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Guarina A, Farruggia P, Mariani E, Saracco P, Barone A, Onofrillo D, Cesaro S, Angarano R, Barberi W, Bonanomi S, Corti P, Crescenzi B, Dell'Orso G, De Matteo A, Giagnuolo G, Iori AP, Ladogana S, Lucarelli A, Lupia M, Martire B, Mastrodicasa E, Massaccesi E, Arcuri L, Giarratana MC, Menna G, Miano M, Notarangelo LD, Palazzi G, Palmisani E, Pestarino S, Pierri F, Pillon M, Ramenghi U, Russo G, Saettini F, Timeus F, Verzegnassi F, Zecca M, Fioredda F, Dufour C. Diagnosis and management of acquired aplastic anemia in childhood. Guidelines from the Marrow Failure Study Group of the Pediatric Haemato-Oncology Italian Association (AIEOP). Blood Cells Mol Dis 2024; 108:102860. [PMID: 38889660 DOI: 10.1016/j.bcmd.2024.102860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 05/28/2024] [Accepted: 05/28/2024] [Indexed: 06/20/2024]
Abstract
Acquired aplastic anemia (AA) is a rare heterogeneous disorder characterized by pancytopenia and hypoplastic bone marrow. The incidence is 2-3 per million population per year in the Western world, but 3 times higher in East Asia. Survival in severe aplastic anemia (SAA) has improved significantly due to advances in hematopoietic stem cell transplantation (HSCT), immunosuppressive therapy, biologic agents, and supportive care. In SAA, HSCT from a matched sibling donor (MSD) is the first-line treatment. If a MSD is not available, options include immunosuppressive therapy (IST), matched unrelated donor, or haploidentical HSCT. The purpose of this guideline is to provide health care professionals with clear guidance on the diagnosis and management of pediatric patients with AA. A preliminary evidence-based document prepared by a group of pediatric hematologists of the Bone Marrow Failure Study Group of the Italian Association of Pediatric Hemato-Oncology (AIEOP) was discussed, modified and approved during a series of consensus conferences that started online during COVID 19 and continued in the following years, according to procedures previously validated by the AIEOP Board of Directors.
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Affiliation(s)
- A Guarina
- Pediatric Onco-Hematology Unit, A.R.N.A.S. Civico Hospital, Palermo, Italy
| | - P Farruggia
- Pediatric Onco-Hematology Unit, A.R.N.A.S. Civico Hospital, Palermo, Italy
| | - E Mariani
- Scuola di Specializzazione in Pediatria, University of Milano-Bicocca, Milan, Italy; Pediatric Hematology and Bone Marrow Transplant Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - P Saracco
- Hematology Unit, "Regina Margherita" Children's Hospital, Turin, Italy
| | - A Barone
- Pediatric Onco-Hematology Unit, University Hospital, Parma, Italy
| | - D Onofrillo
- Hematology Unit, Hospital of Pescara, Pescara, Italy
| | - S Cesaro
- Pediatric Hematology Oncology Department of Mother and Child, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - R Angarano
- Pediatric Oncology-Hematology Unit, AOU Policlinico, Bari, Italy
| | - W Barberi
- Hematology, Department of Hematology, Oncology and Dermatology, AOU Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - S Bonanomi
- Pediatric Hematology and Bone Marrow Transplant Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - P Corti
- Pediatric Hematology and Bone Marrow Transplant Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - B Crescenzi
- Hematology and Bone Marrow Transplantation Unit, Hospital of Perugia, Perugia, Italy
| | - G Dell'Orso
- Hematology Unit, IRCCS Giannina Gaslini Children Hospital, Genoa, Italy
| | - A De Matteo
- Oncology Hematology and Cell Therapies Department, AORN Santobono-Pausilipon, Naples, Italy
| | - G Giagnuolo
- Oncology Hematology and Cell Therapies Department, AORN Santobono-Pausilipon, Naples, Italy
| | - A P Iori
- Hematology and HSCT Unit, University La Sapienza, Rome, Italy
| | - S Ladogana
- Pediatric Onco-Hematology Unit, Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, Italy
| | - A Lucarelli
- Pediatric Emergency Department, Giovanni XXIII Pediatric Hospital, University of Bari, Bari, Italy
| | - M Lupia
- Hematology Unit, IRCCS Giannina Gaslini Children Hospital, Genoa, Italy
| | - B Martire
- Pediatrics and Neonatology Unit, Maternal-Infant Department, "Monsignor A.R. Dimiccoli" Hospital, Barletta, Italy
| | - E Mastrodicasa
- Hematology and Bone Marrow Transplantation Unit, Hospital of Perugia, Perugia, Italy
| | - E Massaccesi
- Hematology Unit, IRCCS Giannina Gaslini Children Hospital, Genoa, Italy
| | - L Arcuri
- Hematology Unit, IRCCS Giannina Gaslini Children Hospital, Genoa, Italy
| | - M C Giarratana
- Hematology Unit, IRCCS Giannina Gaslini Children Hospital, Genoa, Italy
| | - G Menna
- Oncology Hematology and Cell Therapies Department, AORN Santobono-Pausilipon, Naples, Italy
| | - M Miano
- Hematology Unit, IRCCS Giannina Gaslini Children Hospital, Genoa, Italy
| | - L D Notarangelo
- Medical Direction, Children's Hospital, ASST-Spedali Civili, Brescia, Italy
| | - G Palazzi
- Department of Mother and Child, University Hospital of Modena, Modena, Italy
| | - E Palmisani
- Hematology Unit, IRCCS Giannina Gaslini Children Hospital, Genoa, Italy
| | - S Pestarino
- Hematology Unit, IRCCS Giannina Gaslini Children Hospital, Genoa, Italy
| | - F Pierri
- HSCT Unit, IRCCS Giannina Gaslini Children Hospital, Genoa, Italy
| | - M Pillon
- Maternal and Child Health Department Pediatric Hematology, Oncology and Stem Cell Transplant Center, University of Padua, Padua, Italy
| | - U Ramenghi
- Hematology Unit, "Regina Margherita" Children's Hospital, Turin, Italy
| | - G Russo
- Division of Pediatric Hematology/Oncology, University of Catania, Catania, Italy
| | - F Saettini
- Centro Tettamanti, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - F Timeus
- Pediatrics Department, Chivasso Hospital, Turin, Italy
| | - F Verzegnassi
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - M Zecca
- Pediatric Hematology/Oncology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - F Fioredda
- Hematology Unit, IRCCS Giannina Gaslini Children Hospital, Genoa, Italy
| | - C Dufour
- Hematology Unit, IRCCS Giannina Gaslini Children Hospital, Genoa, Italy.
