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Ronnacker J, Urbahn MA, Reicherts C, Kolloch L, Berning P, Sandmann S, Eßeling E, Call S, Floeth M, Marx J, Albring J, Mikesch JH, Schliemann C, Lenz G, Stelljes M. Early blast clearance during sequential conditioning prior to allogeneic stem cell transplantation in patients with acute myeloid leukaemia. Br J Haematol 2024. [PMID: 38831752 DOI: 10.1111/bjh.19552] [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: 02/15/2024] [Accepted: 05/13/2024] [Indexed: 06/05/2024]
Abstract
For patients with relapsed or refractory AML, sequential conditioning prior to allogeneic stem cell transplantation (alloSCT) is an established and potentially curative treatment option. Early response to treatment during conditioning indicates chemotherapy-responsive disease and may have prognostic value. We retrospectively evaluated blast clearance on day 5 after melphalan, administered 11 days prior to alloSCT as part of a sequential conditioning in 176 patients with active AML. Overall survival (OS) was 52% (95% confidence interval [CI] 45%-60%), and relapse-free survival (RFS) was 47% (95% CI 40%-55%) at 3 years. Patients who achieved early blast clearance did not show a significant improvement in OS and RFS (OS, hazard ratio [HR] HR 0.75, p 0.19; RFS, HR 0.71, p 0.09, respectively), but had a significantly lower non-relapse mortality rate (HR 0.46, p 0.017). HLA-mismatched donor, older age, adverse genetic risk and higher comorbidity scores were associated with inferior survival outcomes. A high initial blast count was only associated with inferior prognosis in patients receiving chemotherapy-only compared to total body irradiation containing conditioning therapy. These results indicate that for patients transplanted with active AML, sensitivity to chemotherapy might be of less importance, compared to other disease- and transplant-related factors.
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Affiliation(s)
- Julian Ronnacker
- Department of Medicine A, Haematology and Oncology, University Hospital Muenster, Muenster, Germany
| | - Marc-Andre Urbahn
- Department of Medicine A, Haematology and Oncology, University Hospital Muenster, Muenster, Germany
| | - Christian Reicherts
- Department of Medicine A, Haematology and Oncology, University Hospital Muenster, Muenster, Germany
| | - Lina Kolloch
- Department of Medicine A, Haematology and Oncology, University Hospital Muenster, Muenster, Germany
| | - Philipp Berning
- Department of Medicine A, Haematology and Oncology, University Hospital Muenster, Muenster, Germany
| | - Sarah Sandmann
- Institute of Medical Informatics, University of Muenster, Muenster, Germany
| | - Eva Eßeling
- Department of Medicine A, Haematology and Oncology, University Hospital Muenster, Muenster, Germany
| | - Simon Call
- Department of Medicine A, Haematology and Oncology, University Hospital Muenster, Muenster, Germany
| | - Matthias Floeth
- Department of Medicine A, Haematology and Oncology, University Hospital Muenster, Muenster, Germany
| | - Julia Marx
- Department of Medicine A, Haematology and Oncology, University Hospital Muenster, Muenster, Germany
| | - Jörn Albring
- Department of Medicine A, Haematology and Oncology, University Hospital Muenster, Muenster, Germany
| | - Jan-Henrik Mikesch
- Department of Medicine A, Haematology and Oncology, University Hospital Muenster, Muenster, Germany
| | - Christoph Schliemann
- Department of Medicine A, Haematology and Oncology, University Hospital Muenster, Muenster, Germany
| | - Georg Lenz
- Department of Medicine A, Haematology and Oncology, University Hospital Muenster, Muenster, Germany
| | - Matthias Stelljes
- Department of Medicine A, Haematology and Oncology, University Hospital Muenster, Muenster, Germany
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Schulz F, Jäger P, Tischer J, Fraccaroli A, Bug G, Hausmann A, Baermann BN, Tressin P, Hoelscher A, Kasprzak A, Nachtkamp K, Schetelig J, Hilgendorf I, Germing U, Dietrich S, Kobbe G. Smart Conditioning with Venetoclax-Enhanced Sequential FLAMSA + RIC in Patients with High-Risk Myeloid Malignancies. Cancers (Basel) 2024; 16:532. [PMID: 38339283 PMCID: PMC10854830 DOI: 10.3390/cancers16030532] [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: 11/24/2023] [Revised: 01/03/2024] [Accepted: 01/24/2024] [Indexed: 02/12/2024] Open
Abstract
Up to 50% of patients with high-risk myeloid malignancies die of relapse after allogeneic stem cell transplantation. Current sequential conditioning regimens like the FLAMSA protocol combine intensive induction therapy with TBI or alkylators. Venetoclax has synergistic effects to chemotherapy. In a retrospective survey among German transplant centers, we identified 61 patients with myeloid malignancies that had received FLAMSA-based sequential conditioning with venetoclax between 2018 and 2022 as an individualized treatment approach. Sixty patients (98%) had active disease at transplant and 74% had genetic high-risk features. Patients received allografts from matched unrelated, matched related, or mismatched donors. Tumor lysis syndrome occurred in two patients but no significant non-hematologic toxicity related to venetoclax was observed. On day +30, 55 patients (90%) were in complete remission. Acute GvHD II°-IV° occurred in 17 (28%) and moderate/severe chronic GvHD in 7 patients (12%). Event-free survival and overall survival were 64% and 80% at 1 year as well as 57% and 75% at 2 years, respectively. The off-label combination of sequential FLAMSA-RIC with venetoclax appears to be safe and highly effective. To further validate these insights and enhance the idea of smart conditioning, a controlled prospective clinical trial was initiated in July 2023.
