matched unrelated donors. Before routine use of these less matched donor sources, work is needed to improve patient selection, conditioning regimen, GvHD prophylaxis, and/or other strategies.
Collapse
Affiliation(s)
- Courtney D Fitzhugh
- Molecular and Clinical Hematology Branch, National Institutes of Health, National Heart, Lung and Blood Institute, 9000 Rockville Pike, Bldg 10 9N112, Bethesda, MD, 20892, USA
| | - Allistair Abraham
- Blood and Marrow Transplant, Children's National Hospital System, 111 Michigan Avenue NW, Washington, DC, 20010, USA
| | - Matthew M Hsieh
- Molecular and Clinical Hematology Branch, National Institutes of Health, National Heart, Lung and Blood Institute, 9000 Rockville Pike, Bldg 10 9N112, Bethesda, MD, 20892, USA.
| |
Collapse
|
84
|
Meier ER, Rampersad A. Pediatric sickle cell disease: past successes and future challenges. Pediatr Res 2017; 81:249-258. [PMID: 27706129 DOI: 10.1038/pr.2016.204] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Accepted: 09/30/2016] [Indexed: 02/06/2023]
Abstract
Once a fatal disease of childhood, more than 95% of patients born today with sickle cell disease (SCD) in developed countries are expected to survive into adulthood, largely because of improvements in supportive and preventive care (newborn screening, penicillin prophylaxis, transcranial Doppler (TCD) screening). Hydroxyurea (HU) therapy, the only oral medication currently available to prevent SCD complications, has become more widespread over the past 20 y. The NHLBI recommends that HU be offered to all patients with HbSS beginning at 9 mo of age, and the recently published Abnormal TCD with Transfusions Changing to HU (TWiTCH) trial has shown HU as an acceptable alternative to transfusion therapy for patients at high risk of stroke. While hematopoietic stem cell transplant (HSCT) is a curative option for SCD, less than 25% of patients have a suitable donor. Alternative stem cell sources from unrelated donors and haplo-identical donors are currently under investigation as are gene therapy trials. This review will focus on early efforts to elucidate SCD pathophysiology as well as supportive and preventive care improvements. Findings from recent multi-center studies (Silent Infarct Transfusion (SIT) Trial and TWiTCH) will be summarized. Finally, HSCT trials and gene therapy will be reviewed.
Collapse
Affiliation(s)
- Emily Riehm Meier
- Pediatric Hematology, Indiana Hemophilia and Thrombosis Center, Indianapolis, Indiana
| | - Angeli Rampersad
- Pediatric Hematology, Indiana Hemophilia and Thrombosis Center, Indianapolis, Indiana
| |
Collapse
|
85
|
|
86
|
Mallhi K, Dix DB, Niederhoffer KY, Armstrong L, Rozmus J. Successful umbilical cord blood hematopoietic stem cell transplantation in pediatric patients with MDS/AML associated with underlying GATA2 mutations: two case reports and review of literature. Pediatr Transplant 2016; 20:1004-1007. [PMID: 27416790 DOI: 10.1111/petr.12764] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2016] [Indexed: 11/29/2022]
Abstract
Germline GATA2 mutations have been associated with a vast array of clinical manifestations, as well as hematological deficiencies and a propensity to AML or MDS. We present two cases of pediatric AML/MDS with underlying GATA2 mutations who underwent a successful umbilical cord hematopoietic stem cell transplantation using two different conditioning regimens. These cases illustrate the importance of recognizing the clinical features associated with GATA2 mutations and performing the appropriate molecular testing. Diagnosis of heritable gene mutations associated with familial AML/MDS has significant clinical implication for the patients and affected families.
Collapse
Affiliation(s)
- Kanwaldeep Mallhi
- Division of Hematology/Oncology/BMT, Department of Pediatrics, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - David B Dix
- Division of Hematology/Oncology/BMT, Department of Pediatrics, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Karen Y Niederhoffer
- Department of Medical Genetics, Provincial Medical Genetics Program, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Linlea Armstrong
- Department of Medical Genetics, Provincial Medical Genetics Program, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Jacob Rozmus
- Division of Hematology/Oncology/BMT, Department of Pediatrics, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada.