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2
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Montoro J, Eikema DJ, Tuffnell J, Potter V, Kalwak K, Halkes CJM, Kulagin A, Collin M, Wynn RF, Robinson S, Nicholson E, Sengeloev H, Clay J, Halahleh K, Skorobogatova E, Sanz J, Passweg J, Mielke S, Ryhänen S, Carpenter B, Gedde-Dahl T, Tholouli E, Fanin R, Lewalle P, Kulasekararaj A, Risitano A, Peffault de Latour R. Alternative donor transplantation for severe aplastic anemia: a comparative study of the SAAWP EBMT. Blood 2024; 144:323-333. [PMID: 38643511 DOI: 10.1182/blood.2024024173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 04/09/2024] [Accepted: 04/10/2024] [Indexed: 04/23/2024] Open
Abstract
ABSTRACT Selecting the most suitable alternative donor becomes challenging in severe aplastic anemia (SAA) when a matched sibling donor (MSD) is unavailable. We compared outcomes in patients with SAA undergoing stem cell transplantation (SCT) from matched unrelated donors (MUD) (n = 1106), mismatched unrelated donors (MMUD) (n = 340), and haploidentical donors (Haplo) (n = 206) registered in the European Society for Blood and Marrow Transplantation database (2012-2021). For Haplo SCT, only those receiving posttransplant cyclophosphamide for graft-versus-host disease (GVHD) prophylaxis were included. Median age was 20 years, and the median time from diagnosis to transplantation 8.7 months. Compared with MUD, MMUD (hazard ratio [HR], 2.93; 95% confidence interval [CI], 1.52-5.6) and Haplo (HR, 5.15; 95% CI, 2.5-10.58) showed significantly higher risks of primary graft failure. MUD had lower rates of acute GVHD compared with MMUD and Haplo (grade 2-4: 13%, 22%, and 19%, respectively; P < .001; grade 3-4: 5%, 9%, and 7%, respectively; P = .028). The 3-year nonrelapse mortality rate was 14% for MUD, 19% for MMUD, and 27% for Haplo (P < .001), whereas overall survival and GVHD and relapse-free survival (GRFS) rates were 81% and 73% for MUD, 74% and 65% for MMUD, and 63% and 54% for Haplo, respectively (P < .001). In addition to donor type, multivariable analysis identified other factors associated with GRFS such as patient age, performance status, and interval between diagnosis and transplantation. For patients with SAA lacking an MSD, our findings support MUDs as the preferable alternative donor option. However, selecting between an MMUD and Haplo donor remains uncertain and requires further exploration.
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Affiliation(s)
- Juan Montoro
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Valencia, Spain
- Universidad Católica de Valencia, Valencia, Spain
| | | | | | - Victoria Potter
- Department of Haematological Medicine, Kings College Hospital, London, United Kingdom
| | - Krzysztof Kalwak
- Fundacja Na Ratunek Dzieciom z Choroba Nowotworowa, Wroclaw, Poland
| | | | - Alexander Kulagin
- RM Gorbacheva Research Institute, Pavlov University, St. Petersburg, Russia
| | - Matthew Collin
- Northern Centre for Bone Marrow Transplantation, Newcastle, United Kingdom
| | - Robert F Wynn
- Royal Manchester Children's Hospital, Manchester, United Kingdom
| | | | | | | | - Jennifer Clay
- Yorkshire Blood and Marrow Transplant Programme, Leeds, United Kingdom
| | - Khalid Halahleh
- King Hussein Cancer Centre Adult Blood and Bone Marrow Transplantation Program, Amman, Jordan
| | | | - Jaime Sanz
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Valencia, Spain
| | | | - Stephan Mielke
- Karolinska Institute and University Hospital, Stockholm, Sweden
| | - Samppa Ryhänen
- Hospital for Children and Adolescent, University of Helsinki, Helsinki, Finland
| | - Ben Carpenter
- University College London Hospital, London, United Kingdom
| | | | | | - Renato Fanin
- Azienda Ospedaliero Universitaria di Udine, Udine, Italy
| | | | - Austin Kulasekararaj
- Department of Haematological Medicine, Kings College Hospital, London, United Kingdom
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3
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Zhu J, Yang L, Xia J, Zhou N, Zhu J, Zhu H, Chen J, Qing K, Duan CW. Interleukin-27 Promotes the Generation of Myeloid-derived Suppressor Cells to Alleviate Graft-versus-host Disease. Transplantation 2024:00007890-990000000-00771. [PMID: 38773837 DOI: 10.1097/tp.0000000000005069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2024]
Abstract
BACKGROUND Stimulation of myeloid-derived suppressor cell (MDSC) formation represents a potential curative therapeutic approach for graft-versus-host disease (GVHD), which significantly impacts the prognosis of allogeneic hematopoietic stem cell transplantation. However, the lack of an effective strategy for inducing MDSC production in vivo has hindered their clinical application. In our previous study, MDSC expansion was observed in interleukin (IL)-27-treated mice. METHODS In this study, we overexpressed exogenous IL-27 in mice using a recombinant adeno-associated virus vector to investigate its therapeutic and exacerbating effects in murine GVHD models. RESULTS In our study, we demonstrated that exogenous administration of IL-27 significantly suppressed GVHD development in a mouse model. We found that IL-27 treatment indirectly inhibited the proliferation and activation of donor T cells by rapidly expanding recipient and donor myeloid cells, which act as MDSCs after irradiation or under inflammatory conditions, rather than through regulatory T-cell expansion. Additionally, IL-27 stimulated MDSC expansion by enhancing granulocyte-monocyte progenitor generation. Notably, we verified that IL-27 signaling in donor T cells exerted an antagonistic effect on GVHD prevention and treatment. Further investigation revealed that combination therapy involving IL-27 and T-cell depletion exhibited remarkable preventive effects on GVHD in both mouse and xenogeneic GVHD models. CONCLUSIONS Collectively, these findings suggest that IL-27 promotes MDSC generation to reduce the incidence of GVHD, whereas targeted activation of IL-27 signaling in myeloid progenitors or its combination with T-cell depletion represents a potential strategy for GVHD therapy.