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Affiliation(s)
- Felicitas Schulz
- Department for Hematology, Immunology and Clinical Oncology, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany; (P.J.); (A.H.); (G.K.)
| | - Paul Jäger
- Department for Hematology, Immunology and Clinical Oncology, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany; (P.J.); (A.H.); (G.K.)
| | - Johanna Tischer
- Department of Medicine III, LMU University Hospital, Ludwig-Maximilians-University, 80539 Munich, Germany (A.F.)
| | - Alessia Fraccaroli
- Department of Medicine III, LMU University Hospital, Ludwig-Maximilians-University, 80539 Munich, Germany (A.F.)
| | - Gesine Bug
- Department of Medicine 2, University Hospital, Goethe University Frankfurt, 60590 Frankfurt, Germany;
- Frankfurt Cancer Institute, Goethe University, 60590 Frankfurt, Germany
- German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz and German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Andreas Hausmann
- Department of Hematology, Oncology, Immunology, Palliative Care, Munich Clinic Schwabing, 80804 Munich, Germany;
| | - Ben-Niklas Baermann
- Department for Hematology, Immunology and Clinical Oncology, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany; (P.J.); (A.H.); (G.K.)
| | - Patrick Tressin
- Department for Hematology, Immunology and Clinical Oncology, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany; (P.J.); (A.H.); (G.K.)
| | - Alexander Hoelscher
- Department for Hematology, Immunology and Clinical Oncology, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany; (P.J.); (A.H.); (G.K.)
| | - Annika Kasprzak
- Department for Hematology, Immunology and Clinical Oncology, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany; (P.J.); (A.H.); (G.K.)
| | - Kathrin Nachtkamp
- Department for Hematology, Immunology and Clinical Oncology, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany; (P.J.); (A.H.); (G.K.)
| | - Johannes Schetelig
- Medical Clinic I, Department of Hematology, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01062 Dresden, Germany
| | - Inken Hilgendorf
- Klinik für Innere Medizin II, Abteilung für Hämatologie und Onkologie, Universitätsklinikum Jena, 07747 Jena, Germany
| | - Ulrich Germing
- Department for Hematology, Immunology and Clinical Oncology, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany; (P.J.); (A.H.); (G.K.)
| | - Sascha Dietrich
- Department for Hematology, Immunology and Clinical Oncology, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany; (P.J.); (A.H.); (G.K.)
| | - Guido Kobbe
- Department for Hematology, Immunology and Clinical Oncology, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany; (P.J.); (A.H.); (G.K.)
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Haebe S, Fraccaroli A, Stauffer E, Prevalsek D, Zoellner AK, Drolle H, Stemmler HJ, Dreyling M, von Bergwelt-Baildon M, Tischer J. PTCY-Based Haploidentical Donor Transplantation versus HLA-Matched Related and Unrelated Donor Transplantations in Patients with Refractory or Relapsed Lymphoma-A Matched-Pair Analysis. Cancers (Basel) 2023; 15:5246. [PMID: 37958420 PMCID: PMC10650710 DOI: 10.3390/cancers15215246] [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: 09/15/2023] [Revised: 10/17/2023] [Accepted: 10/29/2023] [Indexed: 11/15/2023] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HSCT) has demonstrated its potential as a curative option for patients with r/r lymphoma. With the introduction of post-transplant cyclophosphamide-based (PTCY) graft-versus-host disease (GvHD) prophylaxis, allo-HCT using haploidentical related donors (Haplo-HSCT) has emerged as a valuable alternative for patients without an available HLA-matched donor. In this study, we compared intermediate and long-term outcomes between Haplo-HSCT and HLA-matched related donor (MRD) and unrelated donor (URD) transplantations in 16 matched pairs using age, disease status, lymphoma classification and performance status as matching criteria. Of note, 88% of patients in each group presented with active disease at the time of conditioning. After a median follow-up of >10 years, 10-year overall and progression-free survival and non-relapse mortality incidence after Haplo-HSCT were 31%, 25% and 38%, respectively, and did not differ compared to the values observed in MRD-HSCT and URD-HSCT. A remarkable lower incidence of acute GvHD ≥ II and moderate and severe chronic GvHD was observed after Haplo-HSCT compared to MRD-HSCT (50%/50%, p = 0.03/0.03) and URD-HSCT (44%/38%, p = 0.04/0.08), resulting in slightly higher 10-year GvHD-free and relapse-free survival (25%) and chronic GvHD-free and relapse-free survival (25%) in the Haplo-HSCT group. In conclusion, Haplo-HSCT is an effective treatment in patients with non-remission NHL. Given its advantage of immediate availability, haploidentical donors should be preferably used in patients with progressive disease lacking an HLA-matched related donor.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Johanna Tischer
- Department of Medicine III, Ludwig-Maximilians-University (LMU) University Hospital Munich, 81377 Munich, Germany (M.v.B.-B.)
