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Furlong E, Carter T. Aplastic anaemia: Current concepts in diagnosis and management. J Paediatr Child Health 2020; 56:1023-1028. [PMID: 32619069 DOI: 10.1111/jpc.14996] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 05/21/2020] [Indexed: 12/26/2022]
Abstract
Aplastic anaemia is a rare, previously fatal condition with a significantly improved survival rate owing to advances in understanding of the pathophysiology and improved treatment strategies including haematopoietic stem cell transplantation. Although a rare condition, aplastic anaemia continues to present a high burden for affected patients, their families and the health system due to the prolonged course of disease often associated with high morbidity and the uncertainty regarding clinical outcome. Modern molecular and genetic techniques including next-generation sequencing have contributed to a better understanding of this heterogeneous group of conditions, albeit at a cost of increased complexity of clinical decision-making regarding prognosis and choice of treatment for individual patients. Here we present a concise and comprehensive review of aplastic anaemia and closely related conditions based on extensive literature review and long-standing clinical experience. The review takes the reader across the complex pathophysiology consisting of three main causative mechanisms of bone marrow destruction resulting in aplastic anaemia: direct injury, immune mediated and bone marrow failure related including inherited and clonal disorders. A comprehensive diagnostic algorithm is presented and an up-to-date therapeutic approach to acquired immune aplastic anaemia, the most represented type of aplastic anaemia, is described. Overall, the aim of the review is to provide paediatricians with an update of this rare, heterogeneous and continuously evolving condition.
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Affiliation(s)
- Eliska Furlong
- Department of Paediatric and Adolescent Haematology, Oncology, Blood and Marrow Transplantation, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Tina Carter
- Department of Paediatric and Adolescent Haematology, Oncology, Blood and Marrow Transplantation, Perth Children's Hospital, Perth, Western Australia, Australia.,Division of Paediatrics, School of Medicine, University of Western Australia, Perth, Western Australia, Australia.,Paediatric and Adolescent Haematology Service, PathWest Laboratory Medicine WA, Perth, Western Australia, Australia
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Conditioning regimen for allogeneic bone marrow transplantation in children with acquired bone marrow failure: fludarabine/melphalan vs. fludarabine/cyclophosphamide. Bone Marrow Transplant 2020; 55:1272-1281. [PMID: 32444864 DOI: 10.1038/s41409-020-0948-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 05/01/2020] [Accepted: 05/05/2020] [Indexed: 11/08/2022]
Abstract
Fludarabine/cyclophosphamide-based conditioning regimens are standard in bone marrow transplantation (BMT) for acquired bone marrow failure in children, however, graft failure may occur. Using the data from a nationwide transplantation registry, we compared the outcomes of children aged <16 years with acquired aplastic anemia and refractory cytopenia of childhood who underwent allogeneic BMT with either fludarabine/melphalan (n = 71) or fludarabine/cyclophosphamide (n = 296) between 2000 and 2016. The fludarabine/melphalan regimen provided excellent outcomes, with 3-year overall survival and failure-free survival rates of 98% and 97%, respectively. The 83% 3-year failure-free survival in the fludarabine/cyclophosphamide group was significantly inferior (P = 0.002), whereas the overall survival did not differ between the two groups. Late graft failure was the most common cause of treatment failure in the fludarabine/cyclophosphamide group, which experienced a significantly higher incidence of late graft failure than the fludarabine/melphalan group (11% vs. 3%; P = 0.035). Multivariate analyses showed that the fludarabine/melphalan regimen was associated with a better failure-free survival (hazard ratio [HR] 0.12; P = 0.005) and lower risk of late graft failure (HR 0.16; P = 0.037). Fludarabine/melphalan-based conditioning regimen can be a promising option for children with acquired bone marrow failure receiving BMT.
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Gu C, Zhu X, Qiao X, Zhai X, Shi W, Xie X. Multivariate logistic analysis of predictors of response to immunosuppressive therapy in children with aplastic anemia: a double-center study. ACTA ACUST UNITED AC 2020; 24:282-289. [PMID: 31793407 DOI: 10.1080/16078454.2019.1565149] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Immunosuppressive therapy (IST) composed of antithymocyte globulin (ATG) and cyclosporine A (CSA) is one of the standard therapies in pediatric patients with acquired aplastic anemia (AA), but predictors of IST are lack of consensus. PROCEDURES Ninety-four patients from two pediatric medical centers in China were included between January 2005 and March 2018. Clinical factors associated with the efficacy were analyzed according to multivariate logistic regression model previously established. RESULTS We discovered that overall responsiveness was 77.66%. Five out of 35 factors were statistically significant in univariate analysis. Based on the cutoff point chosen by receiver operating characteristic (ROC) curve, 5 continuous variables were made categorical, among which 3 variables with significance were employed to establish the logistic regression equation. Based on these 3 variables, we found that starting IST within 126 days of the first appearance of symptoms (X1, p = .003), absolute neutrophil count (ANC) higher than 0.435×109/L (X2, p = .012), and rate of decreased actual lymphocyte count (ALC) higher than 59.2% within the 1st week after IST (X3, p = .001) were three independent risk factors for response to IST. The rate of decreased ALC higher than 59.2% after IST was the most significant variable (OR = 9.355, Log (P) = -2.161 + 2.149X1 + 1.662X2 + 2.236X3). The accuracy, sensitivity, and specificity of the model were 86.2%, 94.5% and 57.1%, respectively. CONCLUSION Duration of AA, ANC and decreased ALC rate after IST might predict the response to IST, among which the rate of decreased ALC after IST is the most important predictive factor.
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Affiliation(s)
- Changjuan Gu
- Department of Paediatrics, Tongji Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
| | - Xiaohua Zhu
- Department of Haematology, Children's Hospital of Fudan University, Shanghai, People's Republic of China
| | - Xiaohong Qiao
- Department of Paediatrics, Tongji Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
| | - Xiaowen Zhai
- Department of Haematology, Children's Hospital of Fudan University, Shanghai, People's Republic of China
| | - Wei Shi
- Department of Paediatrics, Tongji Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
| | - Xiaotian Xie
- Department of Paediatrics, Tongji Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
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Delehaye F, Habes D, Dourthe ME, Bertrand Y, Michel G, Gaudichon J, Debray D, Nelken B, Pasquet M, Blanche S, Leblanc T. Management of childhood aplastic anemia following liver transplantation for nonviral hepatitis: A French survey. Pediatr Blood Cancer 2020; 67:e28177. [PMID: 31925926 DOI: 10.1002/pbc.28177] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 12/18/2019] [Accepted: 12/21/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hepatitis-associated aplastic anemia (AA) is a rare syndrome combining acute hepatitis of variable severity and AA. Hepatitis may be severe enough to require urgent liver transplantation (LT). Herein, we describe clinical presentation and management of a cohort of pediatric patients diagnosed with AA after undergoing LT for nonviral hepatitis. METHODS To describe this rare clinical situation, we performed a national survey and identified nine children treated for AA following LT during the last 10 years in France. RESULTS All patients were treated first for hepatic failure with urgent LT. AA was diagnosed with a median delay of 34 days [21-200] from the diagnosis of hepatitis. Seven children were treated with antithymocyte globulin/cyclosporine, one with CSA alone and one received bone marrow transplantation. At the last visit (median follow-up: 4 years), outcomes were excellent: all patients were alive and in hematological remission (complete remission: 7; partial remission: 2). Immunosuppressive therapy was pursued in all patients due to the liver transplant. No unusual toxicities were reported. CONCLUSION AA after LT is considered a therapeutic challenge. Nevertheless, hematological outcome is good using a standard immunosuppressive approach.
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Affiliation(s)
- Fanny Delehaye
- Department of Pediatric Hematology and Oncology, University Hospital of Caen, Caen, France
| | - Dalila Habes
- Department of Pediatric Hepatology, AP-HP, Kremlin-Bicêtre Hospital, Le Kremlin-Bicêtre, France
| | - Marie-Emilie Dourthe
- Department of Pediatric Hematology and Immunology, AP-HP, Robert-Debré Hospital, Paris, France
| | - Yves Bertrand
- Institute of Pediatric Hematology and Oncology, Hospices Civils de Lyon, University Claude Bernard Lyon 1, Lyon, France
| | - Gerard Michel
- Department of Pediatric Hematology and Oncology and Research Unit EA 3279, Timone Enfants Hospital and Aix-Marseille University, Marseille, France
| | - Jérémie Gaudichon
- Department of Pediatric Hematology and Oncology, University Hospital of Caen, Caen, France
| | - Dominique Debray
- Unit of Pediatric Hepatology, Reference Center for Rare Pediatric Liver Diseases, Necker-Enfants-Malades University Hospital, Paris, France.,Department of medicine, University of Paris-Descartes, Sorbonne Paris-Cité, Paris, France
| | - Brigitte Nelken
- Department of Pediatric Hematology-Oncology, Jeanne de Flandre Hospital, CHRU, Lille, France
| | - Marlène Pasquet
- Department of Pediatric Hematology and Oncology, University hospital of Toulouse, Toulouse, France
| | - Stéphane Blanche
- Department of Pediatric Hematology, Immunology and Rheumatology, AP-HP, Necker Enfants-Malades Hospital, Paris, France
| | - Thierry Leblanc
- Department of Pediatric Hematology and Immunology, AP-HP, Robert-Debré Hospital, Paris, France
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Lejman M, Zawitkowska J, Zaucha-Prażmo A, Cienkusz M, Mroczkowska A, Kowalczyk J, Drabko K. Influence of Mixed Chimerism on Outcome in Children With Anaemia After Haematopoietic Stem Cell Transplantation. In Vivo 2020; 33:2051-2057. [PMID: 31662537 DOI: 10.21873/invivo.11703] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 08/13/2019] [Accepted: 09/04/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND/AIM In patients with non-malignant diseases, mixed chimerism is not a rare phenomenon. The clinical impacts of chimerism following allogeneic haematopoietic stem cell transplantation (allo-HSCT) in children with congenital anaemia (CA) and severe aplastic anaemia (SAA) were analysed. PATIENTS AND METHODS We studied twenty-seven consecutive children with congenital and acquired anaemia who had undergone allogeneic haematopoietic stem cell transplantations. In the observed group of patients, the median of the follow-up was 6.12 years (2.00-14.8 years). RESULTS Overall survival (OS) did not depend on the type of disease p=0.1. OS did not significantly differ in patients who received more than 5x106/kg stem cells (91%) and those who received less than 5x106/kg (85%) (p=0.61). Two patterns of stable mixed chimerism (SMC) were observed: SMC (95-97% cells of the donor), and SMC with a fluctuation between 50-90% of the cells of the donor. None of the surviving patients received immunosuppression treatments of chronic Graft-versus-Host Disease (cGvHD). CONCLUSION Our results showed that mixed chimerism did not influence the survival of children with congenital and aplastic anaemia following allo-HSCT.