| |
Collapse
|
87
|
Steering Committee Of The Blood And Marrow Transplant Clinical Trials Network. The Blood and Marrow Transplant Clinical Trials Network: An Effective Infrastructure for Addressing Important Issues in Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2016; 22:1747-1757. [PMID: 27418009 PMCID: PMC5027144 DOI: 10.1016/j.bbmt.2016.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 07/08/2016] [Indexed: 12/01/2022]
Abstract
Hematopoietic cell transplantation (HCT) is a rapidly evolving field with active preclinical and clinical development of new strategies for patient assessment, graft selection and manipulation, and pre- and post-transplantation drug and cell therapy. New strategies require evaluation in definitive clinical trials; however, HCT trials face unique challenges, including the relatively small number of transplantations performed at any single center, the diverse indications for HCT requiring dissimilar approaches, the complex nature of the intervention itself, the risk of multiple complications in the immediate post-transplantation period, and the risk of important, though infrequent, late effects. The Blood and Marrow Transplant Clinical Trials Network (BMT CTN) was established by the US National Heart Lung and Blood Institute and the National Cancer Institute to meet these challenges. In its 15 years as a network, the BMT CTN has proven to be a successful infrastructure for planning, implementing, and completing such trials and for providing definitive answers to questions leading to improvements in the understanding and practice of HCT. It has opened 37 trials, about one-half phase 2 and one-half phase 3, enrolled more than 8000 patients, and published 57 papers addressing important issues in the treatment of patients with life-threatening malignant and nonmalignant blood disorders. This review describes the network's accomplishments, key components of its success, lessons learned over the past 15 years, and challenges for the future.
Collapse
|
88
|
A trial of unrelated donor marrow transplantation for children with severe sickle cell disease. Blood 2016; 128:2561-2567. [PMID: 27625358 DOI: 10.1182/blood-2016-05-715870] [Citation(s) in RCA: 131] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 09/06/2016] [Indexed: 01/29/2023] Open
Abstract
Children with sickle cell disease experience organ damage, impaired quality of life, and premature mortality. Allogeneic bone marrow transplant from an HLA-matched sibling can halt disease progression but is limited by donor availability. A Blood and Marrow Transplant Clinical Trials Network (BMT CTN) phase 2 trial conducted from 2008 to 2014 enrolled 30 children aged 4 to 19 years; 29 were eligible for evaluation. The primary objective was 1-year event-free survival (EFS) after HLA allele-matched (at HLA-A, -B, -C, and -DRB1 loci) unrelated donor transplant. The conditioning regimen included alemtuzumab, fludarabine, and melphalan. Graft-versus-host disease (GVHD) prophylaxis included calcineurin inhibitor, short-course methotrexate, and methylprednisolone. Transplant indications included stroke (n = 12), transcranial Doppler velocity >200 cm/s (n = 2), ≥3 vaso-occlusive pain crises per year (n = 12), or ≥2 acute chest syndrome episodes (n = 4) in the 2 years preceding enrollment. Median follow-up was 26 months (range, 12-62 months); graft rejection was 10%. The 1- and 2-year EFS rates were 76% and 69%, respectively. The corresponding rates for overall survival were 86% and 79%. The day 100 incidence rate of grade II-IV acute GVHD was 28%, and the 1-year incidence rate of chronic GVHD was 62%; 38% classified as extensive. There were 7 GVHD-related deaths. A 34% incidence of posterior reversible encephalopathy syndrome was noted in the first 6 months. Although the 1-year EFS met the prespecified target of ≥75%, this regimen cannot be considered sufficiently safe for widespread adoption without modifications to achieve more effective GVHD prophylaxis. The BMT CTN #0601 trial was registered at www.clinicaltrials.gov as #NCT00745420.
Collapse
|
89
|
Rocha V. Umbilical cord blood cells from unrelated donor as an alternative source of hematopoietic stem cells for transplantation in children and adults. Semin Hematol 2016; 53:237-245. [PMID: 27788761 DOI: 10.1053/j.seminhematol.2016.08.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 08/09/2016] [Indexed: 01/13/2023]
Abstract
Umbilical cord blood (CB) is an alternative source of hematopoietic stem cells (HSC) for patients requiring allogeneic HSC transplantation but lacking a suitable human leukocyte antigen (HLA)-matched donor. Using CB has many advantages, including lower HLA-matching requirements, increased donor availability, and low rates of graft-versus-host disease. Furthermore, with over 630,000 cryopreserved volunteer CB units currently stored in international CB banks worldwide, CB is rapidly available for those patients requiring urgent transplantation. However, concern remains over the low HSC doses available in CB grafts, resulting in delayed engraftment and poor immune reconstitution. This article reviews the current use and future developments of unrelated allogeneic CB transplantation (CBT). An overview of the encouraging results of CBT and the comparisons with other HSC sources and transplant strategies both in children and adults with malignant and non-malignant diseases are shown. We will discuss important factors that need to be considered when selecting CB units for transplantation to further improve the results of CBT.
