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Lv Q, Huiqin Z, Na X, Chunyan L, Zonghong S, Huaquan W. Treatment of Severe Aplastic Anemia with Porcine Anti-Human Lymphocyte Globulin. Curr Pharm Des 2020; 26:2661-2667. [PMID: 32183661 DOI: 10.2174/1381612826666200317131940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 03/09/2020] [Indexed: 11/22/2022]
Abstract
Aplastic anemia (AA) is a bone marrow failure syndrome characterized by pancytopenia. Decreased numbers of hematopoietic stem cells and impaired bone marrow microenvironment caused by abnormal immune function describe the major pathogenesis of AA. Hematopoietic stem cell transplantation and immunesuppressive therapy are the first-line treatments for AA. Porcine anti-lymphocyte globulin (p-ALG) is a new product developed in China. Several studies have shown that p-ALG exhibited good therapeutic effects in AA.
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Affiliation(s)
- Qi Lv
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin 300052, China
| | - Zhang Huiqin
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin 300052, China
| | - Xiao Na
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin 300052, China
| | - Liu Chunyan
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin 300052, China
| | - Shao Zonghong
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin 300052, China
| | - Wang Huaquan
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin 300052, China
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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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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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Bone Marrow Failure in Children: Approach to Diagnosis and Treatment. Indian J Pediatr 2020; 87:141-149. [PMID: 31628637 DOI: 10.1007/s12098-019-03066-4] [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: 08/01/2019] [Accepted: 08/20/2019] [Indexed: 10/25/2022]
Abstract
Bone marrow failure has many different etiologies, including genetic defects which manifest with specific syndromes, as well as acquired conditions as a result of insults to the bone marrow leading to aplasia. The clinical picture is varied and clues for the underlying cause may or may not be evident at the time of presentation, frequently leading to a complex workup with a battery of tests often done to rule out genetic defects. The treatment approach for bone marrow failure is very dependent on the underlying cause, which makes it all the more critical to have an accurate diagnosis. First line management essentially consists of either hematopoietic stem cell transplant or immunosuppressive therapy. In this review authors will provide a broad look at the causes of bone marrow failure, the stepwise diagnostic algorithm and the approach to decision making for treatment. Fine details of each cause, and of each treatment modality are beyond the scope of this review which aims to provide an overview.
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Geng C, Liu X, Chen M, Yang C, Han B. Comparison of frontline treatment with intensive immunosuppression therapy and HLA-haploidentical hematopoietic stem cell transplantation for young patients with severe aplastic anemia - A meta analysis. Leuk Res 2019; 88:106266. [PMID: 31743865 DOI: 10.1016/j.leukres.2019.106266] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Revised: 10/14/2019] [Accepted: 10/28/2019] [Indexed: 12/30/2022]
Abstract
AIM To compare the survivals and treatment related complications between immunosuppression therapy (IST) and haploidentical hematopoietic stem cell transplantation (haplo-HSCT) on children and young adults with severe aplastic anemia (SAA) in East Asia during the last 10 years. METHODS After looking through Pubmed, Embase, Web of Science and Wanfang Data, a total of 491 patients from 7 retrospective studies conducted in East-Asia were included for meta-analysis based on Stata program. Publication bias was measured by Begger and Egger tests. 1/3/5/10 years overall survivals (OS), failure free survivals (FFS), incidence rates of adverse events and their 95% confidence intervals (CI) were pooled and compared. RESULTS There was no difference of 1/3/5/10 years OS between IST group and haplo-HSCT group, but the 1/3/5/10 years FFS were significantly better in haplo-HSCT group compared with IST group (p < 0.01). However, higher incidence of infections was observed in haplo-HSCT group compared with IST group (76% versus 45%, p < 0.001). The pooled estimates for acute graft versus host disease (aGVHD) and chronic graft versus host disease (cGVHD) were 54% (95% Cl, 43%~64%) and 43% (95% CI, 18%~68%), respectively for haplo-HSCT group. Among them 38% (95%CI, 22%~54%) was grade III aGVHD and 11% (95% Cl, 0%~22%) was grade III-IV aGVHD. Death causes included severe infection, bleeding in IST group and infection, GVHD in haplo-HSCT group. CONCLUSIONS The long-term survivals were similar for young patients with SAA who received IST or haplo-HSCT as the frontline treatment. The haplo-HSCT group showed a better FFS, on the other hand, had higher incidence of infection and GVHD.
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Affiliation(s)
- Chang Geng
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100730, China
| | - Xinjian Liu
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Institute of Hematology of Henan Province, 127 Dongming Road, Zhengzhou, China
| | - Miao Chen
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100730, China
| | - Chen Yang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100730, China
| | - Bing Han
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100730, China.
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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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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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59
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Rogers ZR, Nakano TA, Olson TS, Bertuch AA, Wang W, Gillio A, Coates TD, Chawla A, Castillo P, Kurre P, Gamper C, Bennett CM, Joshi S, Geddis AE, Boklan J, Nalepa G, Rothman JA, Huang JN, Kupfer GM, Cada M, Glader B, Walkovich KJ, Thompson AA, Hanna R, Vlachos A, Malsch M, Weller EA, Williams DA, Shimamura A. Immunosuppressive therapy for pediatric aplastic anemia: a North American Pediatric Aplastic Anemia Consortium study. Haematologica 2019; 104:1974-1983. [PMID: 30948484 PMCID: PMC6886407 DOI: 10.3324/haematol.2018.206540] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 03/28/2019] [Indexed: 12/21/2022] Open
Abstract
Quality of response to immunosuppressive therapy and long-term outcomes for pediatric severe aplastic anemia remain incompletely characterized. Contemporary evidence to inform treatment of relapsed or refractory severe aplastic anemia for pediatric patients is also limited. The clinical features and outcomes for 314 children treated from 2002 to 2014 with immunosuppressive therapy for acquired severe aplastic anemia were analyzed retrospectively from 25 institutions in the North American Pediatric Aplastic Anemia Consortium. The majority of subjects (n=264) received horse anti-thymocyte globulin (hATG) plus cyclosporine (CyA) with a median 61 months follow up. Following hATG/CyA, 71.2% (95%CI: 65.3,76.6) achieved an objective response. In contrast to adult studies, the quality of response achieved in pediatric patients was high, with 59.8% (95%CI: 53.7,65.8) complete response and 68.2% (95%CI: 62.2,73.8) achieving at least a very good partial response with a platelet count ≥50×109L. At five years post-hATG/CyA, overall survival was 93% (95%CI: 89,96), but event-free survival without subsequent treatment was only 64% (95%CI: 57,69) without a plateau. Twelve of 171 evaluable patients (7%) acquired clonal abnormalities after diagnosis after a median 25.2 months (range: 4.3-71 months) post treatment. Myelodysplastic syndrome or leukemia developed in 6 of 314 (1.9%). For relapsed/refractory disease, treatment with a hematopoietic stem cell transplant had a superior event-free survival compared to second immunosuppressive therapy treatment in a multivariate analysis (HR=0.19, 95%CI: 0.08,0.47; P=0.0003). This study highlights the need for improved therapies to achieve sustained high-quality remission for children with severe aplastic anemia.