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Affiliation(s)
- Monika Lejman
- Department of Pediatric Hematology, Oncology and Transplantology, Medical University of Lublin, Laboratory of Genetic Diagnostics, Lublin, Poland
| | - Joanna Zawitkowska
- Department of Pediatric Hematology, Oncology and Transplantology, Medical University of Lublin, Lublin, Poland
| | - Agnieszka Zaucha-Prażmo
- Department of Pediatric Hematology, Oncology and Transplantology, Medical University of Lublin, Lublin, Poland
| | - Magdalena Cienkusz
- Department of Pediatric Hematology, Oncology and Transplantology, Medical University of Lublin, Lublin, Poland
| | - Aleksandra Mroczkowska
- Department of Pediatric Hematology, Oncology and Transplantology, Medical University of Lublin, Lublin, Poland
| | - Jerzy Kowalczyk
- Department of Pediatric Hematology, Oncology and Transplantology, Medical University of Lublin, Lublin, Poland
| | - Katarzyna Drabko
- Department of Pediatric Hematology, Oncology and Transplantology, Medical University of Lublin, Lublin, Poland
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Luo CJ, Chen J, Wang JM, Qin X, Zhang BH, Zhu H, Wang XN, Cai JY, Luo CY. [Alternative donor HSCT for 109 children with acquired severe aplastic anemia: a single center retrospective analysis]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2020; 41:128-131. [PMID: 32135629 PMCID: PMC7357947 DOI: 10.3760/cma.j.issn.0253-2727.2020.02.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
目的 了解替代供者(AD)移植一线治疗儿童再生障碍性贫血(AA)的疗效及安全性。 方法 回顾性分析2010年4月1日至2016年12月31日在上海儿童医学中心一线接受AD移植治疗的AA患儿临床资料,统计分析总生存(OS)率、植入成功率、移植物抗宿主病(GVHD)发生率等指标。 结果 共纳入109例患者,极重型AA(VSAA)32例,重型AA(SAA)64例,非重型AA(NSAA)伴输血依赖13例,中位年龄6(0.8~18)岁,其中44例患者接受全相合无关供者(MUD)移植,44例接受8–9/10位点不全相合无关供者(MMUD)移植,21例接受不全相合亲缘供者(MMRD)移植,所有患者均接受以外周血干细胞(PBSC)为主的移植,≥3个位点不合的单倍型移植加第三方脐血(UCB)一份。所有患者移植前均未接受过抗胸腺细胞球蛋白(ATG)治疗,并排除活动性感染。106例(97.2%)获造血重建,中性粒细胞中位重建时间为13(9~19)d,血小板中位重建时间为16(10~81)d。死亡13例,5年OS率为88.1%(95%CI 81.1%~91.4%),MUD、MMUD及MMRD三组患者OS率差异无统计学意义(P=0.361)。总体急性GVHD(aGVHD)及Ⅱ~Ⅳ度aGVHD发生率分别为74.3%和39.4%,总体慢性GVHD(cGVHD)和中度cGVHD发生率分别为30.7%和9.9%,无一例患者发生重度cGVHD。 结论 对于无同胞全相合供者的SAA/VSAA患儿,早期一线接受AD移植可能是一个选择,但需要进一步探索更有效的预防及治疗GVHD的措施。
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Affiliation(s)
- C J Luo
- Shanghai Jiao Tong University, School of Medicine, Shanghai Children's Medical Center, Shanghai 200217, China
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57
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Zhu Y, Gao Q, Hu J, Liu X, Guan D, Zhang F. Allo-HSCT compared with immunosuppressive therapy for acquired aplastic anemia: a system review and meta-analysis. BMC Immunol 2020; 21:10. [PMID: 32138642 PMCID: PMC7059290 DOI: 10.1186/s12865-020-0340-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 02/26/2020] [Indexed: 11/21/2022] Open
Abstract
Background Allogeneic hematopoietic stem cell transplantation (allo-HSCT) and immunosuppressive therapy (IST) are two major competing treatment strategies for acquired aplastic anemia (AA). Whether allo-HSCT is superior to IST as a front-line treatment for patients with AA has been a subject of debate. To compare the efficacy and safety of allo-HSCT with that of IST as a front-line treatment for patients with AA, we performed a meta-analysis of available studies that examined the impact of the two major competing treatment strategies for AA. Results Fifteen studies including a total of 5336 patients were included in the meta-analysis. The pooled hazard ratio (HR) for overall survival (OS) was 0.4 (95% CI 0.074–0.733, P = 0.016, I2 = 58.8%) and the pooled HR for failure-free survival (FFS) was 1.962 (95% CI 1.43–2.493, P = 0.000, I2 = 0%). The pooled relative risk (RR) for overall response rate (ORR) was 1.691 (95% CI 1.433–1.996, P = 0.000, I2 = 11.6%). Conclusion Although survival was significantly longer among AA patients undergoing first-line allo-HSCT compared to those undergoing first-line IST, the selection of initial treatment for patients with newly diagnosed AA still requires comprehensive evaluation of donor availability, patient age, expected quality of life, risk of disease relapse or clonal evolution after IST, and potential use of adjunctive eltrombopag.
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Affiliation(s)
- Yangmin Zhu
- Department of Therapeutic Center of Anemia, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College (CAMS & PUMC), Tianjin, China
| | - Qingyan Gao
- Department of Therapeutic Center of Anemia, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College (CAMS & PUMC), Tianjin, China
| | - Jing Hu
- Department of Therapeutic Center of Anemia, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College (CAMS & PUMC), Tianjin, China
| | - Xu Liu
- Department of Therapeutic Center of Anemia, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College (CAMS & PUMC), Tianjin, China
| | - Dongrui Guan
- Department of Therapeutic Center of Anemia, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College (CAMS & PUMC), Tianjin, China
| | - Fengkui Zhang
- Department of Therapeutic Center of Anemia, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College (CAMS & PUMC), Tianjin, China.
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Shaw A, Passweg JR, De La Fuente J, Bajwa R, Stein J, Al-Zaben A, Halkes CJ, Norton A, Cummins M, Moppett JP, Shanap MA, Steward CG. Relapse of Aplastic Anemia with Majority Donor Chimerism (Donor-Type Aplasia) Occurring Late after Bone Marrow Transplantation. Biol Blood Marrow Transplant 2020; 26:480-485. [DOI: 10.1016/j.bbmt.2019.11.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 11/02/2019] [Accepted: 11/08/2019] [Indexed: 01/30/2023]
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Im SH, Kim BR, Park SM, Yoon BA, Hwang TJ, Baek HJ, Kook H. Better Failure-Free Survival and Graft-versus-Host Disease-Free/Failure Free Survival with Fludarabine-Based Conditioning in Stem Cell Transplantation for Aplastic Anemia in Children. J Korean Med Sci 2020; 35:e46. [PMID: 32080987 PMCID: PMC7036341 DOI: 10.3346/jkms.2020.35.e46] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 12/24/2019] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND This study aimed to assess the outcome of stem cell transplantation (SCT), including overall survival (OS), failure-free survival (FFS) and graft-versus-host disease (GvHD)-free/failure-free survival (GFFS), and to analyze prognostic factors in children with aplastic anemia (AA). METHODS From 1991 to 2018, 43 allogeneic SCT recipients were enrolled in the study to investigate the demographic characteristics, survival outcomes and prognostic factors. RESULTS With the median follow-up of 7.1 years, the estimated 10-year OS, FFS, GFFS were 86.0%, 60.5%, and 51.2%, respectively. Matched related donors (MRD, n = 28) showed better 10-year OS than unrelated donors (n = 15) (96.4% vs. 66.7%; P = 0.006). Engraftment failure was seen in 13 patients (30.2%). Donor-type aplasia was seen in 13.8% (4/29) after fludarabine (Flu)-based conditioning (Flu-group), while in 42.6% (6/14) after cyclophosphamide (Cy)-based regimen (Cy-group) (P = 0.035). Six patients died. The 10-year OS in Cy-group was 92.9% (n = 14, all MRD), while that of Flu-group was 82.1% (n = 29; P = 0.367). But Flu-group tended to have better FFS and GFFS than Cy-group, although Flu-group had less MRDs (41.4% vs. 100%; P = 0.019), and higher proportion of previous immunosuppressive treatment (IST; 62% vs. 21.4%, P = 0.012). In MRD transplants, OS was similar between Flu-group (100%, n = 14) and Cy-group (92.9%, n = 14), while FFS (100.0% vs. 42.9%; P = 0.001) and GFFS (85.7% vs. 35.7%; P = 0.006) were significantly better in Flu-group. Stem cell sources, irradiation in the conditioning, and method of GvHD prophylaxis did not significantly influence the outcome. CONCLUSION This study reviewed SCT outcomes for pediatric AA with changes of transplant strategies over the last 25 years. The FFS and GFFS were higher in Flu-group than in Cy-group, especially in matched related transplantation. Graft failure including donor-type aplasia remains troublesome even with Flu-based conditioning. Further refinement of transplant strategies to ensure better quality-of-life should be pursued.
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Affiliation(s)
- Seung Hwan Im
- Department of Pediatrics, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Bo Ram Kim
- Department of Pediatrics, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Soo Min Park
- Department of Pediatrics, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Bo Ae Yoon
- Department of Pediatrics, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Tai Ju Hwang
- Department of Pediatrics, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Hee Jo Baek
- Department of Pediatrics, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
- Environmental Health Center for Childhood Leukemia and Cancer, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Hoon Kook
- Department of Pediatrics, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
- Environmental Health Center for Childhood Leukemia and Cancer, Chonnam National University Hwasun Hospital, Hwasun, Korea.
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Rosa M, Gajek K, Salamonowicz-Bodzioch M, Mielcarek-Siedziuk M, Frączkiewicz J, Jarmoliński T, Olejnik I, Ussowicz M. Successful Bone Marrow Recovery After an Immunoablative Regimen With Autologous Cord Blood Transplant in a Child With Idiopathic Severe Aplastic Anemia: A Case Report. Transplant Proc 2020; 52:653-656. [PMID: 32035683 DOI: 10.1016/j.transproceed.2019.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 12/06/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Aplastic anemia is a rare disease that manifests as bone marrow failure. The current treatment options include immunoablative therapy or allogeneic hematopoietic stem cell transplantation. We report a successful immunoablative regimen with autologous umbilical cord blood (auto-UCB) transplant in a 3-year-old boy with severe aplastic anemia. CASE REPORT The immunoablation procedure consisted of 5 × 3.75 mg/kg antithymocyte globulin (Thymoglobulin) (total 18.75 mg/kg), methylprednisolone for 4 days, and cyclosporine A. The patient received auto-UCB containing 0.3 × 105 CD34+ cells per kilogram of body weight. Recovery of leukocyte count above 1000/μL was reached on post-transplant day +39, and recovery of granulocytes above 500/μL was reached on day +40. The final regular transfusions of packed red blood cells and platelet concentrate were performed on day +55. The complications that occurred in the post-transplant period were nausea, diarrhea, septic fever, and hepatic abscess formation. Post-transplant immunosuppression with cyclosporine A was discontinued 17.5 months after auto-UCB, and the patient remained in complete remission with normal blood counts and bone marrow morphology. SUMMARY Auto-UCB transplantation without chemotherapy conditioning can be considered a therapeutic option for children with stored cord blood cells.
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Affiliation(s)
- Monika Rosa
- Department of Paediatric Bone Marrow Transplantation, Oncology, and Hematology, Wrocław Medical University, Wroclaw, Poland
| | - Kornelia Gajek
- Department of Paediatric Bone Marrow Transplantation, Oncology, and Hematology, Wrocław Medical University, Wroclaw, Poland
| | | | - Monika Mielcarek-Siedziuk
- Department of Paediatric Bone Marrow Transplantation, Oncology, and Hematology, Wrocław Medical University, Wroclaw, Poland
| | - Jowita Frączkiewicz
- Department of Paediatric Bone Marrow Transplantation, Oncology, and Hematology, Wrocław Medical University, Wroclaw, Poland
| | - Tomasz Jarmoliński
- Department of Paediatric Bone Marrow Transplantation, Oncology, and Hematology, Wrocław Medical University, Wroclaw, Poland
| | - Igor Olejnik
- Department of Paediatric Bone Marrow Transplantation, Oncology, and Hematology, Wrocław Medical University, Wroclaw, Poland
| | - Marek Ussowicz
- Department of Paediatric Bone Marrow Transplantation, Oncology, and Hematology, Wrocław Medical University, Wroclaw, Poland.
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Comparison of HLA-matched sibling and unrelated donor transplantation in adult patients with acquired severe aplastic anemia. Bone Marrow Transplant 2020; 55:1570-1579. [PMID: 32024992 DOI: 10.1038/s41409-020-0820-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 01/27/2020] [Accepted: 01/28/2020] [Indexed: 12/12/2022]
Abstract
The recent improvements in the outcomes of severe aplastic anemia (SAA) patients who received allogeneic stem cell transplantation (SCT) from unrelated donors (URD) suggest the possibility of its alternative first-line treatment. To address this issue, results of adult SAA patients receiving allogeneic SCT were compared between the following three donor-type groups: 8/8-matched sibling (MSD; n = 153), 8/8 well-matched unrelated (WM-URD; n = 72), and 6-7/8 partially matched unrelated (PM-URD; n = 33). Proportion of patients who experienced immunosuppressive treatment failures was significantly higher in the URD groups than in the MSD group (P< 0.01). The incidences of graft failure and transplant-related mortality, and graft-vs.-host disease-free, failure-free survival rates of the MSD, WM-URD, and PM-URD groups were 14.6, 0, and 0% (P< 0.01); 6.1, 10.3, and 21.7% (P= 0.03); and 76.7, 55.5, and 51.5% (P< 0.01), respectively. The overall survival (OS) rate of the MSD group (93.9%) was higher than that of the PM-URD (78.3%; P < 0.01) group, but not to that of the WM-URD (86.2%; P= 0.18) group. Our study showed comparable OS between the MSD group and WM-URD group, which suggest that the URD-SCT can be used as a first-line treatment for adult SAA patients with WM-URD.