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Fraccaroli A, Vogt D, Rothmayer M, Spiekermann K, Pastore F, Tischer J. Impact of extramedullary disease in AML patients undergoing sequential RIC for HLA-matched transplantation: occurrence, risk factors, relapse patterns, and outcome. Ann Hematol 2023:10.1007/s00277-023-05281-8. [PMID: 37300568 DOI: 10.1007/s00277-023-05281-8] [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: 05/23/2022] [Accepted: 05/14/2023] [Indexed: 06/12/2023]
Abstract
We sought to evaluate the role of extramedullary disease (EMD) in sequential RIC retrospectively analyzing data of 144 high-risk AML patients undergoing HLA-matched transplantation. Median long-term follow-up was 11.6 years. Eighteen percent of patients (n = 26/144) presented with extramedullary AML (EM AML) or a history of EMD at time of transplantation. Overall relapse rate was 25% (n = 36/144) with 15% (n = 21/144) of all patients developing isolated BM relapse and 10% (n = 15/144) developing EM AML relapse with or without concomitant BM relapse (EM ± BM). Manifestation of EM relapse after transplantation occurred frequently at multiple sites and presented mostly as solid tumor mass. Only 3/15 patients with EM ± BM relapse showed a prior EMD manifestation. EMD prior to allogeneic transplantation had no impact on post-transplant OS when compared to non-EMD (median post-transplant OS 3.8 years versus 4.8 years; ns). Risk factors (p = < 0.1) for EM ± BM relapse included younger age and a higher number of prior intensive chemotherapies, whereas the presence of chronic GVHD was a protective factor. Median post-transplant OS (15.5 months vs. 15.5 months), RFS (9.6 months vs 7.3 months), and post-relapse OS (6.7 months vs. 6.3 months) were not significantly different between patients with isolated BM vs. EM ± BM relapse. Taken together, occurrence of EMD prior to as well as of EM ± BM AML relapse after transplantation was moderate, presenting mostly as solid tumor mass after transplantation. However, diagnosis of those does not seem to influence outcomes after sequential RIC. A higher number of chemotherapy cycles prior to transplantation was identified as recent risk factor for EM ± BM relapse.
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Affiliation(s)
- Alessia Fraccaroli
- Department of Internal Medicine III, University Hospital Munich, Ludwig-Maximilian-University (LMU), Munich, Germany
| | - Daniela Vogt
- Department of Internal Medicine III, University Hospital Munich, Ludwig-Maximilian-University (LMU), Munich, Germany
| | - Margarete Rothmayer
- Department of Internal Medicine III, University Hospital Munich, Ludwig-Maximilian-University (LMU), Munich, Germany
| | - Karsten Spiekermann
- Department of Internal Medicine III, University Hospital Munich, Ludwig-Maximilian-University (LMU), Munich, Germany
| | - Friederike Pastore
- Department of Internal Medicine III, University Hospital Munich, Ludwig-Maximilian-University (LMU), Munich, Germany.
| | - Johanna Tischer
- Department of Internal Medicine III, University Hospital Munich, Ludwig-Maximilian-University (LMU), Munich, Germany
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Fraccaroli A, Stauffer E, von Bergwelt-Baildon M, Tischer J. Transplantation/Zelltherapie bei Akuter Myeloischer Leukämie. Dtsch Med Wochenschr 2023; 148:459-466. [PMID: 36990118 DOI: 10.1055/a-1873-4786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
Abstract
To date allogeneic hematopoietic stem cell transplantation (allo-HSCT) is the most effective immunotherapeutic approach for the treatment of acute myeloid leukemia (AML). It involves the transplantation of blood stem cells from a healthy donor into a patient, with the goal of using the donor's immune system to recognize and attack cancer cells (Graft-versus-leukemia effect). Thereby, allo-HSCT is more efficient than chemotherapy alone, as it combines high dose chemotherapy +/- irradiation with immunotherapy establishing a long-term control of leukemic cells while allowing reconstitution of a healthy donor hematopoiesis and a new immune system. However, the procedure carries significant risks, including the possibility of graft-versus-host disease (GvHD), and requires careful patient selection to ensure the best possible outcome. In AML patients with high-risk, relapsed or chemo-refractory disease allo-HSCT provides the only curative option.While allo-HSCT is currently the most established form of immunotherapy in the treatment of AML, other approaches that use the immune system to fight cancer are being researched. These may include immunomodulatory drugs or cell therapies such as CAR-T cells, which stimulate the immune system to attack cancer cells. Even if this does not yet play a role in current standard therapy, as our understanding of the immune system and its role in cancer grows, it is likely that targeted immunotherapies will become increasingly important in the treatment of AML The following article gives you an overview of allo-HSCT in AML patients and the current developments.