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Affiliation(s)
- Zora R Rogers
- Pediatric Hematology/Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Taizo A Nakano
- Center for Cancer and Blood Disorders, Department of Pediatrics, Children's Hospital Colorado and the University of Colorado School of Medicine, Aurora, CO, USA
| | | | | | - Winfred Wang
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Alfred Gillio
- Hackensack University Medical Center, Hackensack, NJ, USA
| | | | | | | | - Peter Kurre
- Oregon Health and Science University, Portland, OR, USA
| | | | | | - Sarita Joshi
- Nationwide Childrens Hospital, Columbus, OH, USA
| | | | - Jessica Boklan
- Center for Cancer and Blood Disorders, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Grzegorz Nalepa
- Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - James N Huang
- UCSF Benioff Children's Hospital, San Francisco, CA, USA
| | | | | | - Bertil Glader
- Stanford University School of Medicine, Palo Alto, CA, USA
| | | | | | | | | | - Maggie Malsch
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, MA, USA
| | - Edie A Weller
- Division of Hematology and Oncology and Biostatistics and Research Design Center of the Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, MA, USA
| | - David A Williams
- Boston Children's Hospital and Dana Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA, USA
| | - Akiko Shimamura
- Boston Children's Hospital and Dana Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA, USA
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Rubio-San-Simón A, Lázaro Rodríguez I, Vázquez Gómez F, Vivanco Martínez JL, Pérez Alonso V. Safety and efficacy of the use of eltrombopag in a case of severe acquired bone marrow aplasia. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2019. [DOI: 10.1016/j.anpede.2018.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Evaluation of eltrombopag in patients with aplastic anemia in real-world experience. Leuk Res Rep 2019; 11:11-13. [PMID: 30911464 PMCID: PMC6416522 DOI: 10.1016/j.lrr.2019.03.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Revised: 02/24/2019] [Accepted: 03/03/2019] [Indexed: 11/22/2022] Open
Abstract
Background Although eltrombopag has recently been approved for treating AA, the effects of its clinical use remain unknown. Methods We retrospectively analyzed 11 patients with AA, who had been treated with eltrombopag from August 2017 to May 2018. Results Overall response rate was 55%. There was tri-lineage recovery in four patients and platelet recovery in two. The reactive time was within 8 weeks after treatment initiation. Stage at the initial assessment, the neutrophil-to-lymphocyte ratio and platelet counts were significantly different between the responders and non-responders. Conclusion Eltrombopag is a promising agent for treating patients with any degree of AA.
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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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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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Affiliation(s)
- Neal S Young
- From the Hematology Branch, National Heart, Lung, and Blood Institute, Bethesda, MD
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Wang ZK, Yu HJ, Cao FL, Liu ZH, Liu ZY, Feng WJ, Liu XL, Yu YY, Xiao Y, Li LM, Zhou J. Donor-derived marrow mesenchymal stromal cell co-transplantation following a haploidentical hematopoietic stem cell transplantation trail to treat severe aplastic anemia in children. Ann Hematol 2018; 98:473-479. [PMID: 30341538 DOI: 10.1007/s00277-018-3523-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Accepted: 10/11/2018] [Indexed: 12/12/2022]
Abstract
Haploidentical hematopoietic stem cell transplantation (haplo-HSCT) is associated with an increased risk of graft failure and severe graft-versus-host disease (GVHD). Recent studies have shown that mesenchymal stromal cells (MSCs) display potent immunosuppressive effects and can support normal hematopoiesis. In a multi-center trial, we co-transplanted culture-expanded donor-derived bone marrow MSCs (BM-MSCs) into 35 children with severe aplastic anemia (SAA) undergoing haplo-HSCT. All 35 patients (100%) achieved hematopoietic reconstitution and showed sustained full donor chimerism. The median time for myeloid engraftment was 14 days (range 10-22 days), while that for platelet engraftment was 18 days (range 9-36 days). The incidence of grade II-IV acute GVHD and chronic GVHD was 25.71 and 22.86%, respectively. The overall survival rate was 85.71% with a median of 22 months (range 3.5-37 months). The combined transplantation of haploidentical HSCs and BM-MSCs into children with SAA without an HLA-identical sibling donor is relatively safe and may represent an effective new therapy to improve survival rates and reduce the risk of graft failure.
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Affiliation(s)
- Z -K Wang
- Central Laboratory of Hematology and Oncology, The First Affiliated Clinical Hospital of Harbin Medical University, Harbin, China
| | - H -J Yu
- Department of Hematology, The First Affiliated Clinical Hospital of Harbin Medical University, Harbin, China
| | - F -L Cao
- Central Laboratory of Hematology and Oncology, The First Affiliated Clinical Hospital of Harbin Medical University, Harbin, China
| | - Z -H Liu
- Department of Hematology, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, China
| | - Z -Y Liu
- Central Laboratory of Hematology and Oncology, The First Affiliated Clinical Hospital of Harbin Medical University, Harbin, China
| | - W -J Feng
- Central Laboratory of Hematology and Oncology, The First Affiliated Clinical Hospital of Harbin Medical University, Harbin, China
| | - X -L Liu
- Central Laboratory of Hematology and Oncology, The First Affiliated Clinical Hospital of Harbin Medical University, Harbin, China
| | - Y -Y Yu
- Central Laboratory of Hematology and Oncology, The First Affiliated Clinical Hospital of Harbin Medical University, Harbin, China
| | - Y Xiao
- Department of Hematology, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, China. .,Stem Cell Translational Medicine Center, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.
| | - L -M Li
- Department of Hematology, The First Affiliated Clinical Hospital of Harbin Medical University, Harbin, China.
| | - J Zhou
- Department of Hematology, The First Affiliated Clinical Hospital of Harbin Medical University, Harbin, China.