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62
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Clucas DB, Fox LC, Wood EM, Hong FS, Gibson J, Bajel A, Szer J, Blombery P, McQuilten ZK, Hiwase D, Firkin F, Cole-Sinclair MF. Revisiting acquired aplastic anaemia: current concepts in diagnosis and management. Intern Med J 2019; 49:152-159. [PMID: 30324755 DOI: 10.1111/imj.14140] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 07/26/2018] [Accepted: 09/30/2018] [Indexed: 12/24/2022]
Abstract
Acquired aplastic anaemia is a rare, serious, immunologically mediated bone marrow failure syndrome, characterised by marrow hypoplasia of varying severity and significant pancytopenia. Careful attention and investigation, including molecular testing, is required to confirm the diagnosis and exclude other mimicking conditions, such as inherited bone marrow failure syndromes. In a proportion of patients, the disease evolves to myelodysplasia or acute myeloid leukaemia and in some there is an association with paroxysmal nocturnal haemoglobinuria. The disease has a major impact on patient quality of life. Haemopoietic stem/progenitor cell transplantation for eligible patients with an available donor is the only current curative therapy. Other patients may receive immunosuppression, most commonly with anti-thymocyte globulin and cyclosporin. An initial response to immunosuppression is often encouraging, but relapse is common. Supportive care, including management of transfusion requirements and infections, is central to management. Promising new diagnostic tools and emerging therapies will likely transform approaches to this important, chronic and life-threatening condition.
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Affiliation(s)
- Danielle B Clucas
- Department of Clinical Haematology, Alfred Hospital, Monash University, Melbourne, Victoria, Australia
| | - Lucy C Fox
- Department of Clinical Haematology, Epworth Hospital, Monash University, Melbourne, Victoria, Australia.,Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Erica M Wood
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Clinical Haematology, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Frank S Hong
- Department of Clinical Haematology, The Northern Hospital, Melbourne, Victoria, Australia.,Clinical Services and Research, Australian Red Cross Blood Service, Melbourne, Victoria, Australia
| | - John Gibson
- Institute of Haematology, Royal Prince Alfred Hospital, Adelaide, South Australia, Australia.,The University of Sydney, Sydney, South Australia, Australia
| | - Ashish Bajel
- Integrated Haematology Service, Victorian Comprehensive Cancer Centre (The Royal Melbourne Hospital/Peter MacCallum Cancer Centre), Melbourne, Victoria, Australia
| | - Jeff Szer
- Integrated Haematology Service, Victorian Comprehensive Cancer Centre (The Royal Melbourne Hospital/Peter MacCallum Cancer Centre), Melbourne, Victoria, Australia
| | - Piers Blombery
- Molecular Haematology Laboratory, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Zoe K McQuilten
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Clinical Haematology, Monash Medical Centre, Melbourne, Victoria, Australia.,Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Devendra Hiwase
- Department of Clinical Haematology, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,The University of Adelaide, Adelaide, South Australia, Australia
| | - Frank Firkin
- Haematology Department, St Vincent's Hospital, Melbourne, Victoria, Australia.,The University of Melbourne, Melbourne, Victoria, Australia
| | - Merrole F Cole-Sinclair
- Haematology Department, St Vincent's Hospital, Melbourne, Victoria, Australia.,The University of Melbourne, Melbourne, Victoria, Australia
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63
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Pagliuca S, Ruggeri A, Peffault de Latour R. Cord blood transplantation for bone marrow failure syndromes: state of art. Stem Cell Investig 2019; 6:39. [PMID: 32039261 DOI: 10.21037/sci.2019.10.04] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 10/16/2019] [Indexed: 12/20/2022]
Abstract
Hematopoietic stem cell transplantation (HSCT) and immunosuppressive therapy (IST) represent the milestones of the treatment algorithm for idiopathic and inherited bone marrow failure (BMF) disorders. However, patients lacking a suitable donor or failing IST still have a poor prognosis. Cord blood transplantation (CBT) has extended the possibility of HSCT for many patients in case of the absence of an eligible donor, and although in the last years, this procedure is less used in several hematological diseases, it remains an option for the treatment of patients with BMF syndromes. Nevertheless, optimization of conditioning regimen and cord blood unit selection is warranted to reduce the risk of graft failure and transplant-related mortality. This review summarizes the state of art of CBT in the field of BMF diseases, focusing on historical and recent issues in idiopathic aplastic anemia and inherited disorders.
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Affiliation(s)
- Simona Pagliuca
- Hematology and Transplantation Unit, Saint Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Annalisa Ruggeri
- Department of Pediatric Hematology and Oncology, IRCCS Ospedale Pediatrico Bambino Gesù, Roma, Italy.,Eurocord-Monacord, Hôpital Saint Louis, Paris, France.,Cellular Therapy and Immunobiology Working Party of EBMT, Leiden, The Netherlands
| | - Régis Peffault de Latour
- Hematology and Transplantation Unit, Saint Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
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64
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Darrigo LG, Colturato V, de Souza MP, Loth G, Calixto R, Seber A, Zecchin VG, Esteves Daudt L, Tavares RB, Arcuri L, de Macedo AV, Vieira AK, Kuwahara C, Ribeiro L, Fernandes JF, Flowers ME, Pasquini R, Bonfim C. Allogeneic Bone Marrow Transplants for Pediatric Severe Aplastic Anemia: Real-world Data comparing Matched Related and Unrelated Donors in a Developing Country. Retrospective study on behalf of the Pediatric Hematopoietic Stem Cell Transplant Working Group of the Brazilian Bone Marrow Transplantation Society (SBTMO) and the Brazil-Seattle Consortium (Gedeco). Pediatr Transplant 2019; 23:e13552. [PMID: 31297928 DOI: 10.1111/petr.13552] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 04/29/2019] [Accepted: 06/18/2019] [Indexed: 01/06/2023]
Abstract
In this study, we report on major MRD or URD BMT outcomes in pediatric patients with SAA in Brazil. This was a retrospective study, which included 106 patients ≤18 years old who received a first BMT for SAA. All patients received bone marrow as graft source from an MRD (n = 69) or a URD (n = 37). Conditioning regimen was non-myeloablative in 73.6% of cases, and GVHD prophylaxis comprised a calcineurin inhibitor plus methotrexate in 89.6% of patients. After a median follow-up of 4.5 years after BMT, 81 patients are alive, with a 4-year OS of 77% and no statistically significant difference between the MRD and URD groups (82% vs. 69%, respectively; P = .08). Grade III-IV aGVHD at 6 months and cGVHD at 2 years were observed in 8% and 14% of cases, respectively, and were not statistically different between the groups. Twenty-five (23%) patients died at a median of 2.9 months after BMT. Our study showed that 4-year OS after BMT was not statistically different between MRD and URD recipients. This study shows that the outcomes of pediatric patients transplanted for SAA with a URD in Brazil are approaching those of MRD transplants. In contrast, OS after MRD BMT was lower than we would expect based on previous reports. The wide range of preparatory regimens used by the study centers highlights the need for standardized protocols for these children. Our findings provide a benchmark for future studies focused on improving BMT outcomes in this setting in Brazil.
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Affiliation(s)
| | | | | | - Gisele Loth
- Universidade Federal do Paraná, Curitiba, Brazil
| | - Rodolfo Calixto
- Real Hospital Português de Beneficência, Recife - PE, Brazil
| | | | | | | | | | | | | | | | | | | | | | - Mary E Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
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Tichelli A, de Latour RP, Passweg J, Knol-Bout C, Socié G, Marsh J, Schrezenmeier H, Höchsmann B, Bacigalupo A, Samarasinghe S, Rovó A, Kulasekararaj A, Röth A, Eikema DJ, Bosman P, Bader P, Risitano A, Dufour C. Long-term outcome of a randomized controlled study in patients with newly diagnosed severe aplastic anemia treated with antithymocyte globulin and cyclosporine, with or without granulocyte colony-stimulating factor: a Severe Aplastic Anemia Working Party Trial from the European Group of Blood and Marrow Transplantation. Haematologica 2019; 105:1223-1231. [PMID: 31582549 PMCID: PMC7193468 DOI: 10.3324/haematol.2019.222562] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 09/30/2019] [Indexed: 12/24/2022] Open
Abstract
This follow-up study of a randomized, prospective trial included 192 patients with newly diagnosed severe aplastic anemia receiving antithymoglobulin and cyclosporine, with or without granulocyte colony-stimulating factor (G-CSF). We aimed to evaluate the long-term effect of G-CSF on overall survival, event-free survival, probability of secondary myelodysplastic syndrome (MDS) or acute myeloid leukemia (AML), clinical paroxysmal nocturnal hemoglobinuria, relapse, avascular osteonecrosis and chronic kidney disease. The median follow-up was 11.7 years (95% CI, 10.9-12.5). The overall survival rate at 15 years was 57±12% in the group given G-CSF and 63±12% in the group not given G-CSF (P=0.92); the corresponding event-free survival rates were 24±10% and 23±10%, respectively (P=0.36). In total, 9 patients developed MDS or AML, 10 only a clonal cytogenetic abnormality, 7 a solid cancer, 18 clinical paroxysmal nocturnal hemoglobinuria, 8 osteonecrosis, and 12 chronic kidney disease, without any difference between patients treated with or without G-CSF. The cumulative incidence of MDS, AML or isolated cytogenetic abnormality at 15 years was 8.5±3% for the G-CSF group and 8.2±3% for the non-G-CSF group (P=0.90). The cumulative incidence of any late event including myelodysplastic syndrome or acute myeloid leukemia, isolated cytogenetic abnormalities, solid cancer, clinical paroxysmal nocturnal hemoglobinuria, aseptic osteonecrosis, chronic kidney disease and relapse was 50±12% for the G-CSF group and 49±12% for the non-G-CSF group (P=0.65). Our results demonstrate that it is unlikely that G-CSF has an impact on the outcome of severe aplastic anemia; nevertheless, very late events are common and eventually affect the prognosis of these patients, irrespectively of their age at the time of immunosuppressive therapy (NCT01163942).
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Affiliation(s)
- André Tichelli
- Division of Hematology, University Hospital Basel, Basel, Switzerland
| | - Régis Peffault de Latour
- Université de Paris, and Hematology-Transplantation, Saint Louis Hospital (AP-HP), Paris, France
| | - Jakob Passweg
- Division of Hematology, University Hospital Basel, Basel, Switzerland
| | | | - Gérard Socié
- Université de Paris, INSERM U976 and Hematology-Transplantation, Saint Louis Hospital (AP-HP), Paris, France
| | - Judith Marsh
- Department of Haematological Medicine, King's College Hospital/King's College London, London, UK
| | - Hubert Schrezenmeier
- Institute of Tranfusion Medicine, University of Ulm and Institute of Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Transfusion Service Baden-Württemberg-Hessen and University Hospital Ulm, Ulm, Germany
| | - Britta Höchsmann
- Institute of Tranfusion Medicine, University of Ulm and Institute of Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Transfusion Service Baden-Württemberg-Hessen and University Hospital Ulm, Ulm, Germany
| | - Andrea Bacigalupo
- Instituto di Ematologia, Fondazione Policlinico Universitario Gemelli IRCSS, Università Cattolica del Sacro Cuore, Roma, Italy
| | | | - Alicia Rovó
- Department of Hematology and Central Hematology Laboratory, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Austin Kulasekararaj
- Department of Haematological Medicine, King's College Hospital, NIHR/Wellcome King's Clinical Research Facility, London, UK
| | - Alexander Röth
- Department of Hematology, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | | | - Paul Bosman
- EBMT Registry Office, Leiden, the Netherlands
| | - Peter Bader
- University Children's Hospital Frankfurt, Frankfurt, Germany
| | - Antonio Risitano
- Hematology Department of Clinical Medicine and Surgery, Federico II University of Naples, Naples, Italy
| | - Carlo Dufour
- Hemato-Onco-SCT Pole, Hematology Unit. G. Gaslini Children's Research Hospital, Genova, Italy
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66
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Gabelli M, Veys P, Chiesa R. Current status of umbilical cord blood transplantation in children. Br J Haematol 2019; 190:650-683. [PMID: 31410846 DOI: 10.1111/bjh.16107] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 06/19/2019] [Accepted: 06/19/2019] [Indexed: 12/19/2022]
Abstract
The first umbilical cord blood (UCB) transplantation was performed 30 years ago. UCB transplantation (UCBT) is now widely used in children with malignant and non-malignant disorders who lack a matched family donor. UCBT affords a lower incidence of graft-versus-host disease compared to alternative stem cell sources, but also presents a slower immune recovery and a high risk of infections if serotherapy is not omitted or targeted within the conditioning regimen. The selection of UCB units with high cell content and good human leucocyte antigen match is essential to improve the outcome. Techniques, such as double UCBT, ex vivo stem cell expansion and intra-bone injection of UCB, have improved cord blood engraftment, but clinical benefit remains to be demonstrated. Cell therapies derived from UCB are under evaluation as potential novel strategies to reduce relapse and viral infections following transplantation. In recent years, improvements within haploidentical transplantation have reduced the overall use of UCBT as an alternative stem cell source; however, each may have its relative merits and disadvantages and tailored use of these alternative stem cell sources may be the optimal approach.