Collapse
Affiliation(s)
- Vanderson Rocha
- Department of Haematology, Oxford University Hospitals NHS Trust, Churchill Hospital, Oxford, United Kingdom; NHS Blood and Transplant, Oxford Centre, John Radcliffe Hospital, Oxford, United Kingdom; Eurocord, Hôpital Saint Louis APHP, University Paris VII IUH Paris, France; Department of Hematology, University of São Paulo, São Paulo, Brazil.
| |
Collapse
|
90
|
Optimal Outcomes in Young Class 3 Patients With Thalassemia Undergoing HLA-Identical Sibling Bone Marrow Transplantation. Transplantation 2016; 100:925-32. [PMID: 26457600 DOI: 10.1097/tp.0000000000000928] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Bone marrow transplantation (BMT) for class 3 patients with thalassemia is challenging due to high rates of graft rejection and transplant-related mortality. Since the first studies of BMT in the late 1980s, a number of conditioning regimens have been designed to improve outcomes, but with suboptimal results. Here we report the outcome of transplantation in class 3 patients using a modified protocol. METHODS Sixty-three patients between 5 and 16.7 years of age with class 3 thalassemia received HLA-matched sibling BMT following either the original protocol (26 patients) or the modified protocol (37 patients). Both regimens comprised preconditioning cytoreduction with hydroxyurea and azathioprine starting at -45 days pretransplant, and fludarabine from days -16 to -12. Conditioning was performed with busulfan and cyclophosphamide (original protocol) or with busulfan, thiotepa, and cyclophosphamide (modified protocol). RESULTS The 2 groups showed similar patient demographics. At day 0, the degree of cytoreduction (lymphopenia, neuthropenia, and thrombocytopenia) achieved by the modified protocol was greater than the original protocol. The incidence of graft failure/rejection was significantly higher in the original group (15%; 95% confidence interval [95% CI], 5-32%) compared with the modified group (0%) (P = 0.014). The respective 5-year thalassemia-free survival rates were 73% (95% CI, 51-86%) and 92% (95% CI, 77-97%) (P = 0.047). Both groups showed similar incidences of grades II to IV acute graft-versus host disease. Modified protocol did not increase nonhematological toxicity or infectious complications. CONCLUSIONS The modified treatment protocol effectively and safely prevented graft failure/rejection and significantly increased thalassemia-free survival of class 3 patients with thalassemia.
Collapse
|
91
|
Long-Term Follow-Up after Reduced-Intensity Conditioning and Stem Cell Transplantation for Childhood Nonmalignant Disorders. Biol Blood Marrow Transplant 2016; 22:1467-1472. [DOI: 10.1016/j.bbmt.2016.04.025] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Accepted: 04/30/2016] [Indexed: 12/21/2022]
|
92
|
Abstract
Both adult and pediatric patients with sickle cell disease face a higher risk of stroke than the general population. Given the different underlying pathophysiology predisposing these patients to stroke, providers should be aware of differences in guidelines for stroke management. This paper reviews diagnostic considerations and recommendations during the evaluation and acute management of patients with sickle cell disease presenting with stroke, focusing on recent updates in the literature. Given the high recurrence rate of stroke in these patients, secondary prevention and curative measures will also be reviewed.