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66
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DeZern AE, Brodsky RA. Haploidentical Donor Bone Marrow Transplantation for Severe Aplastic Anemia. Hematol Oncol Clin North Am 2018; 32:629-642. [PMID: 30047416 PMCID: PMC6063510 DOI: 10.1016/j.hoc.2018.04.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Hematopoietic stem cell transplantation (bone marrow transplantation [BMT]) is the only curative treatment of severe aplastic anemia. BMT from an human leukocyte antigen (HLA)-matched sibling donor is the standard of care for young patients; immunosuppressive therapy is used for older patients or those lacking matched sibling donors. Patients with refractory or relapsed disease are increasingly treated with HLA haploidentical BMT. Historically, haploidentical BMT led to high rates of graft rejection and graft-versus-host disease. High-dose post transplant cyclophosphamide, which mitigates the risk of graft-versus-host disease, is a major advance. This article provides an overview of the haploidentical BMT approach in severe aplastic anemia.
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Affiliation(s)
- Amy E DeZern
- Division of Hematologic Malignancies, The Johns Hopkins University School of Medicine, 1650 Orleans Street, CRBI Room 3M87, Baltimore, MD 21287-0013, USA.
| | - Robert A Brodsky
- Division of Hematology, The Johns Hopkins University School of Medicine, 720 Rutland Avenue, Ross 1025, Baltimore, MD 21205, USA
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67
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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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68
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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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69
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Rubio-San-Simón A, Lázaro Rodríguez I, Vázquez Gómez F, Vivanco Martínez JL, Pérez Alonso V. [Safety and efficacy of the use of eltrombopag in a case of severe acquired bone marrow aplasia]. An Pediatr (Barc) 2018; 90:246-247. [PMID: 29798814 DOI: 10.1016/j.anpedi.2018.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 04/18/2018] [Accepted: 04/23/2018] [Indexed: 11/29/2022] Open
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70
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Zeng Y, Wang S, Wang J, Liu L, Su Y, Lu Z, Zhang X, Zhang Y, Zhong JF, Peng L, Liu Q, Lu Y, Gao L, Zhang X. Optimal donor for severe aplastic anemia patient requiring allogeneic hematopoietic stem cell transplantation: A large-sample study from China. Sci Rep 2018; 8:2479. [PMID: 29410500 PMCID: PMC5802708 DOI: 10.1038/s41598-018-20853-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 01/23/2018] [Indexed: 11/09/2022] Open
Abstract
HLA-haploidentical hematopoietic stem cell transplantation (HSCT) may be an option for severe aplastic anemia (SAA) patients. However, to date, no large-sample studies have been performed to determine which types of SAA patients are suitable for HLA-haploidentical HSCT. We retrospectively studied 189 consecutive patients with SAA who underwent HLA-identical or HLA-haploidentical HSCT at seven transplant centers in China. Propensity score matching (PSM) was applied in this study to reduce the influence of potential confounders. The 5-year overall survival (OS) rate was 72.0% in the HLA-haploidentical group and 76.5% in the HLA-identical group. The median time to achieve engraftment and the incidence of acute GVHD/chronic GVHD were not significantly different between the two groups. In the subgroup analysis, the outcome of patients older than 40 years in the HLA-haploidentical group was significantly poorer than that of patients younger than 40 years in the same group and that of patients older than 40 years in the HLA-identical group. Based on the above results, we suggest that HLA-haploidentical relative HSCT should be considered as a valid alternative option for patients younger than 40 years with SAA for whom no matched sibling donor is available.
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Affiliation(s)
- Yunjing Zeng
- Department of Hematology, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Sanbin Wang
- Department of Hematology, General Hospital of Kunming Military Region of PLA, Kunming, China
| | - Jishi Wang
- Department of Hematology, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Li Liu
- Department of Hematology, Tangdu Hospital, Forth Military Medical University, Xi'an, China
| | - Yi Su
- Department of Hematology, General Hospital of Chengdu Military Region of PLA, Chengdu, Sichuan, China
| | - Zhixiang Lu
- Department of Hematology, First Yunnan Provincial People's Hospital, Kunming, China
| | - Xuemei Zhang
- Department of Hematology, Affiliated Hospital of Kunming Medical College, Kunming, China
| | - Yanqi Zhang
- Department of Health Statistics, College of Military Preventive Medicine, Third Military Medical University, Chongqing, China
| | - Jiang Fan Zhong
- Department of Hematology, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Lihui Peng
- Department of Hematology, General Hospital of Kunming Military Region of PLA, Kunming, China
| | - Qiang Liu
- Department of Hematology, Tangdu Hospital, Forth Military Medical University, Xi'an, China
| | - Yinghao Lu
- Department of Hematology, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Lei Gao
- Department of Hematology, Xinqiao Hospital, Third Military Medical University, Chongqing, China.
| | - Xi Zhang
- Department of Hematology, Xinqiao Hospital, Third Military Medical University, Chongqing, China.