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Affiliation(s)
- Maria Gabelli
- Bone Marrow Transplantation, Great Ormond Street Hospital, London, UK
| | - Paul Veys
- Bone Marrow Transplantation, Great Ormond Street Hospital, London, UK
| | - Robert Chiesa
- Bone Marrow Transplantation, Great Ormond Street Hospital, London, UK
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67
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68
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Pierri F, Dufour C. Management of aplastic anemia after failure of frontline immunosuppression. Expert Rev Hematol 2019; 12:809-819. [PMID: 31311355 DOI: 10.1080/17474086.2019.1645003] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Introduction: About 60% of aplastic anemia (AA) patients are in need of further treatment after frontline standard immunosuppressive therapy (IST). This along with the prolonged survival of AA subjects who do not respond to or relapse after this treatment makes management of these patients a rising and very challenging issue. Areas covered: Literature research, carried out from the most commonly used databases, included the following keywords: aplastic anemia, immunosuppressive treatment, antithymocyte globuline, ciclosporine A, refractory aplastic anemia, relapsing aplastic anemia, hematopoietic stem cell transplantation including haploidentical and cord blood transplantations thrombopoietin mimetics, supportive treatment, chelation and infections. Studies on the treatment of aplastic anemia with different levels of evidence were included. Top level of evidence studies (metanalyses and randomized prospective controlled trials) were a minority because severe AA, particularly in the subset of patients who fail upfront IST, is an extremely rare disease. Guidelines from National Societies and review articles were also included. Expert opinion: The most commonly used treatments after failure of upfront immunosuppression are hematopoietic stem cell transplantation, a second course of immunosuppression and thrombopoietin mimetics alone or in combination with immunosuppression. Other potential options are alemtuzumab, androgens, oral cyclosporine A in monotherapy. Not many comparative studies exist to clearly establish the superiority of one over another strategy. Therefore, the choice of the best treatment for these patients should rely on major driving factors like patient's age and comorbidities, availability of a matched unrelated donor, donor's characteristics and drug-availability.
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Affiliation(s)
- Filomena Pierri
- Hematology Unit, G. Gaslini Children's Research Hospital , Genova , Italy
| | - Carlo Dufour
- Hematology Unit, G. Gaslini Children's Research Hospital , Genova , Italy
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69
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Vaht K, Göransson M, Carlson K, Isaksson C, Lenhoff S, Sandstedt A, Uggla B, Winiarski J, Ljungman P, Andersson PO, Brune M. High Graft-versus-Host Disease-Free, Relapse/Rejection-Free Survival and Similar Outcome of Related and Unrelated Allogeneic Stem Cell Transplantation for Aplastic Anemia: A Nationwide Swedish Cohort Study. Biol Blood Marrow Transplant 2019; 25:1970-1974. [PMID: 31173901 DOI: 10.1016/j.bbmt.2019.05.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 05/26/2019] [Accepted: 05/28/2019] [Indexed: 11/19/2022]
Abstract
Allogeneic stem cell transplantation (SCT) as primary treatment for aplastic anemia (AA) is being increasingly used. Yet, age, stem cell source, and donor type are important outcome factors. We have recently performed a nationwide cohort study of all patients with AA in Sweden diagnosed from 2000 to 2011 and now present outcome data on SCT patients. In total, 68 patients underwent SCT, and 63% of them had failed immunosuppressive therapy. We found that, with a median follow-up of 109 months (range, 35 to 192 months), 5-year overall survival (OS) for all patients was 86.8%, whereas graft-versus-host disease-free, relapse/rejection-free survival (GRFS) at 5 years was 69.1%. There was no survival impact regarding the donor type or stem cell source. Patients aged ≥40 years had a higher transplant-related mortality (29.4% versus 7.8%; P = .023), which translated into a lower 5-year OS: 70.6% versus 92.2% (P = .022) and a trend of lower GRFS (52.9% versus 74.5%; P = .069). In conclusion, we found in this real-world setting that both OS and GRFS were high, but SCT for patients with AA aged ≥40 years is problematic, and clinical trials addressing this issue are warranted.
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Affiliation(s)
- Krista Vaht
- Section of Hematology and Coagulation, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Medicine, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden.
| | - Magnus Göransson
- Department of Pediatrics, The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kristina Carlson
- Department of Hematology, Uppsala University Hospital, Uppsala, Sweden
| | - Cecilia Isaksson
- Department of Hematology, Cancer Centre, University Hospital, Umeå, Sweden
| | - Stig Lenhoff
- Department of Hematology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Anna Sandstedt
- Department of Hematology, Linköping University Hospital, Linköping, Sweden
| | - Bertil Uggla
- Section of Hematology Department of Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Jacek Winiarski
- Astrid Lindgren Children's Hospital, Karolinska University Hospital, Huddinge and CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Per Ljungman
- Centre of Allogeneic Stem Cell Transplantation Unit (CAST), Karolinska University Hospital, Stockholm, Sweden; Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Per-Ola Andersson
- Institute of Medicine, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden; Department of Medicine, Södra Älvsborg Hospital Borås, Borås, Sweden
| | - Mats Brune
- Section of Hematology and Coagulation, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Medicine, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
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70
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Stem cell transplantation in aplastic anemia: Impact on choices for first line therapy. Hemasphere 2019; 3:HemaSphere-2019-0057. [PMID: 35309776 PMCID: PMC8925704 DOI: 10.1097/hs9.0000000000000249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 04/01/2019] [Indexed: 10/28/2022] Open
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71
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Marsh JCW, Risitano AM, Mufti GJ. The Case for Upfront HLA-Matched Unrelated Donor Hematopoietic Stem Cell Transplantation as a Curative Option for Adult Acquired Severe Aplastic Anemia. Biol Blood Marrow Transplant 2019; 25:e277-e284. [PMID: 31129354 DOI: 10.1016/j.bbmt.2019.05.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 05/07/2019] [Accepted: 05/16/2019] [Indexed: 12/20/2022]
Abstract
The improved success of HLA-matched unrelated donor (MUD) hematopoietic stem cell transplantation (HSCT) for severe aplastic anemia (SAA) in recent decades has had an impact on the indications for and timing of this treatment modality. In the absence of a matched sibling donor (MSD), historically MUD HSCT was reserved as an option after failure to respond to at least 2 courses of immunosuppressive therapy (IST) in adults with SAA, but with improved outcomes over time, it is now considered following failure to respond to 1 course of IST. Recent national and international studies and guidelines now recommend upfront MUD HSCT as an option for children for whom an MUD is readily available, because outcomes are similar to those for MSD HSCT. Fludarabine-based conditioning and the use of in vivo T cell depletion with antithymocyte globulin or alemtuzumab has been associated with a reported overall survival (OS) of >85% in adult patients undergoing MUD HSCT. However, the recent introduction of eltrombopag for patients with SAA has transformed the treatment landscape, and there is currently much interest in its use with IST as upfront treatment, which showed a high response rate in an early-phase study. The risks of HSCT, especially graft-versus-host disease (GVHD), need to be carefully balanced against the concerns of IST, namely relapse and later clonal evolution to myelodysplastic syndrome (MDS)/acute myelogenous leukemia (AML). In the absence of a current prospective randomized trial comparing these 2 approaches, in this review we examine the evidence supporting consideration of early MUD HSCT in adults with SAA who would have been considered for MSD HSCT but who lack a MSD and for whom an MUD is readily available, especially using an irradiation-free conditioning regimen, with a low risk of GVHD, as another treatment option. This option may be offered to patients to provide them with an informed choice, with the aim of curing disease rather than achieving freedom from disease, relapse-free survival, or OS. Furthermore, understanding the immune signature for the response to IST and the immunologic responses to somatic mutations and clonal progression to MDS/AML may help define the future indications for upfront HSCT and a more precise medical approach to therapy.
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Affiliation(s)
- Judith C W Marsh
- Department of Haematological Medicine, King's College Hospital/King's College London, London, UK.
| | | | - Ghulam J Mufti
- Department of Haematological Medicine, King's College Hospital/King's College London, London, UK
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72
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Duarte RF, Labopin M, Bader P, Basak GW, Bonini C, Chabannon C, Corbacioglu S, Dreger P, Dufour C, Gennery AR, Kuball J, Lankester AC, Lanza F, Montoto S, Nagler A, Peffault de Latour R, Snowden JA, Styczynski J, Yakoub-Agha I, Kröger N, Mohty M. Indications for haematopoietic stem cell transplantation for haematological diseases, solid tumours and immune disorders: current practice in Europe, 2019. Bone Marrow Transplant 2019; 54:1525-1552. [PMID: 30953028 DOI: 10.1038/s41409-019-0516-2] [Citation(s) in RCA: 176] [Impact Index Per Article: 35.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 03/05/2019] [Accepted: 03/07/2019] [Indexed: 12/20/2022]
Abstract
This is the seventh special EBMT report on the indications for haematopoietic stem cell transplantation for haematological diseases, solid tumours and immune disorders. Our aim is to provide general guidance on transplant indications according to prevailing clinical practice in EBMT countries and centres. In order to inform patient decisions, these recommendations must be considered together with the risk of the disease, the risk of the transplant procedure and the results of non-transplant strategies. In over two decades since the first report, the EBMT indications manuscripts have incorporated changes in transplant practice coming from scientific and technical developments in the field. In this same period, the establishment of JACIE accreditation has promoted high quality and led to improved outcomes of patient and donor care and laboratory performance in transplantation and cellular therapy. An updated report with operating definitions, revised indications and an additional set of data with overall survival at 1 year and non-relapse mortality at day 100 after transplant in the commonest standard-of-care indications is presented. Additional efforts are currently underway to enable EBMT member centres to benchmark their risk-adapted outcomes as part of the Registry upgrade Project 2020 against national and/or international outcome data.