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Wada F, Kanda J, Yoshioka S, Ishikawa T, Akasaka T, Ueda Y, Hirata H, Arai Y, Yago K, Anzai N, Watanabe M, Ikeda T, Yonezawa A, Imada K, Itoh M, Kitano T, Takeoka T, Hishizawa M, Nohgawa M, Arima N, Asagoe K, Kondo T, Takaori-Kondo A. Single Cord Blood Transplantation Versus HLA-Haploidentical-related Donor Transplantation Using Posttransplant Cyclophosphamide in Patients With Hematological Malignancies. Transplantation 2022; 106:1279-1287. [PMID: 34935764 DOI: 10.1097/tp.0000000000004006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Unrelated cord blood (UCB) and haploidentical related donor transplantation using posttransplant cyclophosphamide (PTCy-haplo) have become alternative options to treat patients with hematological malignancies without a HLA-matched donor. METHODS We conducted a retrospective study using registry data from the Kyoto Stem Cell Transplantation Group for patients with hematological malignancies who received their first allogeneic hematopoietic cell transplantation using a single UCB unit (n = 460) or PTCy-haplo (N = 57) between 2013 and 2019. RESULTS We found that overall survival in the UCB group was comparable to that in the PTCy-haplo group (hazard ratio, 1.00; 95% confidence interval, 0.66-1.52), although neutrophil and platelet engraftment were significantly delayed. Nonrelapse mortality risk and the incidence of graft-versus-host disease in the UCB group were also comparable to those in the PTCy-haplo group. Although the relapse risk was similar between the UCB group and the PTCy-haplo group regardless of the disease risk, acute myeloid leukemia patients benefit from UCB transplant with a significantly lower relapse rate (hazard ratio, 0.38; 95% confidence interval, 0.18-0.76). CONCLUSIONS UCB transplant gives outcomes comparable to PTCy-haplo transplant, and both UCB and PTCy-haplo units are suitable as alternative donor sources for patients without an HLA-matched sibling or unrelated donor.
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Affiliation(s)
- Fumiya Wada
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Department of Hematology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Junya Kanda
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Satoshi Yoshioka
- Department of Hematology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Takayuki Ishikawa
- Department of Hematology, Kobe City Medical Center General Hospital, Kobe, Japan
| | | | - Yasunori Ueda
- Department of Hematology, Kurashiki Central Hospital, Okayama, Japan
| | - Hirokazu Hirata
- Department of Hematology, Kansai Electric Power Hospital, Osaka, Japan
| | - Yasuyuki Arai
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kazuhiro Yago
- Department of Hematology, Shizuoka General Hospital, Shizuoka, Japan
| | - Naoyuki Anzai
- Department of Hematology, Takatsuki Red Cross Hospital, Osaka, Japan
| | - Mitsumasa Watanabe
- Department of Hematology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Takashi Ikeda
- Division of Hematology and Stem Cell Transplantation, Shizuoka Cancer Center, Shizuoka, Japan
| | - Akihito Yonezawa
- Department of Hematology, Kokura Memorial Hospital, Fukuoka, Japan
| | - Kazunori Imada
- Department of Hematology, Japanese Red Cross Osaka Hospital, Osaka, Japan
| | - Mitsuru Itoh
- Department of Hematology, Kyoto City Hospital, Kyoto, Japan
| | | | - Tomoharu Takeoka
- Department of Hematology, Japan Red Cross Otsu Hospital, Shiga, Japan
| | | | - Masaharu Nohgawa
- Department of Hematology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | | | - Kousuke Asagoe
- Department of Hematology, Shiga General Hospital, Shiga, Japan
| | - Tadakazu Kondo
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Akifumi Takaori-Kondo
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Long-term outcomes in patients with relapsed/refractory acute myeloid leukemia and other high-risk myeloid malignancies after undergoing sequential conditioning regimen based on IDA-FLAG and high-dose melphalan. Bone Marrow Transplant 2022; 57:1304-1312. [DOI: 10.1038/s41409-022-01703-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 04/25/2022] [Accepted: 04/29/2022] [Indexed: 12/17/2022]
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Wada F, Watanabe M, Konuma T, Okabe M, Kobayashi S, Uchida N, Ikegame K, Tanaka M, Sugio Y, Mukae J, Onizuka M, Kawakita T, Kuriyama T, Takahashi S, Fukuda T, Nakano N, Sawa M, Kimura T, Ichinohe T, Atsuta Y, Kanda J. HLA 1-3 antigen-mismatched related peripheral blood stem cells transplantation using low-dose antithymocyte globulin versus unrelated cord blood transplantation. Am J Hematol 2022; 97:311-321. [PMID: 34978726 DOI: 10.1002/ajh.26446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 12/15/2021] [Accepted: 12/17/2021] [Indexed: 11/08/2022]
Abstract
Little information is available regarding whether unrelated cord blood transplantation (CBT) or an HLA 1-3 antigen-mismatched related donor peripheral blood stem-cell transplantation (PBSCT) using low-dose anti-thymocyte globulin (ATG) is superior as an alternative transplantation for patients who lack an HLA-matched sibling or unrelated donor. Therefore, we evaluated 7861 patients with hematologic malignancies (aged 0 to 70 years) who received either a CBT without ATG (CBT-no ATG, n = 7034) or an HLA 1-3 antigen-mismatched related donor PBSCT using low-dose ATG (PBSCT-ATG, n = 827). CBT-no ATG was associated with significantly better overall survival (OS) than the use of a PBSCT-ATG (hazard ratio [HR], 0.77; p < .001), although PBSCT-ATG patients with an HLA 1 antigen-mismatch showed OS comparable to that in the CBT-no ATG group. Neutrophil and platelet engraftment was significantly delayed, whereas the incidences of nonrelapse mortality, and severe graft-versus-host disease (GVHD) were significantly lower in the CBT-no ATG group. The incidences of relapse and chronic GVHD were comparable between these donors. In conclusion, CBT-no ATG may be a better alternative than HLA-mismatched related donor PBSCT using low-dose ATG. Notably, HLA 2-3 antigen mismatch-related transplantation with low-dose ATG had significant adverse effects on transplantation outcomes.