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71
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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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72
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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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73
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Lengline E, Drenou B, Peterlin P, Tournilhac O, Abraham J, Berceanu A, Dupriez B, Guillerm G, Raffoux E, de Fontbrune FS, Ades L, Balsat M, Chaoui D, Coppo P, Corm S, Leblanc T, Maillard N, Terriou L, Socié G, de Latour RP. Nationwide survey on the use of eltrombopag in patients with severe aplastic anemia: a report on behalf of the French Reference Center for Aplastic Anemia. Haematologica 2017; 103:212-220. [PMID: 29170252 PMCID: PMC5792265 DOI: 10.3324/haematol.2017.176339] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 11/15/2017] [Indexed: 11/24/2022] Open
Abstract
Few therapeutic options are available for patients with aplastic anemia who are ineligible for transplantation or refractory to immunosuppressive therapy. Eltrombopag was recently shown to produce trilineage responses in refractory patients. However, the effects of real-life use of this drug remain unknown. This retrospective study (2012–2016) was conducted by the French Reference Center for Aplastic Anemia on patients with relapsed/refractory aplastic anemia, and patients ineligible for antithymocyte globulin or transplantation, who received eltrombopag for at least 2 months. Forty-six patients with aplastic anemia were given eltrombopag without prior antithymocyte globulin treatment (n=11) or after antithymocyte globulin administration (n=35) in a relapsed/refractory setting. Eltrombopag (median daily dose 150 mg) was introduced 17 months (range, 8–50) after the diagnosis of aplastic anemia. At last followup, 49% were still receiving treatment, 9% had stopped due to a robust response, 2% due to toxicity and 40% due to eltrombopag failure. Before eltrombopag treatment, all patients received regular transfusions. The overall rates of red blood cell and platelet transfusion independence were 7%, 33%, 46% and 46% at 1, 3, 6 months and last follow-up. Responses were slower to develop in antithymocyte treatment-naïve patients. In patients achieving transfusion independence, hemoglobin concentration and platelet counts improved by 3 g/dL (interquartile range, 1.4–4.5) and 42×109/L (interquartile range, 11–100), respectively. Response in at least one lineage (according to National Institutes of Health criteria) was observed in 64% of antithymocyte treatment-naïve and 74% of relapsed/refractory patients, while trilineage improvement was observed in 27% and 34%, respectively. We found high rates of hematologic improvement and transfusion independence in refractory aplastic anemia patients but also in patients ineligible for antithymocyte globulin receiving first-line treatment. In conclusion, elderly patients unfit for antithymocyte globulin therapy may benefit from eltrombopag.
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Affiliation(s)
- Etienne Lengline
- Department of Hematology, CRNMR Aplasie Médullaire, Saint-Louis University Hospital - AP-HP, Paris, France
| | - Bernard Drenou
- Department of Hematology, Hôpital Emile Muller - CH de Mulhouse, France
| | - Pierre Peterlin
- Department of Hematology, Nantes University Hospital, France
| | - Olivier Tournilhac
- Service d'Hematologie Clinique et de Therapie Cellulaire, CHU, Universite d'Auvergne, Clermont-Ferrand, France
| | - Julie Abraham
- Service d'Hématologie Clinique et Thérapie Cellulaire, CHU de Limoges, France
| | - Ana Berceanu
- Department of Hematology, Besançon University Hospital, France
| | | | - Gaelle Guillerm
- Department of Hematology and Oncology, CH Augustin Morvan, Brest, France
| | - Emmanuel Raffoux
- Department of Hematology, CRNMR Aplasie Médullaire, Saint-Louis University Hospital - AP-HP, Paris, France
| | - Flore Sicre de Fontbrune
- Department of Hematology, CRNMR Aplasie Médullaire, Saint-Louis University Hospital - AP-HP, Paris, France
| | - Lionel Ades
- Department of Hematology, CRNMR Aplasie Médullaire, Saint-Louis University Hospital - AP-HP, Paris, France
| | - Marie Balsat
- Department of Hematology 1G, Centre Hospitalier Lyon Sud, Pierre Benite, France
| | - Driss Chaoui
- Department of Hematology, CH Victor Dupouy, Argenteuil, France
| | - Paul Coppo
- Department of Hematology, French Reference Center for Thrombotic Microangiopathies, Saint Antoine University Hospital, Paris, France
| | - Selim Corm
- Department of Hematology, Hôpital Privé Médipole de Savoie, Challes les Eaux, France
| | - Thierry Leblanc
- Department of Hematology, CRNMR Aplasie Médullaire, Saint-Louis University Hospital - AP-HP, Paris, France.,Department of Pediatric Hematology, Robert-Debré University Hospital, Paris, France
| | - Natacha Maillard
- Bone Marrow Transplant Unit Clinical Hematology, Hopital La Miletrie, Poitiers University Hospital, France
| | - Louis Terriou
- Department of Internal Medicine, Clinical Immunology, Hôpital Huriez Lille University Hospital, France
| | - Gerard Socié
- Department of Hematology, CRNMR Aplasie Médullaire, Saint-Louis University Hospital - AP-HP, Paris, France.,University Paris Denis Diderot & INSERM UMR 1160, France
| | - Regis Peffault de Latour
- Department of Hematology, CRNMR Aplasie Médullaire, Saint-Louis University Hospital - AP-HP, Paris, France
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74
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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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75
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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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76
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Yamei W, Rongmu L, Yongbin C, Yingjian S, Xiaohong L, Xiaomei Z, Pei Y, Zhenlan D, Haitao W, Jing W, Bojing W, Xiaoxiong W, Wanming D. Improved outcome of haploidentical transplantation in severe aplastic anemia using reduced-intensity fludarabine-based conditioning. Oncotarget 2017; 8:83817-83830. [PMID: 29137385 PMCID: PMC5663557 DOI: 10.18632/oncotarget.19745] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 06/19/2017] [Indexed: 12/18/2022] Open
Abstract
Significant improvements in hematopoietic stem cell transplantation (HSCT) with haploidentical family donors (HFD) have confirmed its therapeutic role in severe aplastic anemia (SAA) and led to the evolution of treatment algorithms. However, the optimal conditioning regimen for HFD-HSCT remains undefined, especially the dosage of cyclophosphamide (Cy). A total of 77 patients with SAA from two research centers, who received HFD-HSCT with reduced-intensity fludarabine + cyclophosphamide + thymoglobulin ± busulfan conditioning regimen plus third-party cells infusion were included in this study, of which 67 pairs had 4-5 loci mismatched. We were particularly interested in whether the dosage of Cy significantly impacted graft failure (GF) and overall survival (OS). All patients showed sustained hematopoietic engraftment without any increase in severe aGVHD and transplantation-related mortality (TRM). The incidences of grade II-IV aGVHD, grade III-IV aGVHD and extensive cGVHD were 18%, 10% and 7%, respectively. The probabilities of 1-year and 5-year OS were 93.1% and 87.9%, respectively. Furthermore, patient age <15 years, MNC cells >8×108/kg and donor age <45 years were associated with better survival (P=0.043, P=0.023, and P=0.037, respectively) and engraftment (P=0.019, P=0.008, and P=0.001, respectively). Our findings indicated that SAA patients lack MSD benefited the most if HFD-HSCT was performed with reduced-intensity fludarabine-based conditioning regimen. Improved outcomes with HFD-HSCT may lead to a salvaged therapy and an expanded direct role for SAA in the future.