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Affiliation(s)
- Rafael F Duarte
- Hospital Universitario Puerta de Hierro Majadahonda - Universidad Autónoma de Madrid, Madrid, Spain.
| | - Myriam Labopin
- EBMT Paris Study Office, Hopital Saint Antoine, Paris, France
| | - Peter Bader
- Goethe University Hospital, Frankfurt/Main, Germany
| | | | - Chiara Bonini
- Vita-Salute San Raffaele University & Ospedale San Raffaele Scientific Institute, Milan, Italy
| | - Christian Chabannon
- Institut Paoli Calmettes & Centre d'Investigations Cliniques en Biothérapies, Marseille, France
| | | | - Peter Dreger
- Medizinische Klinik V, Universität Heidelberg, Heidelberg, Germany
| | - Carlo Dufour
- Giannina Gaslini Children's Hospital, Genoa, Italy
| | | | - Jürgen Kuball
- University Medical Center Utrecht, Utrecht, The Netherlands
| | - Arjan C Lankester
- Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | | | | | - Arnon Nagler
- Chaim Sheva Medical Center, Tel-Hashomer, Israel
| | | | - John A Snowden
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Jan Styczynski
- Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | | | | | - Mohamad Mohty
- Hopital Saint Antoine, Sorbonne Université, Paris, France
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Severe aplastic anemia: allogeneic bone marrow transplantation as first-line treatment. Blood Adv 2019; 2:2020-2028. [PMID: 30108110 DOI: 10.1182/bloodadvances.2018021162] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 07/21/2018] [Indexed: 12/20/2022] Open
Abstract
Treatment of severe aplastic anemia has improved significantly over the past 4 decades. This review will summarize the key areas of progress in the use of allogeneic hematopoietic cell transplantation and nontransplant immunosuppressive therapy (IST) for the treatment of aplastic anemia and then summarize the recommendations for first-line treatment. Based on recent data, we argue that guidelines for the initial treatment of patients with newly diagnosed severe aplastic anemia require revision. At the time of diagnosis, before beginning treatment, HLA typing should be done to identify a marrow donor among family members or in the unrelated donor registries, and a marrow transplant should be considered first-line therapy. The priority order of donor source for bone marrow transplantation is: (1) HLA-identical sibling, (2) HLA-matched unrelated donor, and (3) HLA-haploidentical donor if an HLA-matched unrelated donor is not rapidly available. Each of these donor marrow sources may be preferable to nontransplant IST. We make this recommendation because of the long-term persistent risk for disease relapse and secondary myelodysplastic syndrome or acute myeloid leukemia with the use of nontransplant IST for patients with aplastic anemia. In contrast, marrow transplantation is associated with high cure rates of aplastic anemia and a relatively low risk for graft-versus-host disease, with many patients now living for decades without the risk for disease recurrence or the development of clonal disorders. Implementation of this first-line treatment strategy will provide patients with severe aplastic anemia the best chance of long-term disease-free survival.
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74
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Zhang Y, Wu L, Mo W, Zhou M, Li Y, Chen X, Wang C, Pan S, Xu S, Zhou W, Zhou R, Wang S. Comparable Outcomes of First-Line Hematopoietic Stem Cell Transplantation from Unrelated and Matched Sibling Donors in Adult Patients with Aplastic Anemia: A Retrospective Single-Center Study. Biol Blood Marrow Transplant 2019; 25:1567-1575. [PMID: 30926448 DOI: 10.1016/j.bbmt.2019.03.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Accepted: 03/19/2019] [Indexed: 12/20/2022]
Abstract
To explore the feasibility of upfront unrelated donor (URD) hematopoietic stem cell transplantation (HSCT) in the treatment of adult aplastic anemia (AA), we conducted a retrospective, single-center study and compared the outcomes of adult patients who underwent first-line URD HSCT or matched sibling donor (MSD) HSCT between August 2012 and June 2018. In all, 23 URD HSCT recipients had an increased cumulative incidence of grade II acute graft-versus-host disease (aGVHD) (21.7% versus 3.4%; P =.007), but similar rates of secondary graft failure (8.7 ± 6.0% versus 6.9 ± 3.4%; P = .764), chronic GVHD (cGVHD) (18.2% versus 8.8%; P = .285), extensive cGVHD (9.1% versus 3.5%; P = .328), 5-year estimated overall survival (87.0% versus 94.2%; P = .501), and 5-year estimated failure-free survival (82.0% versus 89.3%; P = .404) compared with 58 MSD HSCT recipients treated during the same period. After using propensity score matching to reduce the influence of potential confounders, the 2 groups were well balanced in terms of pretransplantation clinical factors. The median survival time was similar, and no significant differences in the aforementioned outcomes were observed between the 2 groups. Our results suggest that URD HSCT may be an effective and feasible option for first-line therapy in adult AA patients who lack an MSD.
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Affiliation(s)
- Yuping Zhang
- Department of Hematology, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, Guangdong, China; Department of Hematology, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Liangliang Wu
- Department of Hematology, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, Guangdong, China; Department of Hematology, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Wenjian Mo
- Department of Hematology, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, Guangdong, China; Department of Hematology, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Ming Zhou
- Department of Hematology, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, Guangdong, China; Department of Hematology, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Yumiao Li
- Department of Hematology, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, Guangdong, China; Department of Hematology, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Xiaowei Chen
- Department of Hematology, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, Guangdong, China; Department of Hematology, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Caixia Wang
- Department of Hematology, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, Guangdong, China; Department of Hematology, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Shiyi Pan
- Department of Hematology, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, Guangdong, China; Department of Hematology, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Shilin Xu
- Department of Hematology, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, Guangdong, China; Department of Hematology, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Wei Zhou
- Department of Hematology, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, Guangdong, China; Department of Hematology, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Ruiqing Zhou
- Department of Hematology, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, Guangdong, China; Department of Hematology, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Shunqing Wang
- Department of Hematology, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, Guangdong, China; Department of Hematology, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, Guangdong, China.
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75
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Aplastic Anemia & MDS International Foundation (AA&MDSIF): Bone Marrow Failure Disease Scientific Symposium 2018. Leuk Res 2019; 80:19-25. [PMID: 30908982 DOI: 10.1016/j.leukres.2019.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 03/15/2019] [Indexed: 11/21/2022]
Abstract
The bone marrow failure (BMF) syndromes are a group of rare disorders characterized by ineffective hematopoiesis resulting from deficiencies in the hematopoietic stem cell compartment. Although these diseases are typically acquired, some forms (e.g., Fanconi anemia, dyskeratosis congenita, Diamond Blackfan anemia, and Shwachman Diamond syndrome) are inherited. Patients with BMF syndromes can develop peripheral blood cytopenias and pancytopenia, and their disease can ultimately progress to acute myelogenous leukemia (AML). Research around the world is shedding light on the biology of the BMF syndromes, their clinical effects, and novel treatments. The Aplastic Anemia and MDS International Foundation (AAMDSIF) is an independent nonprofit organization whose mission is to help patients and family members cope with BMF syndromes. This report summarizes presentations on the latest scientific discoveries in BMF syndromes from the Sixth International Bone Marrow Failure Disease Scientific Symposium sponsored by AAMDSIF on March 22-23, 2018, in Rockville, Maryland.
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76
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Bacigalupo A, Giammarco S. Haploidentical donor transplants for severe aplastic anemia. Semin Hematol 2019; 56:190-193. [PMID: 31202429 DOI: 10.1053/j.seminhematol.2019.03.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 03/18/2019] [Indexed: 11/11/2022]
Abstract
Haploidentical stem cell transplantation (HAPLO) is being increasingly used, and significant progress has been made both with ex vivo T-cell depleted grafts as well as with unmanipulated marrow or peripheral blood grafts. We here review the current status of HAPLO grafts in patients with acquired severe aplastic anemia. Several transplant platforms have been tested, to overcome graft severe rejection and graft vs host disease (GvHD): these include differences in the conditioning regimen, in graft source and graft manipulation, and in GvHD prophylaxis. The latter include ex vivo T-cell depletion and/or antithymocyte globulin and/or high dose post-transplant cyclophosphamide. Some programs also include the use of marrow or cord blood mesenchymal stem cells, infused at the time of transplantation. Extremely encouraging results are being reported especially in the pediatric population, but also in young adults: we will review reports on 375 patients, with an average rejection rate of 6%, grade II-IV GvHD of 23% and 1-year survival of 80%. Finally we will discuss the place of HAPLO transplants in the context of alternative donor grafts for acquired aplastic anemia.
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Affiliation(s)
- Andrea Bacigalupo
- Department of Hematology, Fondazione Policlinico Universitario Gemelli IRCCS, Universita' Cattolica del Sacro Cuore, Roma, Italy.
| | - Sabrina Giammarco
- Department of Hematology, Fondazione Policlinico Universitario Gemelli IRCCS, Universita' Cattolica del Sacro Cuore, Roma, Italy
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77
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Oved JH, Wang Y, Barrett DM, Levy EM, Huang Y, Monos DS, Grupp SA, Bunin NJ, Olson TS. CD3 +/CD19 + Depleted Matched and Mismatched Unrelated Donor Hematopoietic Stem Cell Transplant with Targeted T Cell Addback Is Associated with Excellent Outcomes in Pediatric Patients with Nonmalignant Hematologic Disorders. Biol Blood Marrow Transplant 2019; 25:549-555. [PMID: 30312755 PMCID: PMC7122955 DOI: 10.1016/j.bbmt.2018.10.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 10/02/2018] [Indexed: 01/19/2023]
Abstract
Unrelated donor hematopoietic stem cell transplantation (HSCT) is increasingly being used to cure nonmalignant hematologic diseases (NMHD) in patients who lack HLA matched related donors. Both graft rejection and graft-versus-host disease (GVHD) remain major barriers to safe and effective transplant for these patients requiring unrelated donors. Partial T cell depletion combined with peripheral stem cell transplantation (pTCD-PSCT) has the potential advantages of providing a high stem cell dose to facilitate rapid engraftment, maintaining cells that may facilitate engraftment, and decreasing GVHD risk compared with T cell-replete HSCT. Here, we report a single-institution, retrospective experience of unrelated donor pTCD-PSCT for pediatric patients with NMHD. From 2014 to 2017, 12 pediatric patients with transfusion-dependent NMHD underwent matched unrelated donor (MUD) or mismatched unrelated donor (MMUD) pTCD HSCT in our center using disease-specific conditioning. Donor PSCs underwent CD3+ T cell and CD19+ B cell depletion using CliniMACS, followed by a targeted addback of 1 × 105 CD3+ T cells/kg to the graft before infusion. All 12 patients demonstrated rapid trilinear engraftment. At a median follow-up of 740days (range, 279 to 1466), all patients were alive with over 92% total peripheral blood donor chimerism and without transfusion dependence or recurrence of their underlying hematologic disease. Immune reconstitution was rapid and comparable with T cell-replete HSCT. No patients developed severe acute GVHD (grades III to IV) or chronic extensive GVHD, and all patients had discontinued systemic immune suppression. Viral reactivations were common, but no patient developed symptoms of life-threatening infectious disease. Our data indicate that MUD and MMUD pTCD-PSCTs are safe and effective approaches that enable rapid engraftment and immune reconstitution, prevent severe GVHD, and expand availability of HSCT to any patients with NMHD who have closely MUDs.
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Affiliation(s)
- Joseph H Oved
- Cellular Therapy and Transplant Section, Division of Oncology Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Pediatric Hematology/Oncology Fellowship Program, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Yongping Wang
- Cellular Therapy and Transplant Section, Division of Oncology Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pathology and Laboratory Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David M Barrett
- Cellular Therapy and Transplant Section, Division of Oncology Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ellen M Levy
- Cellular Therapy and Transplant Section, Division of Oncology Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Yanping Huang
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Dimitrios S Monos
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Stephan A Grupp
- Cellular Therapy and Transplant Section, Division of Oncology Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nancy J Bunin
- Cellular Therapy and Transplant Section, Division of Oncology Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Timothy S Olson
- Cellular Therapy and Transplant Section, Division of Oncology Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania.
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78
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[Comparison of different styles of allogeneic hematopoietic stem cell transplantation as first-line treatment treated with severe aplastic anemia in children and adolescents]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2019; 39:184-189. [PMID: 29562461 PMCID: PMC7342997 DOI: 10.3760/cma.j.issn.0253-2727.2018.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Objective: To evaluate the efficacy of allogeneic hematopoietic stem cell transplantation (allo-HSCT) from different donors as first-line treatment for children and adolescents with severe aplastic anemia (SAA) . Methods: The clinical data of 79 children and adolescents with SAA diagnosed from January 2013 to December 2016 in Henan Province were retrospectively analyzed. There were 50 males and 29 females, with a median age of 14(4-18) years. 40 cases received matched sibling transplantation (MSD-HSCT), 17 with unrelated donor transplantation (UD-HSCT), and 22 with haploidentical transplantation (haplo-HSCT). Results: The comparison of MSD-HSCT, UD-HSCT, haplo-HSCT groups was conducted and the median times of neutrophils engraftment were statistically significant [12(9-25) d, 14(10-22) d, 16(11-26) d, respectively (χ2=13.302, P=0.001)], but no difference in+30 d engraftment rate [97.3%(36/37), 100%(15/15), 100%(20/20), χ2=0.959, P=0.619]. The median times of PLT engraftment were not statistically significant [14(6-34)d, 16(7-32)d, 19(10-34)d, respectively, χ2=5.892, P=0.053], and the +30 d engraftment rate had no difference [97.3%(36/37), 100%(15/15), 100%(20/20), χ2=0.959, P=0.619]. The post-transplant infection rate showed no statistically significance [35.0% (14/40), 29.4% (5/17), 45.5% (10/22), χ2=1.158, P=0.560], as well as the incidences of aGVHD, grade III/IV aGVHD and cGVHD(χ2=0.230, P=0.891; χ2=2.628, P=0.269; χ2=3.187, P=0.203). The two-years OS rate was not statistically significant respectively [(77.1±6.7)%, (70.6±11.1)%, (77.3±8.9)%, χ2=0.330, P=0.845]. Severe post-transplant infection (RR=4.617, P=0.009), grade Ⅲ/Ⅳ aGVHD (RR=2.707, P=0.048) were independent risk factors for OS. Conclusion: The overall efficacy of MSD-HSCT, UD-HSCT and haplo-HSCT as first-line therapy for children and adolescents with SAA/VSAA is comparable.