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Affiliation(s)
- Jianmin Zhu
- Pediatric Translational Medicine Institute, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Key Laboratory of Pediatric Hematology and Oncology Ministry of Health, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Liting Yang
- Pediatric Translational Medicine Institute, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Key Laboratory of Pediatric Hematology and Oncology Ministry of Health, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jing Xia
- Pediatric Translational Medicine Institute, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Key Laboratory of Pediatric Hematology and Oncology Ministry of Health, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Neng Zhou
- Pediatric Translational Medicine Institute, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Key Laboratory of Pediatric Hematology and Oncology Ministry of Health, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiayao Zhu
- Pediatric Translational Medicine Institute, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Key Laboratory of Pediatric Hematology and Oncology Ministry of Health, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hua Zhu
- Key Laboratory of Pediatric Hematology and Oncology Ministry of Health, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Hematology and Oncology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jing Chen
- Key Laboratory of Pediatric Hematology and Oncology Ministry of Health, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Hematology and Oncology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Kai Qing
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Cai-Wen Duan
- Pediatric Translational Medicine Institute, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Key Laboratory of Pediatric Hematology and Oncology Ministry of Health, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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4
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Piekarska A, Pawelec K, Szmigielska-Kapłon A, Ussowicz M. The state of the art in the treatment of severe aplastic anemia: immunotherapy and hematopoietic cell transplantation in children and adults. Front Immunol 2024; 15:1378432. [PMID: 38646536 PMCID: PMC11026616 DOI: 10.3389/fimmu.2024.1378432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 03/22/2024] [Indexed: 04/23/2024] Open
Abstract
Acquired aplastic anemia (AA) is an immune-mediated bone marrow (BM) failure where marrow disruption is driven by a cytotoxic T-cell-mediated autoimmune attack against hematopoietic stem cells. The key diagnostic challenge in children, but also in adults, is to exclude the possible underlying congenital condition and myelodysplasia. The choice of treatment options, either allogeneic hematopoietic cell transplantation (alloHCT) or immunosuppressive therapy (IST), depends on the patient's age, comorbidities, and access to a suitable donor and effective therapeutic agents. Since 2022, horse antithymocyte globulin (hATG) has been available again in Europe and is recommended for IST as a more effective option than rabbit ATG. Therefore, an update on immunosuppressive strategies is warranted. Despite an improved response to the new immunosuppression protocols with hATG and eltrombopag, some patients are not cured or remain at risk of aplasia relapse or clonal evolution and require postponed alloHCT. The transplantation field has evolved, becoming safer and more accessible. Upfront alloHCT from unrelated donors is becoming a tempting option. With the use of posttransplant cyclophosphamide, haploidentical HCT offers promising outcomes also in AA. In this paper, we present the state of the art in the management of severe AA for pediatric and adult patients based on the available guidelines and recently published studies.
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Affiliation(s)
- Agnieszka Piekarska
- Department of Hematology and Transplantology, Medical University of Gdansk, Gdansk, Poland
| | - Katarzyna Pawelec
- Department of Oncology, Pediatric Hematology, Clinical Transplantology and Pediatrics, Medical University of Warsaw, Warsaw, Poland
| | | | - Marek Ussowicz
- Department of Pediatric Bone Marrow Transplantation, Oncology and Hematology, Wroclaw Medical University, Wroclaw, Poland
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5
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Kulasekararaj A, Cavenagh J, Dokal I, Foukaneli T, Gandhi S, Garg M, Griffin M, Hillmen P, Ireland R, Killick S, Mansour S, Mufti G, Potter V, Snowden J, Stanworth S, Zuha R, Marsh J. Guidelines for the diagnosis and management of adult aplastic anaemia: A British Society for Haematology Guideline. Br J Haematol 2024; 204:784-804. [PMID: 38247114 DOI: 10.1111/bjh.19236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 10/26/2023] [Accepted: 11/20/2023] [Indexed: 01/23/2024]
Abstract
Pancytopenia with hypocellular bone marrow is the hallmark of aplastic anaemia (AA) and the diagnosis is confirmed after careful evaluation, following exclusion of alternate diagnosis including hypoplastic myelodysplastic syndromes. Emerging use of molecular cyto-genomics is helpful in delineating immune mediated AA from inherited bone marrow failures (IBMF). Camitta criteria is used to assess disease severity, which along with age and availability of human leucocyte antigen compatible donor are determinants for therapeutic decisions. Supportive care with blood and platelet transfusion support, along with anti-microbial prophylaxis and prompt management of opportunistic infections remain key throughout the disease course. The standard first-line treatment for newly diagnosed acquired severe/very severe AA patients is horse anti-thymocyte globulin and ciclosporin-based immunosuppressive therapy (IST) with eltrombopag or allogeneic haemopoietic stem cell transplant (HSCT) from a matched sibling donor. Unrelated donor HSCT in adults should be considered after lack of response to IST, and up front for young adults with severe infections and a readily available matched unrelated donor. Management of IBMF, AA in pregnancy and in elderly require special attention. In view of the rarity of AA and complexity of management, appropriate discussion in multidisciplinary meetings and involvement of expert centres is strongly recommended to improve patient outcomes.