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Affiliation(s)
- Fumiya Wada
- Department of Hematology and Oncology, Graduate School of Medicine Kyoto University Kyoto Japan
- Department of Hematology Kobe City Medical Center General Hospital Kobe Japan
| | - Mizuki Watanabe
- Department of Hematology and Oncology, Graduate School of Medicine Kyoto University Kyoto Japan
| | - Takaaki Konuma
- Department of Hematology/Oncology, The Institute of Medical Science The University of Tokyo Tokyo Japan
| | - Motohito Okabe
- Department of Hematology/Oncology, The Institute of Medical Science The University of Tokyo Tokyo Japan
| | - Shinichi Kobayashi
- Division of Hematology, Department of Internal Medicine National Defense Medical College Saitama Japan
| | - Naoyuki Uchida
- Department of Hematology Federation of National Public Service Personnel Mutual Aid Associations Toranomon Hospital Tokyo Japan
| | - Kazuhiro Ikegame
- Department of Hematology Hyogo College of Medicine Hospital Nishinomiya Japan
| | | | - Yasuhiro Sugio
- Department of Hematology Kitakyushu City Hospital Organization, Kitakyushu Municipal Medical Center Kitakyushu Japan
| | - Junichi Mukae
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital Tokyo Japan
| | - Makoto Onizuka
- Department of Hematology/Oncology Tokai University School of Medicine Isehara‐shi Japan
| | - Toshiro Kawakita
- Department of Hematology National Hospital Organization Kumamoto Medical Center Kumamoto Japan
| | | | - Satoshi Takahashi
- Division of Clinical Precision Research Platform, The Institute of Medical Science The University of Tokyo Tokyo Japan
| | - Takahiro Fukuda
- Department of Hematopoietic Stem Cell Transplantation National Cancer Center Hospital Tokyo Japan
| | - Nobuaki Nakano
- Department of Hematology Imamura General Hospital Kagoshima Japan
| | - Masashi Sawa
- Department of Hematology and Oncology Anjo Kosei Hospital Anjo Japan
| | - Takafumi Kimura
- Preparation Department Japanese Red Cross Kinki Block Blood Center Osaka Japan
| | - Tatsuo Ichinohe
- Department of Hematology and Oncology, Research Institute for Radiation Biology and Medicine Hiroshima University Hiroshima Japan
| | - Yoshiko Atsuta
- Department of Healthcare Administration, Japanese Data Center for Hematopoietic Cell Transplantation Nagoya University Graduate School of Medicine Nagoya Japan
| | - Junya Kanda
- Department of Hematology and Oncology, Graduate School of Medicine Kyoto University Kyoto Japan
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9
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Jondreville L, Roos-Weil D, Uzunov M, Boussen I, Grenier A, Norol F, Morel V, Nguyen S, Souchet L. FLAMSA-Busulfan-Melphalan as a Sequential Conditioning Regimen in HLA-Matched or Haploidentical Hematopoietic Stem Cell Transplantation for High-Risk Myeloid Diseases. Transplant Cell Ther 2021; 27:915.e1-915.e8. [PMID: 34329755 DOI: 10.1016/j.jtct.2021.07.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 06/14/2021] [Accepted: 07/19/2021] [Indexed: 11/17/2022]
Abstract
Given the poor prognosis of relapsed/refractory myeloid malignancies, the concept of sequential conditioning before allogeneic hematopoietic stem cell transplantation (allo-HSCT) has proven to be an effective approach. We sought to evaluate a sequential scheme combining fludarabine, amsacrine, and cytarabine (FLAMSA) for cytoreduction, followed by reduced-intensity conditioning with busulfan and melphalan (FLAMSA-BuMel), which was designed to be suitable for both HLA-matched and haploidentical HSCT. This single-center retrospective study included 36 adult patients with high-risk myeloid malignancies who underwent allo-HSCT from HLA-matched (n = 19) or haploidentical (n = 17) donors. Along with the standard prophylaxis for graft-versus-host disease (GVHD), patients with a haploidentical donor received post-transplantation high-dose cyclophosphamide. A post-transplantation consolidation treatment with low-dose 5-azacytidine and prophylactic donor lymphocyte infusions was provided whenever possible. Thirty patients (83%) achieved complete remission on day +30. With a median follow-up of 30.0 months, the 2-year overall survival was 89% in the HLA-matched group versus 34% in the haploidentical group (P = .0018). The 2-year disease-free survival in these 2 groups was 68% and 34%, respectively (P = .013). At 2 years, the probability of relapse was 32% and 20%, respectively, and nonrelapse mortality was 0% and 58%, respectively (P = .0003). The leading cause of death was relapse in the HLA-matched group (3 of 19) and hemorrhagic events (5 of 17) in the haploidentical group, favored by significantly delayed platelet reconstitution and a severe GVHD context. These data confirm the feasibility of FLAMSA-BuMel as a sequential conditioning in allo-HSCT for high-risk myeloid malignancies. The use of bone marrow as the preferred graft source might reduce the incidence of acute GVHD and nonrelapse mortality in the haploidentical transplantation setting.