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79
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Immunosuppressive therapy versus haploidentical transplantation in adults with acquired severe aplastic anemia. Bone Marrow Transplant 2019; 54:1319-1326. [PMID: 30670825 DOI: 10.1038/s41409-018-0410-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Revised: 11/08/2018] [Accepted: 11/10/2018] [Indexed: 11/08/2022]
Abstract
Our study aimed to compare treatment outcomes between hematopoietic stem cell transplantation (HSCT) from haploidentical donors (HID) and immunosuppressive therapy (IST) in adults with acquired severe aplastic anemia (SAA). The medical records of 113 SAA adults who received IST, including rabbit ATG and cyclosporin (N = 37), or HID HSCT (N = 76) within 6 months of diagnosis at two institutions were retrospectively reviewed. Estimated 8-year overall survival (OS) was comparable between the IST and HID HSCT groups (75.6 vs. 83.7%, respectively, P = 0.328), but failure free survival (FFS) was significantly lower in IST group than HID HSCT group (38.5 vs. 83.7%, respectively, P = 0.001). Furthermore, a significant improvement in FFS was observed with HSCT over IST in patients under 40 years old. At the last follow-up, patients in HSCT group achieved better Karnofsky Performance Status (KPS) than those in IST group (100 [20-100] vs. 90 [20-100], P = 0.002). In terms of blood count, 83.1% (54/65) of patients in HSCT group showed complete recovery compared to only 38.2% (13/34) in IST group (P < 0.001). These data suggest that HID HSCT could be an effective alternative treatment option for SAA adults, and additional prospective studies are necessary.
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80
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Yang S, Yuan X, Ma R, Jiang L, Guo J, Zang Y, Shi J, Yang J, Lei P, Liu Z, Zhang Y, Zhu Z. Comparison of Outcomes of Frontline Immunosuppressive Therapy and Frontline Haploidentical Hematopoietic Stem Cell Transplantation for Children with Severe Aplastic Anemia Who Lack an HLA-Matched Sibling Donor. Biol Blood Marrow Transplant 2019; 25:975-980. [PMID: 30658223 DOI: 10.1016/j.bbmt.2019.01.017] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 01/09/2019] [Indexed: 11/17/2022]
Abstract
We compared the outcomes of immunosuppressive therapy (IST) with those of T cell-replete haploidentical donor hematopoietic stem cell transplantation (haplo-HSCT) in children and adolescents with severe aplastic anemia (SAA). The medical records of 49 patients with SAA who received frontline IST (n = 29) or frontline haplo-HSCT (n = 20) between 2012 and 2016 were analyzed retrospectively. Fourteen patients responded after the first IST, and 1 patient responded after the second IST in the frontline IST group; 12 patients underwent salvage HSCT after IST failure. Sixteen of the 20 patients who underwent frontline haplo-HSCT survived without treatment failure. The 3-year overall survival of the frontline IST group was comparable to that of the frontline haplo-HSCT group (79.3 ± 7.5% versus 85.0 ± 8.0%; χ2 = 0.110; P = .740). The 3-year failure-free survival was lower in the frontline IST group compared with the frontline haplo-HSCT group (35.9 ± 10.9% versus 80.0 ± 8.9%; χ2 = 4.089; P = .043). Five patients of the IST group who underwent salvage HSCT achieved long survival without event. The event-free survival was lower in the salvage HSCT group compared with the haplo-HSCT group (41.7 ± 14.2% versus 80.0 ± 8.9%; χ2 = 3.992; P = .046), and the incidences of acute GVHD, grade II-IV acute GVHD, chronic GVHD, and severe infection were comparable between the 2 groups. Our results suggest that frontline haplo-HSCT may be a better treatment than IST for children and adolescents with SAA who lack an HLA age-matched familial donor.
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Affiliation(s)
- Shiwei Yang
- Institute of Hematology of Henan Provincial People's Hospital, Henan Provincial People's Hospital, Henan, China
| | - Xiaoli Yuan
- Department of Hematology, People's Hospital of Zhengzhou University, Henan, China
| | - Rongjun Ma
- Department of Hematology, People's Hospital of Zhengzhou University, Henan, China
| | - Li Jiang
- Department of Hematology, People's Hospital of Zhengzhou University, Henan, China
| | - Jianmin Guo
- Department of Hematology, People's Hospital of Zhengzhou University, Henan, China
| | - Yuzhu Zang
- Department of Hematology, People's Hospital of Zhengzhou University, Henan, China
| | - Jie Shi
- Department of Hematology, People's Hospital of Zhengzhou University, Henan, China
| | - Jing Yang
- Department of Hematology, People's Hospital of Zhengzhou University, Henan, China
| | - Pingchong Lei
- Department of Hematology, People's Hospital of Zhengzhou University, Henan, China
| | - Zhongwen Liu
- Department of Hematology, People's Hospital of Zhengzhou University, Henan, China
| | - Yin Zhang
- Department of Hematology, People's Hospital of Zhengzhou University, Henan, China
| | - Zunmin Zhu
- Department of Hematology, People's Hospital of Zhengzhou University, Henan, China.
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81
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Kim H, Im HJ, Koh KN, Kang SH, Yoo JW, Choi ES, Cho YU, Jang S, Park CJ, Seo JJ. Comparable Outcome with a Faster Engraftment of Optimized Haploidentical Hematopoietic Stem Cell Transplantation Compared with Transplantations from Other Donor Types in Pediatric Acquired Aplastic Anemia. Biol Blood Marrow Transplant 2019; 25:965-974. [PMID: 30639824 DOI: 10.1016/j.bbmt.2019.01.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 01/04/2019] [Indexed: 01/31/2023]
Abstract
Haploidentical family donors have been used as an alternative source in hematopoietic cell transplantation for patients with severe aplastic anemia. We evaluated and compared the outcomes of transplantation in pediatric acquired severe aplastic anemia based on donor type. Sixty-seven patients who underwent transplantation between 1998 and 2017 were included. Fourteen patients received grafts from matched sibling donors, 21 from suitable unrelated donors, and 32 from haploidentical family donors. Ex vivo CD3+ or αβ+ T cell-depleted grafts were used for haploidentical transplantation. Sixty-five patients (97.0%) achieved neutrophil engraftment at a median of 11 days. Haploidentical transplantation resulted in significantly faster neutrophil engraftment at a median of 10 days, compared with 14 days in cases of matched sibling donors and 12 days in cases of unrelated donor recipients. Nine patients experienced graft failure, and 5 of 7 who underwent a second transplantation are alive. There was no difference in the incidence of acute or chronic graft-versus-host disease based on donor type. The 5-year overall survival and failure-free survival rates were 93.8% ± 3.0% and 83.3% ± 4.6%, respectively, and there was no significant survival difference based on donor type. The survival outcomes of haploidentical transplantation in patients were comparable with those of matched sibling or unrelated donor transplantation. Optimized haploidentical transplantation using selective T cell depletion and conditioning regimens including low-dose total body irradiation for enhancing engraftment may be a realistic therapeutic option for pediatric patients with severe aplastic anemia.
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Affiliation(s)
- Hyery Kim
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, Seoul, Korea
| | - Ho Joon Im
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, Seoul, Korea.
| | - Kyung-Nam Koh
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, Seoul, Korea
| | - Sung Han Kang
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, Seoul, Korea; Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
| | - Jae Won Yoo
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, Seoul, Korea; Department of Pediatrics, Chungnam National University School of Medicine, Daejeon, Korea
| | - Eun Seok Choi
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, Seoul, Korea
| | - Young-Uk Cho
- Department of Laboratory Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Seongsoo Jang
- Department of Laboratory Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Chan-Jeoung Park
- Department of Laboratory Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jong Jin Seo
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, Seoul, Korea
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82
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Georges GE. Consider Allogeneic Bone Marrow Transplantation for Older, FitPatients with Aplastic Anemia. Biol Blood Marrow Transplant 2019; 25:e69-e70. [PMID: 30641134 DOI: 10.1016/j.bbmt.2019.01.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 01/08/2019] [Indexed: 10/27/2022]
Affiliation(s)
- George E Georges
- Fred Hutchison Cancer Research Center, Seattle, Washington; University of Washington, Seattle, Washington.
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83
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Samarasinghe S, Clesham K, Iacobelli S, Sbianchi G, Knol C, Hamladji RM, Socié G, Aljurf M, Koh M, Sengeloev H, Dalle JH, Robinson S, Van Lint MT, Halkes CJM, Beelen D, Mufti GJ, Snowden J, Blaise D, de Latour RP, Marsh J, Dufour C, Risitano AM. Impact of T-cell depletion strategies on outcomes following hematopoietic stem cell transplantation for idiopathic aplastic anemia: A study on behalf of the European blood and marrow transplant severe aplastic anemia working party. Am J Hematol 2019; 94:80-86. [PMID: 30328134 DOI: 10.1002/ajh.25314] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 10/02/2018] [Accepted: 10/15/2018] [Indexed: 12/11/2022]
Abstract
We retrospectively analyzed the outcomes of 1837 adults and children with severe aplastic anemia (SAA) who underwent matched sibling donor (MSD) and matched unrelated donor (MUD) hemopoietic stem cell transplantation (HSCT) between 2000 and 2013. Patients were grouped by transplant conditioning containing either anti-thymocyte globulin (ATG) (n = 1283), alemtuzumab (n = 261), or no serotherapy (NS) (n = 293). The risks of chronic GvHD were significantly reduced when ATG or alemtuzumab were compared with NS (P = .021 and .003, respectively). Acute GVHD was significantly reduced in favor of alemtuzumab compared with ATG (P = .012) and NS (P < .001). By multivariate analysis, when compared with ATG, alemtuzumab was associated with a lower risk of developing acute (OR 0.262; 95% CI 0.14-0.47; P < .001) and chronic GVHD (HR 0.58; 95% CI 0.35-0.94; P = .027). OS was significantly better in ATG and alemtuzumab patients compared with NS (P = .010 and .025). Our data shows inclusion of serotherapy in MSD and MUD HSCT for patients with SAA reduces chronic GVHD and provides a survival advantage over patients not receiving serotherapy. Notably, alemtuzumab reduced the risk of acute and chronic GvHD compared with ATG and indicates that alemtuzumab might be the serotherapy of choice for MSD and MUD transplants for SAA.
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Affiliation(s)
| | - Katherine Clesham
- UCL Great Ormond Street Hospital for Children; London United Kingdom
| | - Simona Iacobelli
- Dipartimento di Biologia; Tor Vergata Università di Roma; Rome Italy
| | - Giulia Sbianchi
- Dipartimento di Biologia; Tor Vergata Università di Roma; Rome Italy
| | - Cora Knol
- EBMT Data Office; Leiden The Netherlands
| | | | | | - Mahmoud Aljurf
- King Faisal Hospital & Research Centre; Riyadh Saudi Arabia
| | - Mickey Koh
- St. George's Hospital; London United Kingdom
| | | | | | | | | | | | | | - Ghulam J. Mufti
- King's College Hospital/King's College London; London United Kingdom
| | - John Snowden
- Sheffield Teaching Hospitals NHS Foundation Trust; Sheffield United Kingdom
| | | | | | - Judith Marsh
- King's College Hospital/King's College London; London United Kingdom
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84
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Noronha SA. Aplastic and Hypoplastic Anemias. Pediatr Rev 2018; 39:601-611. [PMID: 30504252 DOI: 10.1542/pir.2017-0250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Suzie A Noronha
- Division of Pediatric Hematology/Oncology, University of Rochester, Rochester, NY
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85
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Bacigalupo A. Alternative donor transplants for severe aplastic anemia. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2018; 2018:467-473. [PMID: 30504347 PMCID: PMC6245994 DOI: 10.1182/asheducation-2018.1.467] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Allogeneic hematopoietic stem-cell transplantation remains the only curative treatment for patients with acquired severe aplastic anemia (SAA). When a matched sibling is not available, one can search for a matched unrelated donor or a cord blood unit (CB) in the international registries or, more recently, for an HLA haploidentical (HAPLO) family member. International guidelines call for a course of antithymocyte globulin (ATG) and cyclosporine before a patient with SAA receives a transplant from a donor other than an HLA identical sibling, but whether this is necessary for patients age <20 years is less clear. Here I will examine the rapid increase in HAPLO transplantations for SAA, showing encouraging early results both in children and young adults. Graft-versus-host disease prophylaxis remains of primary importance in patients with SAA, and in vivo T-cell depletion with either ATG or alemtuzumab offers a significant survival advantage. Finally, I will discuss the strong age effect, which is particularly evident at >40 and 50 years of age for reasons not entirely clear and which should be taken into account when designing a treatment strategy for a given patient.