Collapse
|
93
|
Abraham A, Jacobsohn DA, Bollard CM. Cellular therapy for sickle cell disease. Cytotherapy 2016; 18:1360-1369. [PMID: 27421743 DOI: 10.1016/j.jcyt.2016.06.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 05/25/2016] [Accepted: 06/16/2016] [Indexed: 02/02/2023]
Abstract
Sickle cell disease (SCD) is a monogenic red cell disorder affecting more than 300 000 annual births worldwide and leading to significant organ toxicity and premature mortality. Although chronic therapies such as hydroxyurea have improved outcomes, more durable therapeutic and curative options are still being investigated. Newer understanding of the disease has implicated invariant natural killer T cells as a critical immune profile that potentiates SCD. Hence, targeting this cell population may offer a new approach to disease management. Hematopoietic stem cell transplant is a curative option for patients with SCD, but the under-representation of minorities on the unrelated donor registry means that this is not a feasible option for more than 75% of patients. Work in this area has therefore focused on increasing the donor pool and decreasing transplant-related toxicities to make this a treatment option for the majority of patients with SCD. This review focuses on the currently available cell and gene therapies for patients with SCD and acknowledges that newer gene-editing approaches to improve gene therapy efficiency and safety are the next wave of potentially curative approaches.
Collapse
Affiliation(s)
- Allistair Abraham
- Division of Blood and Marrow Transplant, Children's National Health System and The George Washington University, Washington, DC, USA; Program for Cell Enhancement and Technologies for Immunotherapy, Children's National Health System and The George Washington University, Washington, DC, USA.
| | - David A Jacobsohn
- Division of Blood and Marrow Transplant, Children's National Health System and The George Washington University, Washington, DC, USA
| | - Catherine M Bollard
- Division of Blood and Marrow Transplant, Children's National Health System and The George Washington University, Washington, DC, USA; Program for Cell Enhancement and Technologies for Immunotherapy, Children's National Health System and The George Washington University, Washington, DC, USA
| |
Collapse
|
94
|
Arnold SD, Bhatia M, Horan J, Krishnamurti L. Haematopoietic stem cell transplantation for sickle cell disease - current practice and new approaches. Br J Haematol 2016; 174:515-25. [PMID: 27255787 DOI: 10.1111/bjh.14167] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Sickle cell disease is an inherited disorder that affects over 5 million people worldwide. Current maintenance therapy has been successful in reducing complications and enhancing life expectancy; yet subclinical complications persist. To date, allogeneic haematopoietic stem cell transplant (HSCT) remains the only available curative therapy for sickle cell disease. With declining incidences of rejection and transplant- related mortality, disease-free survival after human leucocyte antigen-identical sibling transplant exceeds 90%. However, the majority of individuals with sickle cell disease do not have an human leucocyte antigen (HLA)-identical sibling; therefore, research is expanding to focus on new approaches to alternative donor transplant. Advances in supportive care and conditioning regimens have led to expansion of the pool of donors to unrelated donors and haploidentical donors. Challenges remain in improving the safety and efficacy of HSCT from alternate donors. Early results from gene therapy may provide another curative option in patients with sickle cell disease. These approaches show early promise, but larger, longitudinal studies are needed to better determine the optimal clinical circumstances for transplant in sickle cell disease.
Collapse
Affiliation(s)
- Staci D Arnold
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta and Emory University School of Medicine, Department of Pediatrics, Atlanta, GA, USA
| | - Monica Bhatia
- Department of Pediatrics, Columbia University Medical Center, New York, NY, USA
| | - John Horan
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta and Emory University School of Medicine, Department of Pediatrics, Atlanta, GA, USA
| | - Lakshmanan Krishnamurti
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta and Emory University School of Medicine, Department of Pediatrics, Atlanta, GA, USA
| |
Collapse
|
95
|
Abstract
PURPOSE OF REVIEW Hematopoietic cell transplantation (HCT) is a curative therapy for sickle cell disease (SCD) that is utilized very rarely because of limited allogeneic donor availability, limited healthcare resources needed to expand the treatment to regions in the world where most affected individuals reside, and by a view among SCD experts that HCT lacks the evidential rigor with short and long-term toxicity profiles that together might support its broader application. RECENT FINDINGS In this update, recent advances focused on donor selection, reduced toxicity preparation for HCT, and treatment of young adults will be presented. The current status of conventional bone marrow transplantation with a human leukocyte antigen-identical sibling donor is summarized. SUMMARY HCT for SCD is curative in almost all children who have a human leukocyte antigen-matched sibling donor. The future of this therapy will hinge on expanding the number of individuals who might be treated.