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Affiliation(s)
- Ludovic Jondreville
- Service d'Hématologie Clinique, Hôpital Pitié-Salpêtrière, APHP, Sorbonne Université, Paris, France.
| | - Damien Roos-Weil
- Service d'Hématologie Clinique, Hôpital Pitié-Salpêtrière, APHP, Sorbonne Université, Paris, France
| | - Madalina Uzunov
- Service d'Hématologie Clinique, Hôpital Pitié-Salpêtrière, APHP, Sorbonne Université, Paris, France
| | - Inès Boussen
- Service d'Hématologie Clinique, Hôpital Pitié-Salpêtrière, APHP, Sorbonne Université, Paris, France
| | - Adrien Grenier
- Service d'Hématologie Clinique, Hôpital Pitié-Salpêtrière, APHP, Sorbonne Université, Paris, France
| | - Françoise Norol
- Service d'Hématologie Clinique, Hôpital Pitié-Salpêtrière, APHP, Sorbonne Université, Paris, France
| | - Véronique Morel
- Service d'Hématologie Clinique, Hôpital Pitié-Salpêtrière, APHP, Sorbonne Université, Paris, France
| | - Stéphanie Nguyen
- Service d'Hématologie Clinique, Hôpital Pitié-Salpêtrière, APHP, Sorbonne Université, Paris, France
| | - Laetitia Souchet
- Service d'Hématologie Clinique, Hôpital Pitié-Salpêtrière, APHP, Sorbonne Université, Paris, France
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10
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[Bone marrow transplantation patients in the intensive care unit]. Med Klin Intensivmed Notfmed 2021; 116:111-120. [PMID: 33564899 PMCID: PMC7871956 DOI: 10.1007/s00063-021-00782-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 11/20/2020] [Accepted: 01/08/2021] [Indexed: 10/31/2022]
Abstract
Allogeneic hematopoetic stem cell transplantation yields improved long-term survival for patients with high-risk malignant and non-malignant hematologic disease. However, it is associated with high morbidity and mortality. A proportion of patients need intensive care due to infectious, immunological and/or toxic complications. The utility of intensive care unit (ICU) treatments as mechanical ventilation and renal replacement therapy for these patients is uncertain since mortality is high. We describe the most frequent complications and the treatment options concerning the ICU in recipients of allogeneic hematopoetic stem cells.
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11
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Heinicke T, Labopin M, Polge E, Stelljes M, Ganser A, Tischer J, Brecht A, Kröger N, Beelen DW, Scheid C, Bethge W, Dreger P, Bunjes D, Wagner E, Platzbecker U, Savani BN, Nagler A, Mohty M. Evaluation of six different types of sequential conditioning regimens for allogeneic stem cell transplantation in relapsed/refractory acute myelogenous leukemia - a study of the Acute Leukemia Working Party of the EBMT. Leuk Lymphoma 2020; 62:399-409. [PMID: 33040622 DOI: 10.1080/10428194.2020.1827248] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The Acute Leukemia Working Party (ALWP) of the EBMT assessed the outcome of allogeneic stem cell transplantation (alloSCT) in patients with relapsed/refractory AML (r/rAML) evaluating six sequential conditioning regimens (SR) groups. A total of 2132 patients were included. LFS at 2 years was 28.9%, 33.6%, 35.3%, 20.6%, 24.4%, and 27% for the FLAMSA-TBI4, FLAMSA-Chemo, Mel-Flu-TBI8, Mel-Treo-Flu, Thio-ETO-Cy-Bu2-Flu, and Clo-ARAC-(Bu2/TBI4)-Cy groups, respectively. In patients <55 years of age Mel-Flu-TBI8 had the best LFS, which was statistically significant only in comparison to the Mel-Treo-Flu group, while in patients ≥55 years LFS was best with FLAMSA-Chemo without significant differences compared to FLAMSA-TBI4 and Mel-Flu-TBI8. Furthermore, best NRM rates were obtained with the two FLAMSA regimens groups. Our study suggests that in younger (<55 years) patients a more intense regimen might be used whereas in older (≥55 years) patients the focus might be more on tolerability.