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Affiliation(s)
- Austin Kulasekararaj
- King's College Hospital NHS Foundation Trust, London and King's College London, London, UK
| | - Jamie Cavenagh
- St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Inderjeet Dokal
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London and Barts Health NHS Trust, London, UK
| | - Theodora Foukaneli
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- NHS Blood and Transplant, Bristol, UK
| | - Shreyans Gandhi
- King's College Hospital NHS Foundation Trust, London and King's College London, London, UK
| | - Mamta Garg
- Leicester Royal Infirmary, Leicester, UK
- British Society Haematology Task Force Representative, London, UK
| | | | | | - Robin Ireland
- King's College Hospital NHS Foundation Trust, London and King's College London, London, UK
| | - Sally Killick
- University Hospitals Dorset NHS Foundation Trust, The Royal Bournemouth Hospital, Bournemouth, UK
| | - Sahar Mansour
- St George's Hospital/St George's University of London, London, UK
| | - Ghulam Mufti
- King's College Hospital NHS Foundation Trust, London and King's College London, London, UK
| | - Victoria Potter
- King's College Hospital NHS Foundation Trust, London and King's College London, London, UK
| | - John Snowden
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Simon Stanworth
- Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Radcliffe Department of Medicine, University of Oxford and NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Roslin Zuha
- James Paget University Hospitals NHS Foundation Trust, Great Yarmouth, Norfolk, England
| | - Judith Marsh
- King's College Hospital NHS Foundation Trust, London and King's College London, London, UK
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6
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Buxbaum NP, Socié G, Hill GR, MacDonald KPA, Tkachev V, Teshima T, Lee SJ, Ritz J, Sarantopoulos S, Luznik L, Zeng D, Paczesny S, Martin PJ, Pavletic SZ, Schultz KR, Blazar BR. Chronic GvHD NIH Consensus Project Biology Task Force: evolving path to personalized treatment of chronic GvHD. Blood Adv 2023; 7:4886-4902. [PMID: 36322878 PMCID: PMC10463203 DOI: 10.1182/bloodadvances.2022007611] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 10/26/2022] [Accepted: 10/26/2022] [Indexed: 01/26/2023] Open
Abstract
Chronic graft-versus-host disease (cGvHD) remains a prominent barrier to allogeneic hematopoietic stem cell transplantion as the leading cause of nonrelapse mortality and significant morbidity. Tremendous progress has been achieved in both the understanding of pathophysiology and the development of new therapies for cGvHD. Although our field has historically approached treatment from an empiric position, research performed at the bedside and bench has elucidated some of the complex pathophysiology of cGvHD. From the clinical perspective, there is significant variability of disease manifestations between individual patients, pointing to diverse biological underpinnings. Capitalizing on progress made to date, the field is now focused on establishing personalized approaches to treatment. The intent of this article is to concisely review recent knowledge gained and formulate a path toward patient-specific cGvHD therapy.
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Affiliation(s)
- Nataliya P Buxbaum
- Department of Pediatrics, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Gerard Socié
- Hematology-Transplantation, Assistance Publique-Hopitaux de Paris & University of Paris - INSERM UMR 676, Hospital Saint Louis, Paris, France
| | - Geoffrey R Hill
- Division of Medical Oncology, The University of Washington, Seattle, WA
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Kelli P A MacDonald
- Department of Immunology, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - Victor Tkachev
- Division of Hematology/Oncology, Boston Children's Hospital, Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Takanori Teshima
- Department of Hematology, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Stephanie J Lee
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Jerome Ritz
- Dana-Farber Cancer Institute, Harvard Medical School, Brigham and Women's Hospital, Boston, MA
| | - Stefanie Sarantopoulos
- Department of Medicine, Division of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Duke Cancer Institute, Durham, NC
| | - Leo Luznik
- Division of Hematologic Malignancies, Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Defu Zeng
- Arthur D. Riggs Diabetes and Metabolism Research Institute, The Beckman Research Institute, Hematologic Maligancies and Stem Cell Transplantation Institute, City of Hope National Medical Center, Duarte, CA
| | - Sophie Paczesny
- Department of Microbiology and Immunology and Cancer Immunology Program, Hollings Cancer Center, Medical University of South Carolina, Charleston, SC
| | - Paul J Martin
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Steven Z Pavletic
- Immune Deficiency Cellular Therapy Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Kirk R Schultz
- Michael Cuccione Childhood Cancer Research Program, British Columbia Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Bruce R Blazar
- Department of Pediatrics, Division of Blood & Marrow Transplant & Cellular Therapy, University of Minnesota, Minneappolis, MN
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7
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Pan P, Chen C, Hong J, Gu Y. Autoimmune pathogenesis, immunosuppressive therapy and pharmacological mechanism in aplastic anemia. Int Immunopharmacol 2023; 117:110036. [PMID: 36940553 DOI: 10.1016/j.intimp.2023.110036] [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: 12/28/2022] [Revised: 02/26/2023] [Accepted: 03/10/2023] [Indexed: 03/23/2023]
Abstract
Acquired aplastic anemia (AA) is an autoimmune disease of bone marrow failure mediated by abnormally activated T cells, manifested by severe depletion of hematopoietic stem and progenitor cells (HSPCs) and peripheral blood cells. Due to the limitation of donors for hematopoietic stem cell transplantation, immunosuppressive therapy (IST) is currently an effective first-line treatment. However, a significant proportion of AA patients remain ineligible for IST, relapse, and develop other hematologic malignancies, such as acute myeloid leukemia after IST. Therefore, it is important to elucidate the pathogenic mechanisms of AA and to identify treatable molecular targets, which is an attractive way to improve these outcomes. In this review, we summarize the immune-related pathogenesis of AA, pharmacological targets, and clinical effects of the current mainstream immunosuppressive agents. It provides new insight into the combination of immunosuppressive drugs with multiple targets, as well as the discovery of new druggable targets based on current intervention pathways.