Collapse
Affiliation(s)
- Mark C Walters
- Jordan Family Director, Blood and Marrow Transplant Program, Division of Hematology/Oncology/BMT, UCSF Benioff Children's Hospital, Oakland, California, USA
| |
Collapse
|
96
|
Alfraih F, Aljurf M, Fitzhugh CD, Kassim AA. Alternative donor allogeneic hematopoietic cell transplantation for hemoglobinopathies. Semin Hematol 2016; 53:120-8. [PMID: 27000737 DOI: 10.1053/j.seminhematol.2016.01.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) offers a curative therapy for patients with hemoglobinopathies, mainly severe sickle cell disease (SCD) and thalassemia (TM). However, the applicability of HSCT has been limited mainly by donor availability, with a less than 25%-30% of eligible patients having human leukocyte antigen (HLA)-matched sibling donors. Previous outcomes using alternate donor options have been markedly inferior due to increased regimen-related toxicity, transplant-related mortality, graft failure, and graft-versus-host disease (GVHD). Advances in transplant technology, including high-resolution HLA typing, improved GVHD prophylactic approaches with tolerance induction, and better supportive care over the last decade, are addressing these historical challenges, resulting in increasing donor options. Herein, we review alternate donor HSCT approaches for severe SCD and TM using unrelated donors, umbilical cord blood units, or related haploidentical donors. Though this is an emerging field, early results are promising and in selected patients, this may be the preferred option to mitigate against the age-related morbidity and early mortality associated with these disorders.
Collapse
Affiliation(s)
- Feras Alfraih
- Adult Hematology and Hematopoietic Stem Cell Transplantation, King Faisal Hospital and Research Centre, Riyadh, Saudi Arabia.
| | - Mahmoud Aljurf
- Molecular and Clinical Hematology Branch, NHLBI, NIH, Bethesda, MD, USA
| | - Courtney D Fitzhugh
- Division of Hematology and Oncology, Department of Medicine and Vanderbilt- Meharry Center for Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Adetola A Kassim
- Division of Hematology and Oncology, Department of Medicine and Vanderbilt- Meharry Center for Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, TN, USA
| |
Collapse
|
97
|
Stenger EO, Krishnamurti L, Galipeau J. Mesenchymal stromal cells to modulate immune reconstitution early post-hematopoietic cell transplantation. BMC Immunol 2015; 16:74. [PMID: 26674007 PMCID: PMC4681052 DOI: 10.1186/s12865-015-0135-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 11/19/2015] [Indexed: 12/21/2022] Open
Abstract
Mesenchymal stromal cells (MSCs) are multipotent progenitor cells known to modulate the immune system and to promote hematopoiesis. These dual effects make MSCs attractive for use as cellular therapy in hematopoietic cell transplantation (HCT). MSCs can be used peri-HCT or pre-engraftment to modulate immune reconstitution, promoting hematopoietic stem cell (HSC) engraftment and/or preventing graft-versus-host disease (GVHD). Pre-clinical studies have demonstrated that MSCs can potentiate HSC engraftment and prevent GVHD in a variety of animal models. Clinical trials have been small and largely non-randomized but have established safety and early evidence of efficacy, supporting the need for larger randomized trials.
Collapse
Affiliation(s)
- Elizabeth O Stenger
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, 1405 Clifton Road, Atlanta, GA, 30322, USA.
| | - Lakshmanan Krishnamurti
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, 1405 Clifton Road, Atlanta, GA, 30322, USA.
| | - Jacques Galipeau
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, 1405 Clifton Road, Atlanta, GA, 30322, USA. .,Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, 1365 Clifton Road, Atlanta, GA, 30322, USA.