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Affiliation(s)
- Wu Yamei
- Department of Hematology, The First Affiliated Hospital, Chinese PLA General Hospital, Beijing 100048, China
| | - Luo Rongmu
- Department of Hematology, Affiliated BaYi Children's Hospital, PLA Army General Hospital, Beijing 100700, China
| | - Cao Yongbin
- Department of Hematology, The First Affiliated Hospital, Chinese PLA General Hospital, Beijing 100048, China
| | - Si Yingjian
- Department of Hematology, Affiliated BaYi Children's Hospital, PLA Army General Hospital, Beijing 100700, China
| | - Li Xiaohong
- Department of Hematology, The First Affiliated Hospital, Chinese PLA General Hospital, Beijing 100048, China
| | - Zhang Xiaomei
- Department of Hematology, Affiliated BaYi Children's Hospital, PLA Army General Hospital, Beijing 100700, China
| | - Yan Pei
- Department of Hematology, The First Affiliated Hospital, Chinese PLA General Hospital, Beijing 100048, China
| | - Du Zhenlan
- Department of Hematology, Affiliated BaYi Children's Hospital, PLA Army General Hospital, Beijing 100700, China
| | - Wang Haitao
- Department of Hematology, The First Affiliated Hospital, Chinese PLA General Hospital, Beijing 100048, China
| | - Wang Jing
- Department of Hematology, The First Affiliated Hospital, Chinese PLA General Hospital, Beijing 100048, China
| | - Wang Bojing
- Department of Hematology, The First Affiliated Hospital, Chinese PLA General Hospital, Beijing 100048, China
| | - Wu Xiaoxiong
- Department of Hematology, The First Affiliated Hospital, Chinese PLA General Hospital, Beijing 100048, China
| | - Da Wanming
- Department of Hematology, The First Affiliated Hospital, Chinese PLA General Hospital, Beijing 100048, China.,Department of Hematology, Affiliated BaYi Children's Hospital, PLA Army General Hospital, Beijing 100700, China.,Department of Hematology, Chinese PLA General Hospital, Beijing 100853, China
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77
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Abstract
Acquired severe aplastic anemia (SAA) is a rare hematologic disease associated with significant morbidity and mortality. Immune destruction of hemopoietic stem cells plays an important role in pathogenesis, as shown by successful treatment with immunosuppressive agents, leading to transfusion independence or complete recovery of peripheral blood counts in a proportion of patients. Growth factors can be combined with immunosuppressive therapy (IST) and may improve response rates, as recently shown with thrombopoietin analogs. Anabolic steroids may still play a role in combination with IST. The problem with IST is failure to respond and the development of late clonal disorders. Bone marrow transplantation (BMT) is the other therapeutic option: a matched sibling donor remains the best choice. For patients lacking a matched family donor, unrelated donors can be readily found, although mostly for patients of Caucasian origin. Other BMT options include unrelated cord blood or mismatched family donors. Acute and chronic graft-versus-host disease remain important complications of BMT. Patient age is a strong predictor of outcome for both IST and BMT, and must be considered when designing therapeutic strategies. Early diagnosis and treatment, as well as long-term monitoring, remain crucial steps for successful treatment of SAA.
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78
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Haploidentical transplantation for pediatric patients with acquired severe aplastic anemia. Bone Marrow Transplant 2016; 52:381-387. [PMID: 27941773 DOI: 10.1038/bmt.2016.281] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 07/23/2016] [Accepted: 08/04/2016] [Indexed: 11/09/2022]
Abstract
Techniques for haploidentical hematopoietic stem cell transplantation (haplo-HSCT) to treat severe aplastic anemia (SAA) have recently improved, but no protocol has been evaluated in a large number of pediatric patients. Fifty-two children with SAA received haplo-HSCT in our center. The treatment protocol used G-CSF-primed bone marrow with G-CSF-mobilized PBSCs without in vitro T-cell depletion. The conditioning regimen included busulfan/cyclophosphamide and antithymocyte globulin. Fifty-one patients achieved primary engraftment; one child died of regimen-related toxicity on the day +1. Secondary graft failure occurred in three patients. The cumulative incidences of aGVHD grade II-IV and grade III-IV were 39.2±0.5 and 13.7±0.2%, respectively. The cumulative incidence of cGVHD was 34.2±0.5%. The 3-year overall and failure-free survival rates were 84.5±5.0 and 82.7±5.2%, respectively, with a median follow-up time of 744.5 days (100-3294) for surviving patients. The Eastern Cooperative Oncology Group score was the only predictor of overall and failure-free survival rates. Clinical outcomes were similar between the upfront and salvage group. This result suggests that both newly diagnosed and refractory pediatric SAA patients benefit from haplo-HSCT, especially when patients are in good general condition. Therefore, haplo-HSCT might be an alternative therapy for pediatric SAA patients without HLA-matched sibling donors.
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79
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Abstract
OBJECTIVE Use of high-dose cyclophosphamide without hematopoietic stem cell transplant to treat severe aplastic anemia (SAA) has been controversial due to concern for increased infectious toxicity as compared with antithymocyte globulin and cyclosporine A. As children often tolerate dose-intensive therapy better than adults, we sought to perform a detailed retrospective analysis of both treatment response and toxicity in 28 patients younger than 22 years of age treated with 29 courses of high-dose cyclophosphamide as the sole form of immunosuppression. STUDY DESIGN Children and adolescents with SAA who lacked an human leukocyte antigen-matched sibling donor were treated with cyclophosphamide 50 mg/kg/d for 4 consecutive days then received daily granulocyte colony stimulating factor until neutrophil recovery, transfusion support, and antimicrobial prophylaxis. RESULTS Overall survival was 85%, with hematologic response of 79% and complete response of 66%. Cumulative incidences of bacterial infection (86%) and fungal infection (62%) were high but deaths due to infection were rare, as were clonal evolution (1/28), clinically relevant paroxysmal nocturnal (1/28), and relapse (2/28). CONCLUSIONS Response rates and survival following high-dose cyclophosphamide in pediatric patients with SAA exceed those seen in adults and compare favorably to antithymocyte globulin/cyclosporine A with manageable infectious toxicity.