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Affiliation(s)
- Pengpeng Pan
- Key Laboratory of Anti-inflammatory and Immune Medicine, Ministry of Education, Institute of Clinical Pharmacology, Anhui Medical University, Hefei 230032, PR China
| | - Congcong Chen
- Key Laboratory of Anti-inflammatory and Immune Medicine, Ministry of Education, Institute of Clinical Pharmacology, Anhui Medical University, Hefei 230032, PR China
| | - Jian Hong
- Department of Hematology, The First Affiliated Hospital of Anhui Medical University, Hefei 230032, PR China
| | - Yue Gu
- Key Laboratory of Anti-inflammatory and Immune Medicine, Ministry of Education, Institute of Clinical Pharmacology, Anhui Medical University, Hefei 230032, PR China.
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8
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Zhang Y, Chen X, Li L, Li Y, Lin L, Cao Y, Wang N, Yang D, Pang A, Zhang R, Ma Q, Zhai W, He Y, Wei J, Jiang E, Han M, Zhang Y, Feng S. Retrospective Comparison of Efficacy and Safety of Rabbit Anti-Thymocyte Globulin and Porcine Anti-Lymphocyte Globulin in Patients With Acquired Aplastic Anemia Undergoing Hematopoietic Stem Cell Transplantation From Matched Sibling Donors. Front Immunol 2022; 13:889784. [PMID: 35784311 PMCID: PMC9241985 DOI: 10.3389/fimmu.2022.889784] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 05/04/2022] [Indexed: 12/02/2022] Open
Abstract
We compared the efficacy and safety of porcine anti-lymphocyte globulin (pALG) (n=140) and rabbit anti-thymocyte globulin (rATG) (n=86) in patients with acquired aplastic anemia (AA) receiving hematopoietic stem cell transplantation (HSCT) from matched sibling donors (MSD) in two transplantation centers in China ranging from 2005 to 2020. The groups had similar baseline characteristics except for a higher number of infused mononuclear cells (P<0.001) and a higher proportion of peripheral blood stem cells as graft sources (P=0.003) in the pALG group. The rates of neutrophil engraftment at day 28 (P=1), platelet engraftment at day 28 (P=0.228), bloodstream infection before engraftment (P=0.867), invasive fungal diseases (P=0.362), cytomegalovirus viremia (P=0.667), and graft rejection (P=0.147) were similar in the two groups. A higher cumulative incidence of grades II-IV acute graft versus host disease (aGvHD) at 100 days occurred in the pALG group (19% vs. 8%, P=0.035) while no significant differences in grades III-IV aGvHD (P=0.572), mild to severe chronic GvHD (cGvHD) (P=0.181), and moderate to severe cGvHD (P=0.586) were observed. The actuarial 5-year overall survival (OS), failure-free survival (FFS), and GvHD-free, FFS rates of the pALG group were 87% (95% confidence interval [CI], 82-93), 85% (95% CI, 80-92), and 78% (95% CI, 72-92) versus 91% (95% CI, 86-99) (P=0.33), 88% (95% CI, 82-97) (P=0.428), and 79% (95% CI, 72-90) (P=0.824) in the rATG group, respectively. A busulfan-containing conditioning regimen was the only adverse risk factor for OS and FFS in multivariate analysis. In conclusion, pALG is an alternative to rATG in patients with severe AA receiving MSD-HSCT. A prospective, large-sample study is needed to explore this therapy further.
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Affiliation(s)
- Yuanfeng Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Department of Hematology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Xin Chen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Lin Li
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yun Li
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Li Lin
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yang Cao
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Na Wang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Donglin Yang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Aiming Pang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Rongli Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Qiaoling Ma
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Weihua Zhai
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Yi He
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Jialin Wei
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Erlie Jiang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - MingZhe Han
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Yicheng Zhang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Sizhou Feng, ; ; Yicheng Zhang,
| | - Sizhou Feng
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- *Correspondence: Sizhou Feng, ; ; Yicheng Zhang,
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9
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Atay D, Akcay A, Yenigurbuz FD, Akinci B, Bagirova K, Hasanova S, Ozturk G. Clinical study of graft-versus-host disease prophylaxis in unrelated hematopoietic stem cell transplantation for pediatric nonmalignant diseases with different doses anti-human T-lymphocyte immunoglobulin. Pediatr Transplant 2021; 25:e14098. [PMID: 34313359 DOI: 10.1111/petr.14098] [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: 02/27/2021] [Revised: 06/13/2021] [Accepted: 07/13/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Anti-human T-lymphocyte immunoglobulin is commonly used as prophylaxis for graft-versus-host disease after allogeneic hematopoietic stem cell transplantation from unrelated donors. The studies according to optimum dose of ATLG especially in pediatric patients are limited. PATIENTS AND METHODS Outcomes of 99 pediatric patients diagnosed with nonmalignant diseases, who received ATLG as GVHD prophylaxis for matched unrelated donor HSCT at a dose of 10 mg/kg (group 1), 20 mg/kg (group 2), and 30 mg/kg (group 3), were analyzed retrospectively. RESULTS The incidences of acute and chronic GVHD were statistically not different between three groups (p = .20 and p = .13), but we did not observe chronic GVHD in group 3 patients. Cox regression analysis showed that ATLG dose of 10 mg/kg (p = .007) and severe acute GVHD (p = .001) were significant prognostic factors for inferior overall survival. Although ATLG dose of 10 mg/kg is effective in pediatric patients on acute and chronic GVHD prevention, TRM and overall survival were superior in ATLG doses ≥20 mg/kg (p = .04 and p = .037) with no difference between 20 and 30 mg/kg. CONCLUSION Although ATLG dose of 10 mg/kg is effective in pediatric patients on acute and chronic GVHD prevention and safe from the point of infection, TRM and OS were superior in ATLG doses ≥20 mg/kg with no difference between 20 and 30 mg/kg. These observations should be supported with other multicenter prospective studies including larger patient population.