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Affiliation(s)
- Thomas Heinicke
- Department of Hematology and Oncology, Otto-von-Guericke University, Magdeburg, Germany
| | - Myriam Labopin
- Department of Hematology and Cell Therapy, Hopital Saint-Antoine, Paris, France.,Acute Leukemia Working Party of EBMT Office, Hopital St. Antoine, Paris, France
| | - Emmanuelle Polge
- Acute Leukemia Working Party of EBMT Office, Hopital St. Antoine, Paris, France
| | - Matthias Stelljes
- Department of Internal Medicine A, University of Muenster, Muenster, Germany
| | - Arnold Ganser
- Department of Haematology, Hemostasis, Oncology, Hannover Medical School, Hannover, Germany
| | - Johanna Tischer
- Department of Internal Medicine III, Hematopoietic Stem Cell Transplantation, University Hospital of Munich-Campus Grosshadern, LMU, Munich, Germany
| | - Arne Brecht
- DKD Helios-Klinikum, KMT-Abteilung, Wiesbaden, Germany
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Hospital Eppendorf, Hamburg, Germany
| | - Dietrich W Beelen
- Department of Bone Marrow Transplantation, University Hospital Essen, Essen, Germany
| | - Christof Scheid
- I Department of Medicine, University of Cologne, Cologne, Germany
| | - Wolfgang Bethge
- Medizinische Klinik II, University Tübingen, Tübingen, Germany
| | - Peter Dreger
- Medizinische Klinik u. Poliklinik V, University of Heidelberg, Heidelberg, Germany
| | - Donald Bunjes
- Klinik fuer Innere Medzin III, University Hospital Ulm, Ulm, Germany
| | - Eva Wagner
- Department of Hematology, Oncology and Pneumology, University Medical Center Mainz, Mainz, Germany
| | - Uwe Platzbecker
- Medical Clinic and Policlinic 1, University Hospital Leipzig, Leipzig, Germany
| | - Bipin N Savani
- Division of Hematology-Oncology, Vanderbilt University Medical Center, Brentwood, TN, USA
| | - Arnon Nagler
- Acute Leukemia Working Party of EBMT Office, Hopital St. Antoine, Paris, France.,Hematology Division and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel-Hashomer and Tel Aviv University, Tel HaShomer, Israel
| | - Mohamad Mohty
- Department of Hematology and Cell Therapy, Hopital Saint-Antoine, Paris, France.,Acute Leukemia Working Party of EBMT Office, Hopital St. Antoine, Paris, France
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12
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Mennitto A, Huber V, Ratta R, Sepe P, de Braud F, Procopio G, Guadalupi V, Claps M, Stellato M, Daveri E, Rivoltini L, Verzoni E. Angiogenesis and Immunity in Renal Carcinoma: Can We Turn an Unhappy Relationship into a Happy Marriage? J Clin Med 2020; 9:E930. [PMID: 32231117 PMCID: PMC7231111 DOI: 10.3390/jcm9040930] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 03/22/2020] [Accepted: 03/26/2020] [Indexed: 12/13/2022] Open
Abstract
The frontline treatment options for patients with metastatic renal cell carcinoma (mRCC) are evolving rapidly since the approval of combination immunotherapies by the U.S. Food and Drug Administration (USFDA) and the European Medicines Agency (EMA). In particular, in combination with vascular endothelial growth factor receptor (VEGFR) tyrosine-kinase inhibitors (TKIs), immune checkpoint inhibitors (ICIs) have significantly improved the outcome of patients with mRCC compared to TKI monotherapy. Here, we review the preclinical data supporting the combination of ICIs with VEGFR TKIs. The VEGF-signaling inhibition could ideally sustain immunotherapy through a positive modulation of the tumor microenvironment (TME). Antiangiogenetics, in fact, with their inhibitory activity on myelopoiesis that indirectly reduces myeloid-derived suppressor cells (MDSCs) and regulatory T cells' (Tregs) frequency and function, could have a role in determining an effective anti-tumor immune response. These findings are relevant for the challenges posed to clinicians concerning the clinical impact on treatment strategies for mRCC.