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80
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Analysis of allogeneic hematopoietic stem cell transplantation with high-dose cyclophosphamide-induced immune tolerance for severe aplastic anemia. Int J Hematol 2016; 104:720-728. [PMID: 27709450 DOI: 10.1007/s12185-016-2106-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Revised: 09/27/2016] [Accepted: 09/27/2016] [Indexed: 01/26/2023]
Abstract
The study was aimed to explore the efficacy and safety of allo-HSCT with high-dose cyclophosphamide-induced immune tolerance for SAA. In the present study, 20 cases (12 male, 8 female; average age = 17.8 years) received reduced-intensity conditioning allo-HSCT from August 2012 to August 2014 in the Beijing Military Region General Hospital. All were HLA mismatched and received CSA; 11 received ATG-intensive immune therapy. Donors underwent mobilization with cell colony-stimulating factor. The modified preconditioning regimen included reduced-strength fludarabine combined with Busulfex and cytarabine, cyclophosphamide. Cyclophosphamide (50 mg/kg/d) induced immune tolerance 3 days after transplantation and was combined with immunosuppressive agents, including CSA, MTX, and FK506, for GVHD prophylaxis and the management of observed toxicity, GVHD and DFS. Hematopoietic reconstitution was achieved in 17 cases and engraftment after a second transplantation in an additional three cases. The average times to engraftment were 17.4 and 21.3 days, respectively, with neutrophils ≥0.5 × 109/L and platelets ≥20 × 109/L. Engraftment was confirmed by the evidence of 100 % donor hematopoiesis; T lymphocyte subset counts also increased significantly after transplantation. During follow-up monitoring to April 2015 (median duration = 17.7 months), three patients died of complications, while the other 17 showed disease-free survival (DFS rate = 85 %; longest DFS period = 32 months). Reduced-intensity allo-HSCT with high-dose cyclophosphamide-induced immune tolerance treatment is effective for SAA and can be the key technology extensively used in clinic, but its efficacy needs to be confirmed further with prospective randomized study with increased sample size.
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81
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Choi YB, Yi ES, Lee JW, Sung KW, Koo HH, Yoo KH. Immunosuppressive therapy versus alternative donor hematopoietic stem cell transplantation for children with severe aplastic anemia who lack an HLA-matched familial donor. Bone Marrow Transplant 2016; 52:47-52. [PMID: 27668766 DOI: 10.1038/bmt.2016.223] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 07/11/2016] [Accepted: 07/17/2016] [Indexed: 01/03/2023]
Abstract
We compared the outcomes of immunosuppressive treatment (IST) with those of alternative donor hematopoietic stem cell transplantation (HSCT) in children and adolescents with severe aplastic anemia (SAA). The medical records of 42 patients with SAA who received frontline IST (N=19) or frontline HSCT with an alternative donor (N=23) between 1998 and 2012 were analyzed retrospectively. Six patients responded in the frontline IST group, whereas 11 underwent salvage HSCT after IST failure. Twenty-one of 23 patients who underwent frontline HSCT survived without treatment failure. The estimated failure-free survival rate of the frontline HSCT group was higher than that of the frontline IST group (91.3% vs 30.7% respectively, P<0.001). Six of 11 patients who underwent salvage HSCT experienced event-free survival (EFS). The estimated EFS of the frontline HSCT group was higher than that of the salvage HSCT group (91.3% vs 50.9% respectively, P=0.015). The outcome of alternative donor HSCT was better than commonly reported rates, especially in patients who underwent frontline HSCT. These results suggest that frontline alternative donor HSCT may be a better treatment option than IST for children and adolescents with SAA who lack a human leukocyte Ag-matched familial donor.
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Affiliation(s)
- Y B Choi
- Department of Pediatrics, Chung-Ang University Hospital, Seoul, Korea
| | - E S Yi
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - J W Lee
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - K W Sung
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - H H Koo
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - K H Yoo
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Department of Medical Device Management and Research, SAIHST, Sungkyunkwan University, Seoul, Korea
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82
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Mackarel J, Iatan M, Kumar L, Storey L, O'Marcaigh A, Smith O. In support of upfront stem cell transplantation as first-line therapy for paediatric patients with idiopathic severe aplastic anaemia who lack a sibling donor. Br J Haematol 2016; 177:806-808. [PMID: 27099199 DOI: 10.1111/bjh.14097] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Jill Mackarel
- Department of Paediatric Haematology and Oncology, Our Lady's Children's Hospital, Dublin, Ireland
| | - Maria Iatan
- Department of Paediatric Haematology and Oncology, Our Lady's Children's Hospital, Dublin, Ireland
| | - Lakshman Kumar
- Department of Paediatric Haematology and Oncology, Our Lady's Children's Hospital, Dublin, Ireland
| | - Lorna Storey
- Department of Paediatric Haematology and Oncology, Our Lady's Children's Hospital, Dublin, Ireland
| | - Aengus O'Marcaigh
- Department of Paediatric Haematology and Oncology, Our Lady's Children's Hospital, Dublin, Ireland
| | - Owen Smith
- Department of Paediatric Haematology and Oncology, Our Lady's Children's Hospital, Dublin, Ireland
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83
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Acquired aplastic anemia in Korean children: treatment guidelines from the Bone Marrow Failure Committee of the Korean Society of Pediatric Hematology Oncology. Int J Hematol 2016; 103:380-6. [PMID: 26894608 DOI: 10.1007/s12185-016-1956-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 01/25/2016] [Indexed: 10/22/2022]
Abstract
The treatment of choice for aplastic anemia (AA) in children has been HLA-matched family donor (MFD) hematopoietic stem cell transplantation (HSCT). For those lacking MFD, immunosuppressive therapy (IST) consisting of horse antithymocyte globulin (ATG) and cyclosporine has been successful. The choices of second and third line treatments are more complex and debatable, especially in the situation of unavailability of horse ATG. IST with rabbit ATG seems to be less effective. Recently, improved survival of non-MFD HSCTs has been documented. The outcome of matched or mismatched unrelated donor, umbilical cord blood, or haploidentical family donor transplantations will be discussed in AA children after IST failure. Experimental approaches of upfront HSCT using non-MFDs will be briefly touched. In this review, a treatment guideline for children with AA from the Korean Society of Pediatric Hematology Oncology will be presented along with a brief review of literature on current clinical practices in Korea.