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Affiliation(s)
- Didem Atay
- Department of Pediatric Hematology/Oncology & Bone Marrow Transplantation Unit, School of Medicine, Altunizade Hospital, Acıbadem University, Istanbul, Turkey
| | - Arzu Akcay
- Department of Pediatric Hematology/Oncology & Bone Marrow Transplantation Unit, School of Medicine, Altunizade Hospital, Acıbadem University, Istanbul, Turkey
| | - Fatma Demir Yenigurbuz
- Department of Pediatric Hematology/Oncology & Bone Marrow Transplantation Unit, School of Medicine, Altunizade Hospital, Acıbadem University, Istanbul, Turkey
| | - Burcu Akinci
- Department of Pediatric Hematology/Oncology & Bone Marrow Transplantation Unit, School of Medicine, Altunizade Hospital, Acıbadem University, Istanbul, Turkey
| | - Konul Bagirova
- Department of Pediatric Hematology/Oncology & Bone Marrow Transplantation Unit, School of Medicine, Altunizade Hospital, Acıbadem University, Istanbul, Turkey.,National Center Hematology and Transfusiology, Baku, Azerbaijan
| | - Samira Hasanova
- Department of Pediatric Hematology/Oncology & Bone Marrow Transplantation Unit, School of Medicine, Altunizade Hospital, Acıbadem University, Istanbul, Turkey.,National Center Hematology and Transfusiology, Baku, Azerbaijan
| | - Gulyuz Ozturk
- Department of Pediatric Hematology/Oncology & Bone Marrow Transplantation Unit, School of Medicine, Altunizade Hospital, Acıbadem University, Istanbul, Turkey
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10
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Bernard F, Uppungunduri CRS, Meyer S, Cummins M, Patrick K, James B, Skinner R, Tewari S, Carpenter B, Wynn R, Veys P, Amrolia P. Excellent overall and chronic graft-versus-host-disease-free event-free survival in Fanconi anaemia patients undergoing matched related- and unrelated-donor bone marrow transplantation using alemtuzumab-Flu-Cy: the UK experience. Br J Haematol 2021; 193:804-813. [PMID: 33855694 DOI: 10.1111/bjh.17418] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 02/26/2021] [Accepted: 02/27/2021] [Indexed: 12/20/2022]
Abstract
Haematopoietic stem cell transplantation (HSCT) remains the only curative option in Fanconi anaemia (FA). We analysed the outcome of children transplanted for FA between 1999 and 2018 in the UK. A total of 94 transplants were performed in 82 patients. Among the donors, 51·2% were matched related donors (MRD) while the remainder were alternative donors. Most patients received a fludarabine-cyclophosphamide (Flu-Cy)-based conditioning regimen (86·6%) and in vivo T-cell depletion with alemtuzumab (69·5%). Five-year overall survival (OS) was 85·4% [70·4-93.2] with MRD, 95·7% [72·9-99.4] with matched unrelated donors (MUD), 44·4% [6·6-78.5] with mismatched unrelated donors (MMUD) and 44·4% [13·6-71.9] with mismatched related donors (MMRD) (P < 0·001). Other factors significantly impacting OS were pre-transplant bone marrow status, source of stem cells, cytomegalovirus (CMV) serostatus, preparation with Flu-Cy, use of total body irradiation (TBI) and alemtuzumab as serotherapy. In multivariate analysis, absence of myelodysplastic syndrome (MDS) or leukaemia, bone marrow as source of stem cells, cytomegalovirus (CMV) other than +/- (Recipient/Donor) and Flu-Cy were protective factors for five-year OS. Five-year chronic graft-versus-host-disease (cGVHD)-free event-free survival was 75·4% with the same risk factors except for CMV serostatus. Five-year non-relapse mortality was 13·8% [7·3-22.3]. Only five patients (6·1%) developed grade II-IV acute GVHD and two patients chronic GVHD. These data confirm the excellent outcome of matched related or unrelated HSCT in children with FA.