| |
Collapse
|
98
|
King AA, Kamani N, Bunin N, Sahdev I, Brochstein J, Hayashi RJ, Grimley M, Abraham A, Dioguardi J, Wah Chan K, Douglas D, Adams R, Andreansky M, Anderson E, Gilman A, Chaudhury S, Yu L, Dalal J, Hale G, Cuvelier G, Jain A, Krajewski J, Gillio A, Kasow KA, Delgado D, Hanson E, Murray L, Shenoy S. Successful matched sibling donor marrow transplantation following reduced intensity conditioning in children with hemoglobinopathies. Am J Hematol 2015; 90:1093-8. [PMID: 26348869 DOI: 10.1002/ajh.24183] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Accepted: 09/04/2015] [Indexed: 01/04/2023]
Abstract
Fifty-two children with symptomatic sickle cell disease sickle cell disease (SCD) (N = 43) or transfusion-dependent thalassemia (N = 9) received matched sibling donor marrow (46), marrow and cord product (5), or cord blood (1) allografts following reduced intensity conditioning (RIC) with alemtuzumab, fludarabine, and melphalan between March 2003 and May 2014*. The Kaplan-Meier probabilities of overall and event-free survival at a median of 3.42 (range, 0.75-11.83) years were 94.2% and 92.3% for the group, 93% and 90.7% for SCD, and 100% and 100% for thalassemia, respectively. Treatment-related mortality (all related to graft versus host disease, GVHD) was noted in three (5.7%) recipients, all 17-18 years of age. Acute and chronic GVHD was noted in 23% and 13%, respectively, with 81% of recipients off immunosuppression by 1 year. Graft rejection was limited to the single umbilical cord blood recipient who had prompt autologous hematopoietic recovery. Fourteen (27%) had mixed chimerism at 1 year and beyond; all had discontinued immunosuppression between 4 and 12 months from transplant with no subsequent consequence on GVHD or rejection. Infectious complications included predominantly bacteremia (48% were staphylococcus) and CMV reactivation (43%) necessitating preemptive therapy. Lymphocyte recovery beyond 6 months was associated with subsidence of infectious complications. All patients who engrafted were transfusion independent; no strokes or pulmonary complications of SCD were noted, and pain symptoms subsided within 6 months posttransplant. These findings support using RIC for patients with hemoglobinopathy undergoing matched sibling marrow transplantation (*www.Clinical Trials.gov: NCT00920972, NCT01050855, NCT02435901).
Collapse
Affiliation(s)
- Allison A. King
- Department of Pediatric; Washington University School of Medicine; St. Louis Missouri
| | - Naynesh Kamani
- Department of Pediatrics; Children's National Medical Center; Washington District of Columbia
| | - Nancy Bunin
- Department of Pediatrics; Children's Hospital of Philadelphia; Philadelphia Pennsylvania
| | - Indira Sahdev
- Department of Pediatrics; Cohen Children's Medical Center of New York; New Hyde Park New York
| | - Joel Brochstein
- Department of Pediatrics; Cohen Children's Medical Center of New York; New Hyde Park New York
| | - Robert J. Hayashi
- Department of Pediatric; Washington University School of Medicine; St. Louis Missouri
| | - Michael Grimley
- Department of Pediatrics; Cincinnati Children's Hospital; Cincinnati Ohio
| | - Allistair Abraham
- Department of Pediatrics; Children's National Medical Center; Washington District of Columbia
| | - Jacqueline Dioguardi
- Department of Pediatrics; Children's National Medical Center; Washington District of Columbia
| | - Ka Wah Chan
- Department of Pediatrics; Methodist Children's Hospital of South Texas; San Antonio Texas
| | - Dorothea Douglas
- Department of Pediatrics; Phoenix Children's Hospital; Phoenix Arizona
| | - Roberta Adams
- Department of Pediatrics; Phoenix Children's Hospital; Phoenix Arizona
| | - Martin Andreansky
- Department of Pediatrics; University of Miami Health System; Miami Florida
| | | | - Andrew Gilman
- Department of Pediatrics; Levine Children's Hospital; Charlotte North Carolina
| | - Sonali Chaudhury
- Department of Pediatrics; Lurie Children's Hospital; Chicago Illinois
| | - Lolie Yu
- Department of Pediatrics; Louisiana State University Medical Center; New Orleans Louisiana
| | - Jignesh Dalal
- Department of Pediatrics; Children's Mercy Hospitals and Clinics; Kansas City Missouri
| | - Gregory Hale
- Department of Pediatrics; All Children's Hospital; St. Petersburg Florida
| | - Geoff Cuvelier
- Department of Pediatrics; CancerCare Manitoba; CAN Manitoba, Canada
| | - Akshat Jain
- Department of Pediatrics; Cohen Children's Medical Center of New York; New Hyde Park New York