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Affiliation(s)
- Andrea Bacigalupo
- Department of Hematology, Fondazione Policlinico Universitario Gemelli IRCCS, Universita' Cattolica del Sacro Cuore, Rome, Italy
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86
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Affiliation(s)
- Neal S Young
- From the Hematology Branch, National Heart, Lung, and Blood Institute, Bethesda, MD
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87
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Clesham K, Dowse R, Samarasinghe S. Upfront Matched Unrelated Donor Transplantation in Aplastic Anemia. Hematol Oncol Clin North Am 2018; 32:619-628. [DOI: 10.1016/j.hoc.2018.03.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Abstract
PURPOSE OF REVIEW This review aimed to provide updated guidelines for the management of children with acquired aplastic anemia (AA), particularly focusing on hematopoietic stem cell transplantation (HSCT). RECENT FINDINGS Failure-free survival for children with aplastic anemia has been shown to be better after bone marrow transplantation (BMT) from matched or one-locus mismatched related donors (MRD/1MMRD) than after immunosuppressive therapy (IST). A combination of the absence of minor paroxysmal nocturnal hemoglobinuria clones and short telomere length was identified as a strong predictor of a poor response to IST. Upfront HSCT from matched unrelated donors (MUD) and MRD was recently demonstrated to have comparable outcomes. Moreover, unrelated cord blood transplantation (UCBT) and haploidentical HSCT have shown promising outcomes, and the fludarabine/melphalan-based regimen has resulted in excellent survival without poor graft function. BMT from MRD/1MMRD is the treatment of choice. When a MRD/1MMRD is not available, upfront BMT from a MUD should be considered for patients with only a slim chance of responding to IST. UCBT and haploidentical HSCT are promising options. This updated treatment algorithm should improve overall outcomes for children with AA.
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90
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Lu Y, Sun RJ, Zhao YL, Xiong M, Cao XY, Zhang JP, Wei ZJ, Zhou JR, Liu DY, Lu DP. Unmanipulated Haploidentical Hematopoietic Stem Cell Transplantation Achieved Outcomes Comparable With Matched Unrelated Donor Transplantation in Young Acquired Severe Aplastic Anemia. Biol Blood Marrow Transplant 2018; 24:1881-1887. [PMID: 29772350 DOI: 10.1016/j.bbmt.2018.05.015] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Accepted: 05/09/2018] [Indexed: 12/16/2022]
Abstract
Salvage haploidentical hematopoietic stem cell transplantation (haplo-HSCT) is considered in patients with severe aplastic anemia (SAA) if a matched unrelated donor (MUD) is unavailable. However, studies on haplo- and MUD transplantation in SAA are lacking. The present study retrospectively analyzed the outcomes of 89 young SAA patients who underwent unmanipulated alternative HSCT between September 2012 and September 2016 at our single center. Forty-one patients received haploidentical donors and forty-eight patients MUDs for HSCT. Most were heavily transfused and refractory to previous immunotherapy. The median durations for myeloid engraftment in the haplo- and MUD cohorts were 14 (range, 10 to 21) and 13 (range, 10 to 18) days, respectively. Compared with the MUD cohort, haplo-HSCT cohorts had an increased cumulative incidence of acute graft-versus-host disease (GVHD) grades II to IV (43.9% ± 7.8% versus 12.5% ± 4.8%, P = .001) and grades III to IV (21.1% ± 6.7% versus 6.6% ± 3.7%, P = .045) and similar limited chronic GVHD (47.7% ± 8.5% versus 38.5% ± 7.3%, P = .129) and extensive chronic GVHD (12.1% ± 6.8% versus 9.1% ± 4.3%, P = .198). The median follow-up time of the surviving patients was 26 months (range, 6 to 45). No significant differences were observed between haplo-HSCT and MUD HSCT cohorts in 3-year overall survival (80.3% ± 5.1% versus 89.6% ± 7.0%, P = .210), disease-free survival (76.4% ± 5.1% versus 89.4% ± 7.7%, P = .127), and GVHD-free failure-free survival (79.0% ± 8.6% versus 71.6% ± 9.3%, P = .976). Thus, haplo-HSCT, as salvage therapy, achieved similar outcomes as MUD HSCT in young SAA patients, thereby rendering it as an effective and safe option for SAA.
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Affiliation(s)
- Yue Lu
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang, Hebei, China
| | - Rui-Juan Sun
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang, Hebei, China
| | - Yan-Li Zhao
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang, Hebei, China
| | - Min Xiong
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang, Hebei, China
| | - Xing-Yu Cao
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang, Hebei, China
| | - Jian-Ping Zhang
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang, Hebei, China
| | - Zhi-Jie Wei
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang, Hebei, China
| | - Jia-Rui Zhou
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang, Hebei, China
| | - De-Yan Liu
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang, Hebei, China
| | - Dao-Pei Lu
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang, Hebei, China.
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Vaht K, Göransson M, Carlson K, Isaksson C, Lenhoff S, Sandstedt A, Uggla B, Winiarski J, Ljungman P, Brune M, Andersson PO. Low response rate to ATG-based immunosuppressive therapy in very severe aplastic anaemia - A Swedish nationwide cohort study. Eur J Haematol 2018. [DOI: 10.1111/ejh.13057] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Krista Vaht
- Section of Haematology and Coagulation; Sahlgrenska University Hospital; Gothenburg Sweden
- Institute of Medicine; Sahlgrenska Academy at Gothenburg University; Gothenburg Sweden
| | - Magnus Göransson
- Department of Pediatrics; The Queen Silvia Children's Hospital; Sahlgrenska University Hospital; Gothenburg Sweden
| | - Kristina Carlson
- Department of Haematology; Uppsala University Hospital; Uppsala Sweden
| | - Cecilia Isaksson
- Department of Haematology; Cancer Centre; University Hospital; Umeå Sweden
| | - Stig Lenhoff
- Department of Haematology; Skåne University Hospital; Lund University; Lund Sweden
| | - Anna Sandstedt
- Department of Haematology; Linköping University Hospital; Linköping Sweden
| | - Bertil Uggla
- Section of Haematology Department of Medicine; Faculty of Medicine and Health; Örebro University; Örebro Sweden
| | - Jacek Winiarski
- Astrid Lindgren Children's Hospital; Karolinska Institutet; Karolinska University Hospital and CLINTEC; Stockholm Sweden
| | - Per Ljungman
- Centre of Allogeneic Stem Cell Transplantation Unit (CAST); Department of Medicine; Karolinska Institutet; Karolinska University Hospital; Stockholm Sweden
| | - Mats Brune
- Section of Haematology and Coagulation; Sahlgrenska University Hospital; Gothenburg Sweden
- Institute of Medicine; Sahlgrenska Academy at Gothenburg University; Gothenburg Sweden
| | - Per-Ola Andersson
- Institute of Medicine; Sahlgrenska Academy at Gothenburg University; Gothenburg Sweden
- Department of Medicine; Södra Älvsborg Hospital Borås; Borås Sweden
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92
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Guilcher GMT, Shah R, Shenoy S. Principles of alemtuzumab immunoablation in hematopoietic cell transplantation for non-malignant diseases in children: A review. Pediatr Transplant 2018; 22. [PMID: 29352515 DOI: 10.1111/petr.13142] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/29/2017] [Indexed: 12/19/2022]
Abstract
Alemtuzumab is a humanized mAb targeted to CD52. Alemtuzumab is highly immunosuppressive with the ability to deplete T and B cells (in addition to other immune cell lines). A growing understanding of the PKs, dosing, and timing of administration of alemtuzumab has allowed for the study of its use as a conditioning agent for allogeneic HCT. The highly immunosuppressive properties of the drug are particularly appealing in the setting of non-malignant HCT, where GVHD provides no clinical benefit and relapse of malignancy is not applicable. In addition, the degree of immune suppression achieved with alemtuzumab has allowed for a reduction in the intensity of myeloablative cytotoxic agents included in some HCT conditioning regimens, allowing for fewer acute and late toxicities. This review paper will provide a comprehensive summary of the mechanism of action, PKs, dosing, and timing of alemtuzumab, a brief description of its use in various allogeneic HCT protocols for non-malignant conditions and a summary of the data regarding its use for GVHD therapy. The goal of this review was to provide an understanding as to how alemtuzumab might be safely incorporated into HCT conditioning regimens for children with non-malignant disease, allowing for expanded access to curative HCT therapy.
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Affiliation(s)
- Gregory M T Guilcher
- Section of Paediatric Oncology/BMT, Departments of Oncology and Paediatrics, University of Calgary, Calgary, AB, Canada
| | - Ravi Shah
- Department of Paediatric Haematology/BMT, Great Ormond Street Hospital, NHS Foundation Trust, London, UK
| | - Shalini Shenoy
- Division of Pediatric Hematology/Oncology, Washington University School of Medicine, St. Louis, MO, USA
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93
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Abstract
PURPOSE OF REVIEW Improvements in allogeneic hematopoietic cell transplantation (HCT) with better donor selection, conditioning regimens and graft vs. host disease prophylaxis make it reasonable to move HCT earlier in the algorithm for management of severe aplastic anemia (SAA). Recent progress in transplantation is reviewed whereas issues related to developing countries are also addressed. RECENT FINDINGS Multiple research centers are reporting on clonality, mutations and telomere disorders in SAA, which may help to choose the most appropriate therapy upfront. Eltrombopag, in combination with immunosuppressive therapy (IST), has shown remarkable improvement over historical IST, and long-term follow-up is awaited. In younger patients and in experienced centers, matched unrelated-donor (MUD) and related haploidentical transplants (haplo-HCT) are being reported with survival approaching that seen with sibling transplants. Literature from resource-limited countries highlight the need to modify guidelines to make them affordable and cost-effective. Bone marrow remains the graft source of choice; peripheral blood stem cells may be acceptable in special circumstances in resource-constrained countries. SUMMARY The potential of novel research findings and new therapeutic trials should be maximized by validation in different centers, countries and patient populations to provide personalized care to patients with aplastic anemia.
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94
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Cheng Y, Xu Z, Zhang Y, Wu J, Wang F, Mo X, Chen Y, Han W, Jia J, Wang Y, Zhang X, Huang X, Zhang L, Xu L. First-line choice for severe aplastic anemia in children: Transplantation from a haploidentical donor vs immunosuppressive therapy. Clin Transplant 2018; 32. [PMID: 29297952 DOI: 10.1111/ctr.13179] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2017] [Indexed: 01/06/2023]
Abstract
We retrospectively compared the outcomes of children with severe aplastic anemia (SAA) who received immunosuppressive therapy (IST) or who underwent hematopoietic stem cell transplantation (HSCT) from a haploidentical donor (HID), between 2007 and 2016. A total of 52 children with SAA under the age of 17 years were initially treated with IST (n = 24) or haploidentical HSCT (n = 28) as first-line treatment. The estimated 10-year overall survival was 73.4 ± 12.6% and 89.3 ± 5.8% in patients treated with IST or HID-HSCT (P = .806). The failure-free survival was significantly inferior in patients receiving IST than in those undergoing transplantation from an HID (52.6 ± 10.5% vs 89.3 ± 5.8, P = .008). In univariate and multivariate analysis, the choice of first-line immunosuppressive therapy was the only adverse predictor for failure-free survival. At the last follow-up, completely normal blood count was observed in 11 of 20 (55.0%) and 24 of 25 (96.0%) live cases in IST and HID-HSCT cohort (P = .003). These suggest that HSCT from a haploidentical donor could be considered as first-line treatment in children who lack a matched related donor, especially in experienced transplantation centers.