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Affiliation(s)
- Fanette Bernard
- Paediatric Onco-Haematology Unit, Geneva University Hospital, Geneva, Switzerland
| | | | - Stephan Meyer
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK.,Teenage and Young Adult Cancer, The Christie NHS Foundation Trust, Manchester, UK.,Department of Haematology and Oncology, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Michelle Cummins
- Department of Paediatric Haematology and Bone Marrow Transplantation, Bristol Royal Hospital for Children, Bristol, UK
| | - Katharine Patrick
- Department of Paediatric Haematology, Sheffield Children's Hospital, Sheffield, UK
| | - Beki James
- Department of Paediatric Oncology and Haematology, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Roderick Skinner
- Department of Paediatric and Adolescent Haematology and Oncology, Great North Children's Hospital, Newcastle upon Tyne, UK
| | - Sanjay Tewari
- Department of Paediatric Haematology/Oncology, The Royal Marsden Hospital NHS Trust, Sutton, UK
| | - Ben Carpenter
- Department of Haematology, University College London Hospitals NHS Trust, London, UK
| | - Robert Wynn
- Department of Blood and Marrow Transplant, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Paul Veys
- Department of Bone Marrow Transplant and Haematology, Great Ormond Street Hospital for Children, London, UK
| | - Persis Amrolia
- Department of Bone Marrow Transplant and Haematology, Great Ormond Street Hospital for Children, London, UK.,Molecular and Cellular Immunology Section, UCL Great Ormond Street Institute of Child Health, London, UK
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11
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Akhmedov M. Infectious complications in allogeneic hematopoietic cell transplant recipients: Review of transplant-related risk factors and current state of prophylaxis. Clin Transplant 2020; 35:e14172. [PMID: 33247497 DOI: 10.1111/ctr.14172] [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: 07/08/2020] [Revised: 11/13/2020] [Accepted: 11/16/2020] [Indexed: 01/23/2023]
Abstract
Allogeneic hematopoietic cell transplantation is a complex procedure that carries a significant risk of complications. Infections are among the most common of them. Several direct factors such as neutropenia, hypogammaglobulinemia, lymphopenia, mucosal barrier injury, and graft-versus-host disease have been shown to be associated with increased infectious risk post-transplant. Apart from direct factors, there are also indirect transplant-related factors that are the primary trigger to the formers' development. The most important of them are type of preparative regimen, graft source, donor type, graft-versus-host disease prophylaxis, and graft manipulation techniques. In this review, an attempt has been made to summarize the role of the transplant-related factors in the development of infectious complications and provide evidence underlying the current concept of infectious disease prophylaxis in patients after allogeneic hematopoietic cell transplantation.
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Affiliation(s)
- Mobil Akhmedov
- Department of Bone Marrow Transplantation, National Hematology Research Center, Moscow, Russian Federation
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12
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Iftikhar R, Chaudhry QUN, Anwer F, Neupane K, Rafae A, Mahmood SK, Ghafoor T, Shahbaz N, Khan MA, Khattak TA, Shamshad GU, Rehman J, Farhan M, Khan M, Ansar I, Ashraf R, Marsh J, Satti TM, Ahmed P. Allogeneic hematopoietic stem cell transplantation in aplastic anemia: current indications and transplant strategies. Blood Rev 2020; 47:100772. [PMID: 33187812 DOI: 10.1016/j.blre.2020.100772] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 09/12/2020] [Accepted: 10/15/2020] [Indexed: 12/18/2022]
Abstract
Treatment options for newly diagnosed aplastic anemia (AA) patient includes upfront allogeneic hematopoietic stem cell transplant (HSCT) or immunosuppressive therapy (IST). With recent advances in supportive care, conditioning regimens and post-transplant immunosuppression the overall survival for HSCT approaches 70-90%. Transplant eligibility needs to be assessed considering age, comorbidities, donor availability and probability of response to immunosuppressive therapy (IST). Upfront HSCT should be offered to children and young adults with matched related donor (MRD). Upfront HSCT may also be offered to children and young adults with rapidly available matched unrelated donor (MUD) who require urgent HSCT. Bone marrow (BM) graft source and cyclosporine (CsA) plus methotrexate (MTX) as graft versus host disease (GVHD) prophylaxis are preferable when using anti-thymocyte globulin (ATG) based conditioning regimens. Alemtuzumab is an acceptable alternative to ATG and is used with CsA alone and with either BM or peripheral blood stem cells (PBSC). Cyclophosphamide (CY) plus ATG conditioning is preferable for patients receiving MRD transplant, while Fludarabine (Flu) based conditioning is reserved for older adults, those with risk factors of graft failure and those receiving MUD HSCT. For haploidentical transplant, use of low dose radiotherapy and post-transplant cyclophosphamide has resulted in a marked reduction in graft failure and GVHD.
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Affiliation(s)
- Raheel Iftikhar
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan.
| | - Qamar Un Nisa Chaudhry
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Faiz Anwer
- Department of Hematology, Medical Oncology, Tausig Cancer Center, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Karun Neupane
- Department of Internal Medicine, Manipal College of Medical Sciences, Pokhara 33700, Nepal
| | - Abdul Rafae
- Department of Internal Medicine, McLaren Flint Michigan State University, United States
| | - Syed Kamran Mahmood
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Tariq Ghafoor
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Nighat Shahbaz
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Mehreen Ali Khan
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Tariq Azam Khattak
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Ghassan Umair Shamshad
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Jahanzeb Rehman
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Muhammad Farhan
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Maryam Khan
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Iqraa Ansar
- Shifa College of Medicine, Islamabad 44000, Pakistan
| | - Rabia Ashraf
- King Edward Medical University, Lahore 54000, Pakistan
| | - Judith Marsh
- Department of Hematological Medicine, King's College Hospital, Denmark Hill, London SE59RS, UK
| | | | - Parvez Ahmed
- Department of Hematology Oncology and Stem Cell Transplant, Quaid-e-Azam International Hospital, Islamabad 44000, Pakistan
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13
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Similar outcomes of alemtuzumab-based hematopoietic cell transplantation for SAA patients older or younger than 50 years. Blood Adv 2020; 3:3070-3079. [PMID: 31648330 DOI: 10.1182/bloodadvances.2019000480] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 08/27/2019] [Indexed: 12/11/2022] Open
Abstract
Survival after allogeneic hematopoietic cell transplantation (HSCT) for severe aplastic anemia (SAA) among older patients remains poor and associated with increased risk for graft-versus-host disease (GVHD). In this retrospective study of 65 consecutive patients with acquired SAA who were transplanted using fludarabine, low-dose cyclophosphamide, and alemtuzumab (FCC), outcomes of 27 patients aged at least 50 years were compared with those of 38 patients younger than 50 years. The median age of the older cohort was 61 years (range, 51-71 years); 21 (78%) patients were transplanted from unrelated donors (3 of 21 from HLA 9/10 mismatch donors) and 6 from matched sibling donors. One-year GVHD-free, relapse-free survival (GRFS) was comparable to that of patients younger than 50 years (84% vs 94%, respectively; P = .23). Both groups showed low rates of acute (5% vs 4%) and chronic (18% vs 14%) GVHD, with no cases of severe GVHD among matched donor transplants, and similar 1-year transplant-related mortality (14% vs 5.4%, older vs younger; P = .23). HSCT comorbidity index (HTC-CI) scores were similar between the groups, but overall survival with an HCT-CI of at least 3 was lower compared with a score less than 3 (76% vs 98%; P = .005). Median donor T-cell chimerism among older patients was 64% and 60% at 1 and 3 years, respectively, and was similar to that of younger patients. Increased B regulatory cells potentially contributed to low alloreactivity and mutual donor-recipient tolerance in older patients. Effect of comorbidities rather than age alone may be a more important determinant of suitability for FCC HSCT in older patients.