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Affiliation(s)
- Alessia Mennitto
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy
| | - Veronica Huber
- Unit of Immunotherapy of Human Tumors, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy
| | - Raffaele Ratta
- Oncology and Supportive Care Department, Hôpital Foch, 40 Rue Worth, 92151 Suresnes, France
| | - Pierangela Sepe
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy
| | - Filippo de Braud
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy
| | - Giuseppe Procopio
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy
| | - Valentina Guadalupi
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy
| | - Mélanie Claps
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy
| | - Marco Stellato
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy
| | - Elena Daveri
- Unit of Immunotherapy of Human Tumors, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy
| | - Licia Rivoltini
- Unit of Immunotherapy of Human Tumors, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy
| | - Elena Verzoni
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy
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13
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Thiotepa and antithymocyte globulin-based conditioning prior to haploidentical transplantation with posttransplant cyclophosphamide in high-risk hematological malignancies. Bone Marrow Transplant 2019; 55:763-772. [PMID: 31673080 DOI: 10.1038/s41409-019-0726-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Revised: 07/28/2019] [Accepted: 08/10/2019] [Indexed: 12/16/2022]
Abstract
We report results of a thiotepa-based conditioning in haploidentical stem cell transplantation (haplo-SCT) with posttransplant cyclophosphamide (PT-CY) and antithymocyte globulin (ATG), for unmanipulated peripheral blood stem cell (PBSC) transplants, in 80 patients with hematological malignancies. Patients in complete remission (CR) received a thiotepa-busulfan-fludarabine (TBF) regimen, while patients with relapsed/refractory (R/R) malignancies received a sequential regimen consisting of thiotepa-etoposide-cyclophosphamide (TEC) and reduced-intensity conditioning (RIC). The median age was 52 (range, 17-72) years, 44% patients had R/R disease at transplant, and the median follow-up was 417 (range, 180-1595) days. The median days to neutrophil engraftment was 17 (range, 12-34). The cumulative incidences (CI) of acute graft-versus-host disease (GVHD) grade III to IV, severe chronic GVHD, nonrelapse mortality (NRM), and relapse were 16%, 16%, 26, and 26%, respectively. The 2-year overall survival (OS) and disease-free survival (DFS) were 53% and 47%, respectively. There were no significant differences between the patients in CR and R/R patients in terms of engraftment, GVHD, NRM, relapse, OS, or DFS. We conclude that thiotepa-based regimen with PT-CY can be modified with PBSC and ATG, still providing low toxicity, protection against GVHD, and low relapse incidence. Particularly encouraging are the results with the modification to sequential regimen in R/R patients.
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14
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Allogeneic stem-cell transplantation with sequential conditioning in adult patients with refractory or relapsed acute lymphoblastic leukemia: a report from the EBMT Acute Leukemia Working Party. Bone Marrow Transplant 2019; 55:595-602. [PMID: 31562398 DOI: 10.1038/s41409-019-0702-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 07/23/2019] [Accepted: 08/06/2019] [Indexed: 12/21/2022]
Abstract
Treatment of relapsed/refractory acute lymphoblastic leukemia (RR-ALL) remains a clinical challenge with generally dismal prognosis. Allogeneic stem-cell transplantation using sequential conditioning ("FLAMSA"-like) has shown promising results in relapsed/refractory acute myeloid leukemia, but little is known about its efficacy in RR-ALL. We identified 115 patients (19-66 years) with relapsed (74%) or primary-refractory (26%) ALL allografted from matched related (31%), matched unrelated (58%), or haploidentical donor (11%). Median follow-up was 37 (13-111) months. At day 100, cumulative incidences of grade II-IV/III-IV acute graft-versus-host-disease (GVHD) were 30% and 17%, respectively. Two-year cumulative incidence of chronic GVHD was 25% with 11% extensive cases. Two-year relapse incidence (RI) was 45%, non-relapse mortality was 41%. Two-year leukemia free survival (LFS) was 14%, overall survival (OS) 17%, and GVHD relapse-free survival (GRFS) was 14%. In multivariable analysis, Karnofsky score <90 negatively affected RI, LFS, OS, and GRFS. Conditioning with chemotherapy alone, compared with total body irradiation (TBI) negatively affected RI (HR = 3.3; p = 0.008), LFS (HR = 1.94; p = 0.03), and OS (HR = 2.0; p = 0.03). These patients still face extremely poor outcomes, highlighting the importance of incorporating novel therapies (e.g., BITE antibodies, inotuzumab, CAR-T cells). Nevertheless, patients with RR-T-cell ALL remain with an unmet treatment need, for which TBI-based sequential conditioning could be one of few available options.
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15
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Emerging agents and regimens for treatment of relapsed and refractory acute myeloid leukemia. Cancer Gene Ther 2019; 27:1-14. [PMID: 31292516 DOI: 10.1038/s41417-019-0119-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 06/14/2019] [Accepted: 06/23/2019] [Indexed: 12/28/2022]
Abstract
Relapsed and refractory acute myeloid leukemia (R/R AML) has complicated pathogenesis. Its treatment is complicated, and the prognosis is poor. So far, there is no consensus on what is the optimal treatment strategy. With the deepening of research, new chemotherapy regimens, new small molecule inhibitors, and immunotherapy have been increasingly applied to clinical trials, providing more possibilities for the treatment of R/R AML. The most effective treatment for patients who achieve complete remission after recurrence is still sequential conditioning therapy followed by allogeneic hematopoietic cell transplantation. Finding the best combination of treatments is still an important goal for the future.
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