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Affiliation(s)
- Yifei Cheng
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Zhengli Xu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Yuanyuan Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Jun Wu
- Department of Pediatrics, Peking University People's Hospital, Beijing, China
| | - Fengrong Wang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Xiaodong Mo
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Yuhong Chen
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Wei Han
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Jinsong Jia
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Yu Wang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Xiaohui Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Xiaojun Huang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Leping Zhang
- Department of Pediatrics, Peking University People's Hospital, Beijing, China
| | - Lanping Xu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
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95
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Samarasinghe S, Veys P, Vora A, Wynn R. Paediatric amendment to adult BSH Guidelines for aplastic anaemia. Br J Haematol 2017; 180:201-205. [DOI: 10.1111/bjh.15066] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Sujith Samarasinghe
- Department of Haematology; Great Ormond Street Hospital for Children NHS Foundation Trust; London UK
| | - Paul Veys
- Department of Bone Marrow Transplantation; Great Ormond Street Hospital for Children NHS Foundation Trust; London UK
| | - Ajay Vora
- Department of Haematology; Great Ormond Street Hospital for Children NHS Foundation Trust; London UK
- Department of Bone Marrow Transplantation; Great Ormond Street Hospital for Children NHS Foundation Trust; London UK
| | - Rob Wynn
- Blood and Marrow Transplant Unit; Royal Manchester Children's Hospital; Manchester UK
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96
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Broglie L, Margolis D, Medin JA. Yin and Yang of mesenchymal stem cells and aplastic anemia. World J Stem Cells 2017; 9:219-226. [PMID: 29321823 PMCID: PMC5746642 DOI: 10.4252/wjsc.v9.i12.219] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 09/14/2017] [Accepted: 10/17/2017] [Indexed: 02/07/2023] Open
Abstract
Acquired aplastic anemia (AA) is a bone marrow failure syndrome characterized by peripheral cytopenias and bone marrow hypoplasia. It is ultimately fatal without treatment, most commonly from infection or hemorrhage. Current treatments focus on suppressing immune-mediated destruction of bone marrow stem cells or replacing hematopoietic stem cells (HSCs) by transplantation. Our incomplete understanding of the pathogenesis of AA has limited development of targeted treatment options. Mesenchymal stem cells (MSCs) play a vital role in HSC proliferation; they also modulate immune responses and maintain an environment supportive of hematopoiesis. Some of the observed clinical manifestations of AA can be explained by mesenchymal dysfunction. MSC infusions have been shown to be safe and may offer new approaches for the treatment of this disorder. Indeed, infusions of MSCs may help suppress auto-reactive, T-cell mediated HSC destruction and help restore an environment that supports hematopoiesis. Small pilot studies using MSCs as monotherapy or as adjuncts to HSC transplantation have been attempted as treatments for AA. Here we review the current understanding of the pathogenesis of AA and the function of MSCs, and suggest that MSCs should be a target for further research and clinical trials in this disorder.
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Affiliation(s)
- Larisa Broglie
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI 53226, United States
| | - David Margolis
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI 53226, United States
| | - Jeffrey A Medin
- Departments of Pediatrics and Biochemistry, Medical College of Wisconsin, Milwaukee, WI 53226, United States
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97
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Gupta A, Fu P, Hashem H, Vatsayan A, Shein S, Dalal J. Outcomes and healthcare utilization in children and young adults with aplastic anemia: A multiinstitutional analysis. Pediatr Blood Cancer 2017; 64. [PMID: 28696061 DOI: 10.1002/pbc.26704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 06/04/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND Aplastic anemia is a bone marrow failure syndrome with high mortality affecting children and young adults. Although current treatment guidelines recommend hematopoietic stem cell transplant (HCT) for patients with matched sibling donors, outcomes with alternate donor options have been improving. PROCEDURE We analyzed a validated multiinstitutional pediatric cohort using one of the largest pediatric and young adult database, the Pediatric Health Information System, for patients diagnosed with aplastic anemia (AA) from 2006 to 2015. Outcomes with upfront and salvage transplants were analyzed along with healthcare utilization. RESULTS Among 2,169 patients in the study period, almost 20% underwent HCT, while others received immunosuppressive therapy. In a multivariate model, there was no significant difference in mortality with upfront or salvage transplants (odds ratio [OR] 1.24, 95% confidence interval [CI] 0.6-2.58, P = 0.567), while every platelet transfusion was associated with higher mortality (OR 1.37, 95% CI 1.12-1.67, P = 0.002). Healthcare utilization was significantly higher in salvage transplants requiring frequent hospitalization and transfusion requirements. Treatment mortality and graft failure rates were significantly reduced in the salvage transplant group in recent years (2011-2015 as compared to 2006-2010). CONCLUSION As outcomes with HCT continue to improve in severe AA, transplant with good alternate donors should be considered upfront in children and young adults.
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Affiliation(s)
- Ashish Gupta
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Pingfu Fu
- Department of Biostatistics, Case Western Reserve University, Cleveland, Ohio
| | - Hasan Hashem
- Division of Pediatric Bone Marrow Transplant, Nationwide Children's Hospital, Columbus, Ohio
| | - Anant Vatsayan
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Steven Shein
- Division of Pediatric Critical Care, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Jignesh Dalal
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, Ohio
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98
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Abstract
OPINION STATEMENT Acquired aplastic anemia (AA) is a rare, life-threatening bone marrow failure (BMF) disorder that affects patients of all ages and is caused by lymphocyte destruction of early hematopoietic cells. Diagnosis of AA requires a comprehensive approach with prompt evaluation for inherited and secondary causes of bone marrow aplasia, while providing aggressive supportive care. The choice of frontline therapy is determined by a number of factors including AA severity, age of the patient, donor availability, and access to optimal therapies. For newly diagnosed severe aplastic anemia, bone marrow transplant should be pursued in all pediatric patients and in younger adult patients when a matched sibling donor is available. Frontline therapy in older adult patients and in all patients lacking a matched sibling donor involves immunosuppressive therapy (IST) with horse antithymocyte globulin and cyclosporine A. Recent improvements in upfront therapy include encouraging results with closely matched unrelated donor transplants in younger patients and the emerging benefits of eltrombopag combined with initial IST, with randomized studies underway. In the refractory setting, several therapeutic options exist, with improving outcomes of matched unrelated donor and haploidentical bone marrow transplantation as well as the addition of eltrombopag to the non-transplant AA armamentarium. With the recent appreciation of frequent clonal hematopoiesis in AA patients and with the growing use of next-generation sequencing in the clinic, utmost caution should be exercised in interpreting the significance of somatic mutations in AA. Future longitudinal studies of large numbers of patients are needed to determine the prognostic significance of somatic mutations and to guide optimal surveillance and treatment approaches to prevent long-term clonal complications.
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Affiliation(s)
- Scott A Peslak
- Division of Hematology and Oncology, Department of Medicine, Hospital of the University of Pennsylvania, Perelman Center for Advanced Medicine, 12 South, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Timothy Olson
- Comprehensive Bone Marrow Failure Center, Children's Hospital of Philadelphia, 3615 Civic Center Boulevard, Philadelphia, PA, 19104, USA
- Division of Oncology, Department of Pediatrics, Children's Hospital of Philadelphia, 3615 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Daria V Babushok
- Division of Hematology and Oncology, Department of Medicine, Hospital of the University of Pennsylvania, Perelman Center for Advanced Medicine, 12 South, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA.
- Comprehensive Bone Marrow Failure Center, Children's Hospital of Philadelphia, 3615 Civic Center Boulevard, Philadelphia, PA, 19104, USA.
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99
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Abstract
PURPOSE OF REVIEW There has been a steady improvement in outcomes with allogeneic bone marrow transplantation (BMT) for severe aplastic anemia (SAA), because of progress in optimization of the conditioning regimens, donor hematopoietic cell source, and supportive care. Here, we review recently published data that highlight the improvements and current issues in the treatment of SAA. RECENT FINDINGS Approximately one-third of aplastic anemia patients treated with immune suppressive therapy (IST) have acquired mutations in myeloid cancer candidate genes. Because of the greater probability for eventual failure of IST, human leukocyte antigen (HLA)-matched sibling donor BMT is the first-line of treatment for SAA. HLA-matched unrelated donor (URD) BMT is generally recommended for patients who have failed IST. However, in younger patients for whom a 10/10-HLA-allele matched URD can be rapidly identified, there is a strong rationale to proceed with URD BMT as first-line therapy. HLA-haploidentical BMT using posttransplant cyclophosphamide conditioning regimens is now a reasonable second-line treatment for patients who failed IST. SUMMARY Improved outcomes have led to an increased first-line role of BMT for treatment of SAA. The optimal cell source from an HLA-matched donor is bone marrow. Additional studies are needed to determine the optimal conditioning regimen for HLA-haploidentical donors.
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100
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Kairiene I, Pasauliene R, Lipunova N, Vaitkeviciene G, Rageliene L, Rascon J. Improved outcome of childhood acute myeloid leukemia in an Eastern European country: Lithuanian experience. Eur J Pediatr 2017; 176:1329-1337. [PMID: 28812191 DOI: 10.1007/s00431-017-2978-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 07/31/2017] [Indexed: 10/19/2022]
Abstract
UNLABELLED The reported treatment outcomes of children treated for cancer in Eastern European countries are inferior to those in Northern/Western Europe. We hypothesized that recent survival rates could be comparable to the current standards and performed a population-based analysis of treatment outcome of childhood acute myeloid leukemia (AML) in Lithuania, a small Eastern European country. Children < 18 years old who were treated for AML from 2000 to 2013 were included (n = 54). Estimates of 5-year event-free (EFS5y) and overall survival (OS5y) rates were analyzed. Comparing periods 2000-2006 (n = 32) and 2007-2013 (n = 22), the EFS5y improved from 31 to 63% (p = 0.04), and the OS5y improved from 31 to 72% (p = 0.02) because of reductions in toxicity-related mortality (42 vs. 15%, p = 0.08) and relapse (43 vs. 25%, p = 0.08). The most significant improvement was demonstrated in high-risk patients (OS5y improved from 26 to 75%, p = 0.02) who benefited from hematopoietic stem cell transplantation: the post-transplant EFS5y increased from 13 to 86% (p = 0.01). CONCLUSIONS The current survival rate of Lithuanian children treated for AML was comparable to the expected rate in other parts of Europe. What is Known: • In the last three decades, significant improvement has been achieved in treating childhood cancer, with an overall survival (OS) rate of > 80% in high-income countries. The difference in survival rates between Northern/Western and Eastern European countries as well as between high- and middle-/low-income countries is as much as 20%. Recently, the 5-year event-free survival rate of acute myeloid leukemia (AML) has reached > 60% in high-income countries. The survival rates for myeloproliferative diseases were the lowest in Eastern European countries. • The reported inferior survival rates were calculated based on outcome data of patients treated until 2007. The recent survival rates in Eastern European countries are unknown. What is New: • Being a small Eastern European country, Lithuania has experienced good economic growth during the last decade. We hypothesized that economic growth and gain of experience could result in better survival rates of children treated for cancer in our country in recent years. • A population-based analysis of treatment outcome of childhood AML treated in Lithuania in the recent years was performed for the first time. The survival rates of childhood AML in Lithuania are comparable to those of other high-income countries. Current survival rates of children treated for cancer in Eastern European countries could be comparable to the best current standards contributing to better European survival rates of childhood cancer in general.
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Affiliation(s)
- Igne Kairiene
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Ramune Pasauliene
- Center for Pediatric Oncology and Hematology, Children's Hospital, Affiliate of Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Nadezda Lipunova
- Cancer Control and Prevention Center, National Cancer Institute, Vilnius, Lithuania
| | - Goda Vaitkeviciene
- Center for Pediatric Oncology and Hematology, Children's Hospital, Affiliate of Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Lina Rageliene
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania.,Center for Pediatric Oncology and Hematology, Children's Hospital, Affiliate of Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Jelena Rascon
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania. .,Center for Pediatric Oncology and Hematology, Children's Hospital, Affiliate of Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania.
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