| | - Jennifer Krajewski
- Department of Pediatrics; Joseph M. Sanzari Children's Hospital; Hackensack New Jersey
| | - Alfred Gillio
- Department of Pediatrics; Joseph M. Sanzari Children's Hospital; Hackensack New Jersey
| | - Kimberly A. Kasow
- Department of Pediatrics; University of Chapel Hill, Chapel Hill; North Carolina
| | - David Delgado
- Department of Pediatrics; Riley Hospital for Children; Indianapolis Indiana
| | - Eric Hanson
- Department of Pediatric; Washington University School of Medicine; St. Louis Missouri
| | - Lisa Murray
- Department of Pediatric; Washington University School of Medicine; St. Louis Missouri
| | - Shalini Shenoy
- Department of Pediatric; Washington University School of Medicine; St. Louis Missouri
| |
Collapse
|
99
|
Abdel-Azim H, Mahadeo KM, Zhao Q, Khazal S, Kohn DB, Crooks GM, Shah AJ, Kapoor N. Unrelated donor hematopoietic stem cell transplantation for the treatment of non-malignant genetic diseases: An alemtuzumab based regimen is associated with cure of clinical disease; earlier clearance of alemtuzumab may be associated with graft rejection. Am J Hematol 2015; 90:1021-6. [PMID: 26242764 DOI: 10.1002/ajh.24141] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 07/26/2015] [Accepted: 08/03/2015] [Indexed: 12/11/2022]
Abstract
Hematopoietic stem cell transplantation (HSCT) with matched unrelated donors (MUD), offers potentially curative therapy for patients with non-malignant genetic diseases. In this pilot study conducted from 2006 to 2014, we report the outcomes of 15 patients with non-malignant genetic diseases who received a myeloablative regimen with a reduced cyclophosphamide dose, adjunctive serotherapy and MUD HSCT [intravenous alemtuzumab (52 mg/m(2) ), busulfan (16 mg/kg), fludarabine (140mg/m(2) ), and cyclophosphamide (105 mg/kg)]. Graft-versus-host-disease (GVHD) prophylaxis consisted of tacrolimus/cyclosporine and methylprednisolone. Median (range) time to neutrophil engraftment (>500 cells/µL) and platelet engraftment (>20,000/mm(3) ) were 15 (12-28) and 25 (17-30) days, respectively. At a median follow-up of 2 (0.2-5.4) years, the overall survival (OS) was 93.3% (95% CI: 0.61-0.99) and disease-free survival (DFS) was 73.3% (95% CI: 0.44-0.89). Among this small sample, earlier alemtuzumab clearance was significantly associated with graft rejection (P = 0.047), earlier PHA response (P = 0.009) and a trend toward earlier recovery of recent thymic emigrants (RTE) (P = 0.06). This regimen was associated with durable donor engraftment and relatively low rates of regimen related toxicity (RRT); future alemtuzumab pharmacokinetic studies may improve outcomes, by allowing targeted alemtuzumab clearance to reduce graft rejection and promote more rapid immune reconstitution.
Collapse
Affiliation(s)
- Hisham Abdel-Azim
- Division of Hematology; Oncology and Blood and Marrow Transplantation, Children's Hospital Los Angeles, University of Southern California; Los Angeles California
| | - Kris Michael Mahadeo
- Department of Pediatrics; Pediatric Blood and Marrow Transplantation Program; Children's Hospital at Montefiore, Albert Einstein College of Medicine; Bronx New York
| | - Quan Zhao
- Division of Hematology; Oncology and Blood and Marrow Transplantation, Children's Hospital Los Angeles, University of Southern California; Los Angeles California
| | - Sajad Khazal
- Division of Hematology; Oncology and Blood and Marrow Transplantation, Children's Hospital Los Angeles, University of Southern California; Los Angeles California
| | - Donald B. Kohn
- Division of Hematology/Oncology; Mattel Children's Hospital, University of California; Los Angeles Los Angeles California
| | - Gay M. Crooks
- Division of Hematology/Oncology; Mattel Children's Hospital, University of California; Los Angeles Los Angeles California
| | - Ami J. Shah
- Division of Hematology/Oncology; Mattel Children's Hospital, University of California; Los Angeles Los Angeles California
| | - Neena Kapoor
- Division of Hematology; Oncology and Blood and Marrow Transplantation, Children's Hospital Los Angeles, University of Southern California; Los Angeles California
| |
Collapse
|
100
|
Satwani P, Kahn J, Jin Z. Making strides and meeting challenges in pediatric allogeneic hematopoietic cell transplantation clinical trials in the United States: Past, present and future. Contemp Clin Trials 2015; 45:84-92. [DOI: 10.1016/j.cct.2015.06.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 06/08/2015] [Accepted: 06/15/2015] [Indexed: 12/19/2022]
|