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84
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Dietz AC, Lucchini G, Samarasinghe S, Pulsipher MA. Evolving hematopoietic stem cell transplantation strategies in severe aplastic anemia. Curr Opin Pediatr 2016; 28:3-11. [PMID: 26626557 PMCID: PMC4725196 DOI: 10.1097/mop.0000000000000299] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW Significant improvements in unrelated donor hematopoietic stem cell transplantation (HSCT) in recent years have solidified its therapeutic role in severe aplastic anemia (SAA) and led to the evolution of treatment algorithms, particularly for children. RECENT FINDINGS Advances in understanding the genetics of inherited bone marrow failure syndromes (IBMFS) have allowed more confidence in accurately diagnosing SAA and avoiding treatments that could be dangerous and ineffective in individuals with IBMFS, which can be diagnosed in 10-20% of children presenting with a picture of SAA. Additionally long-term survival after matched sibling donor and matched unrelated donor HSCT now exceed 90% in children. Late effects after HSCT for SAA are minimal with current strategies, and compare favorably to late effects after upfront immunosuppressive therapy, except for patients with chronic graft versus host disease. SUMMARY Careful assessment for signs or symptoms of IBMFS, along with genetic screening for these disorders, is of major importance. Matched sibling donor HSCT is already considered the standard of care for upfront therapy and some groups are evaluating matched unrelated donor HSCT as primary therapy. Ongoing studies will continue to challenge treatment algorithms and may lead to an even more expanded role for HSCT in SAA.
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Affiliation(s)
- Andrew C Dietz
- aChildren's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California, USA bDepartment of Paediatric Bone Marrow Transplant cDepartment of Paediatric Haematology, Great Ormond Street Hospital, London, UK *Andrew C. Dietz and Giovanna Lucchini contributed equally to the writing of this article
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85
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Dufour C, Veys P, Carraro E, Bhatnagar N, Pillon M, Wynn R, Gibson B, Vora AJ, Steward CG, Ewins AM, Hough RE, de la Fuente J, Velangi M, Amrolia PJ, Skinner R, Bacigalupo A, Risitano AM, Socie G, Peffault de Latour R, Passweg J, Rovo A, Tichelli A, Schrezenmeier H, Hochsmann B, Bader P, van Biezen A, Aljurf MD, Kulasekararaj A, Marsh JC, Samarasinghe S. Similar outcome of upfront-unrelated and matched sibling stem cell transplantation in idiopathic paediatric aplastic anaemia. A study on behalf of the UK Paediatric BMT Working Party, Paediatric Diseases Working Party and Severe Aplastic Anaemia Working Party of EBMT. Br J Haematol 2015. [PMID: 26223288 DOI: 10.1111/bjh.13614] [Citation(s) in RCA: 113] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
We explored the feasibility of unrelated donor haematopoietic stem cell transplant (HSCT) upfront without prior immunosuppressive therapy (IST) in paediatric idiopathic severe aplastic anaemia (SAA). This cohort was then compared to matched historical controls who had undergone first-line therapy with a matched sibling/family donor (MSD) HSCT (n = 87) or IST with horse antithymocyte globulin and ciclosporin (n = 58) or second-line therapy with unrelated donor HSCT post-failed IST (n = 24). The 2-year overall survival in the upfront cohort was 96 ± 4% compared to 91 ± 3% in the MSD controls (P = 0·30) and 94 ± 3% in the IST controls (P = 0·68) and 74 ± 9% in the unrelated donor HSCT post-IST failure controls (P = 0·02).The 2-year event-free survival in the upfront cohort was 92 ± 5% compared to 87 ± 4% in MSD controls (P = 0·37), 40 ± 7% in IST controls (P = 0·0001) and 74 ± 9% in the unrelated donor HSCT post-IST failure controls (n = 24) (P = 0·02). Outcomes for upfront-unrelated donor HSCT in paediatric idiopathic SAA were similar to MSD HSCT and superior to IST and unrelated donor HSCT post-IST failure. Front-line therapy with matched unrelated donor HSCT is a novel treatment approach and could be considered as first-line therapy in selected paediatric patients who lack a MSD.
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Affiliation(s)
- Carlo Dufour
- Clinical and Experimental Haematology Unit, Giannina Gaslini Children's Hospital, Genova, Italy
| | - Paul Veys
- Department of Haematology & Bone Marrow Transplantation, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Elisa Carraro
- Paediatric Haematology and Oncology, University of Padova, Padova, Italy
| | - Neha Bhatnagar
- Department of Haematology & Bone Marrow Transplantation, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Marta Pillon
- Paediatric Haematology and Oncology, University of Padova, Padova, Italy
| | - Rob Wynn
- Blood and Marrow Transplant Unit, Royal Manchester Children's Hospital, Manchester, UK
| | - Brenda Gibson
- Department of Paediatric Haematology & Oncology, Royal Hospital for Sick Children, Glasgow, UK
| | - Ajay J Vora
- Department of Paediatric Haematology, The Children's Hospital, Sheffield, UK
| | | | - Anna M Ewins
- Department of Paediatric Haematology & Oncology, Royal Hospital for Sick Children, Glasgow, UK
| | | | - Josu de la Fuente
- Division of Paediatrics, Imperial College Healthcare NHS Trust, London, UK
| | | | - Persis J Amrolia
- Department of Haematology & Bone Marrow Transplantation, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Roderick Skinner
- Department of Paediatric and Adolescent Haematology/Oncology and BMT, Great North Children's Hospital & Northern Institute for Cancer Research, Newcastle upon Tyne, UK
| | - Andrea Bacigalupo
- Haematology and Oncology Department, IRCCS A.O.U. San Martino Hospital, IST, Genoa, Italy
| | | | | | | | - Jakob Passweg
- Stem Cell Transplant Team, Division of Haematology, University Hospital Basel, Basel, Switzerland
| | - Alicia Rovo
- Haematology, University Hospital of Basel, Basel, Switzerland
| | - André Tichelli
- Haematology, University Hospital of Basel, Basel, Switzerland
| | - Hubert Schrezenmeier
- Institute for Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Transfusion Service Baden-Württemberg-Hessen und University Hospital Ulm, Ulm, Germany
| | - Britta Hochsmann
- Institute for Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Transfusion Service Baden-Württemberg-Hessen und University Hospital Ulm, Ulm, Germany
| | - Peter Bader
- Division for Stem Cell Transplantation and Immunology, Hospital for Children and Adolescents, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Anja van Biezen
- EBMT Data Office, University Medical Centre, Leiden, The Netherlands
| | - Mahmoud D Aljurf
- Adult Haematology/HSCT Oncology Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Austin Kulasekararaj
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Judith C Marsh
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Sujith Samarasinghe
- Department of Haematology & Bone Marrow Transplantation, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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86
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Kudo K, Muramatsu H, Yoshida N, Kobayashi R, Yabe H, Tabuchi K, Kato K, Koh K, Takahashi Y, Hashii Y, Kawano Y, Inoue M, Cho Y, Sakamaki H, Kawa K, Kato K, Suzuki R, Kojima S. Second allogeneic hematopoietic stem cell transplantation in children with severe aplastic anemia. Bone Marrow Transplant 2015; 50:1312-5. [PMID: 26121106 DOI: 10.1038/bmt.2015.153] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 04/27/2015] [Accepted: 05/15/2015] [Indexed: 11/09/2022]
Abstract
The outcome of 55 children with severe aplastic anemia (SAA) who received a second hematopoietic stem cell transplantation (HSCT) was retrospectively analyzed using the registration data of the Japanese Society for Hematopoietic Cell Transplantation. The 5-year overall survival (OS) and failure-free survival (FFS) after the second transplantation were 82.9% (95% confidence interval (CI), 69.7-90.8)) and 81.2% (95% CI, 67.8-89.4), respectively. FFS was significantly better when the interval between the first and second transplantation was >60 days (88.9%; 95% CI, 73.0-95.7) than when it was ⩽60 days (61.4%; 95% CI, 33.3-80.5; P=0.026). All 12 patients who were conditioned with regimens containing fludarabine and melphalan were alive with hematopoietic recovery. These findings justify the recommendation of a second HSCT for children with SAA who have experienced graft failure after first HSCT.
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Affiliation(s)
- K Kudo
- Department of Pediatrics, Fujita Health University School of Medicine, Toyoake, Japan
| | - H Muramatsu
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - N Yoshida
- Division of Pediatric Hematology/Oncology, Children's Medical Center, Japanese Red Cross Nagoya First Hospital, Nagoya, Japan
| | - R Kobayashi
- Department of Pediatrics, Sapporo Hokuyu Hospital, Sapporo, Japan
| | - H Yabe
- Department of Cell Transplantation and Regeneration Medicine, Tokai University School of Medicine, Isehara, Japan
| | - K Tabuchi
- Division of Pediatrics, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - K Kato
- Division of Pediatric Hematology and Oncology, Ibaraki Children's Hospital, Mito, Japan
| | - K Koh
- Department of Hematology and Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Y Takahashi
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Y Hashii
- Department of Pediatrics, Osaka University Hospital, Suita, Japan
| | - Y Kawano
- Department of Pediatrics, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima City, Japan
| | - M Inoue
- Department of Hematology/Oncology, Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi, Japan
| | - Y Cho
- Department of Pediatrics, Hokkaido University Hospital, Sapporo, Japan
| | - H Sakamaki
- Division of Hematology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - K Kawa
- Japanese Red Cross Kinki Block Blood Center, Ibaraki, Japan
| | - K Kato
- Division of Pediatric Hematology/Oncology, Children's Medical Center, Japanese Red Cross Nagoya First Hospital, Nagoya, Japan
| | - R Suzuki
- Department of Hematopoietic Stem Cell Transplantation, Data Management and Biostatistics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - S Kojima
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
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87
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Im HJ, Koh KN, Seo JJ. Haploidentical hematopoietic stem cell transplantation in children and adolescents with acquired severe aplastic anemia. KOREAN JOURNAL OF PEDIATRICS 2015. [PMID: 26213547 PMCID: PMC4510352 DOI: 10.3345/kjp.2015.58.6.199] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Severe aplastic anemia (SAA) is a life-threatening disorder for which allogeneic hematopoietic stem cell transplantation (HSCT) is the current available curative treatment. HSCT from matched sibling donors (MSDs) is the preferred therapy for children with acquired SAA. For patients who lack MSDs, immunosuppressive therapy (IST) is widely accepted as a first-line treatment before considering HCT from an unrelated donor (URD). Given the recent progress in HSCT using URDs for childhood SAA, well-matched URDs became a realistic alternative for pediatric patients who have no suitable related donors and who are refractory to IST. However, it is quite challenging to treat patients with refractory SAA who lack suitable related or URDs. Even though haploidentical HSCT from genetically mismatched family members seemed to be an attractive procedure with the amazing benefit of readily available donors for most patients, early attempts were disappointing because of refractory graft-versus-host disease (GVHD) and excessively high transplant-related mortality. Recent advances with effective ex vivo depletion of T cells or unmanipulated in vivo regulation of T cells, better supportive care, and optimal conditioning regimens have significantly improved the outcome of haploidentical transplant. Besides considerable progress in the treatment of malignant diseases, recent emerging evidences for haploidentical HSCT in SAA has provided additional therapeutic options for patients with refractory diseases. Further improvements to decrease the rates of graft failure, GVHD, and infectious complications will facilitate the emergence of haploidentical HSCT as a front-line therapy for treating acquired SAA in children and adolescents who have no suitably matched donors.
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Affiliation(s)
- Ho Joon Im
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyung-Nam Koh
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Jong Jin Seo
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
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88
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Abstract
PURPOSE OF REVIEW The role of hematopoietic cell transplantation in non-malignant disorders has increased exponentially with the recognition that multiple diseases can be controlled or cured if engrafted with donor-derived cells. This review provides an overview of advances made in alternative donor transplants for nonmalignant disorders. RECENT FINDINGS Stem cell sources, novel transplant methods, and sophisticated supportive care have simultaneously made giant strides toward improving the safety and efficacy of hematopoietic cell transplantation. This has led to the utilization of marrow, cord, peripheral blood stem cell and haploidentical stem cell sources, and novel reduced toxicity or reduced intensity conditioning regimens to transplant non-malignant disorders such as immune dysfunctions, marrow failure syndromes, metabolic disorders and hemoglobinopathies. Transplant complications such as graft rejection, infections, and graft versus host disease are better combated in this modern era of medicine, achieving better survival with decreased late effects. These aspects of transplant for non-malignant disorders are discussed. SUMMARY This review presents the progress made in the realm of hematopoietic cell transplantation for non-malignant disorders. It advocates the consideration of alternative donor transplants in the absence of human leukocyte antigen matched siblings when indicated by disease severity. The ultimate goal is to provide curative transplant options for more patients that can benefit from this intervention, prior to detrimental outcomes.
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