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14
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Fludarabine, Campath, and Low-Dose Cyclophosphamide (FCC low) with or without TBI Conditioning Results in Excellent Transplant Outcomes in Children with Severe Aplastic Anemia. Biol Blood Marrow Transplant 2020; 26:1900-1905. [PMID: 32640311 DOI: 10.1016/j.bbmt.2020.06.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 05/24/2020] [Accepted: 06/28/2020] [Indexed: 11/22/2022]
Abstract
Various reduced-intensity conditioning regimens are in use for allogeneic hematopoietic cell transplant (HSCT) in patients with idiopathic severe aplastic anemia (SAA). We describe the use of fludarabine, Campath, and low-dose cyclophosphamide (FCClow) conditioning in 15 children undergoing related or unrelated donor transplants. Total body irradiation (TBI) of 2 Gy was added for unrelated donor HSCT. At a median follow-up of 2.3 years, the failure-free survival was 100%, with low rates of infection and toxicity. There was no occurrence of grade III to IV acute graft-versus-host disease (GVHD). All patients had full donor myeloid chimerism post-HSCT, even with mixed chimerism in the T cell lineage. The absence of chronic GVHD and long-term stable mixed donor T cell chimerism confirms immune tolerance following FCClow (± TBI) conditioned transplantation in children with SAA.
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15
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Bonifazi F, Rubio MT, Bacigalupo A, Boelens JJ, Finke J, Greinix H, Mohty M, Nagler A, Passweg J, Rambaldi A, Socie G, Solano C, Walker I, Barosi G, Kröger N. Rabbit ATG/ATLG in preventing graft-versus-host disease after allogeneic stem cell transplantation: consensus-based recommendations by an international expert panel. Bone Marrow Transplant 2020; 55:1093-1102. [PMID: 31969678 PMCID: PMC7269907 DOI: 10.1038/s41409-020-0792-x] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 12/04/2019] [Accepted: 01/13/2020] [Indexed: 11/26/2022]
Abstract
This collaborative initiative aimed to provide recommendations on the use of polyclonal antithymocyte globulin (ATG) or anti-T lymphocyte globulin (ATLG) for the prevention of graft-versus-host disease (GvHD) after allogeneic hematopoietic stem cell transplantation (HSCT). A comprehensive review of articles released up to October, 2018 was performed as a source of scientific evidence. Fourteen clinically relevant key questions to the domains indication, administration, and post-transplant management were developed and recommendations were produced using the Delphi technique involving a Panel of 14 experts. ATG/ATLG was strongly recommended as part of myeloablative conditioning regimen prior to matched or mismatched unrelated bone marrow or peripheral blood allogeneic HSCT in malignant diseases to prevent severe acute and chronic GvHD. ATG/ATLG was also recommended prior to HLA-identical sibling peripheral HSCT with good but lesser bulk of evidence. In reduced intensity or nonmyeloablative conditioning regimens, ATG/ATLG was deemed appropriate to reduce the incidence of acute and chronic GvHD, but a higher risk of relapse should be taken into account. Recommendations regarding dose, application, and premedication were also provided as well as post-transplant infectious prophylaxis and vaccination. Overall, these recommendations can be used for a proper and safe application of polyclonal ATG/ATLG to prevent GvHD after allogeneic HSCT.
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Affiliation(s)
- Francesca Bonifazi
- Institute of Hematology "Seragnoli", University Hospital "S. Orsola Malpighi", Bologna, Italy.
| | - Marie-Thérèse Rubio
- Department of Hematology, Hôpital Brabois, CHRU Nancy and CNRS UMR 7365, Biopole del'Université del Lorraine, Vendoeuvre les Nancy, France
| | - Andrea Bacigalupo
- "Fondazione Policlinico Universitario A. Gemelli IRCCS", Rome, Italy
- Institute of Hematology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Jaap Jan Boelens
- Stem Cell Transplantation and Cellular Therapies, MSK Kids, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jürgen Finke
- Freiburg University Medical Faculty and Medical Center, Department for Medicine, Hematology, Oncology and Stem Cell Transplantation, Freiburg, Germany
| | - Hildegard Greinix
- Division of Hematology, Medical University of Graz, Auenbruggerplatz 38, 8036, Graz, Austria
| | - Mohamad Mohty
- Service d'Hématologie clinique et Thérapie cellulaire, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne University, INSERM UMRs 938, Paris, France
| | - Arnon Nagler
- Hematology Division, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Jakob Passweg
- Division of Hematology, Department of Medicine, University Hospital Basel, Basel, Switzerland
| | - Alessandro Rambaldi
- Department of Oncology, University of Milano and Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Gérard Socie
- Service d' Hématologie-greffe, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Université Paris Diderot, Inserm UMR 976, Paris, France
| | - Carlos Solano
- Hematology Service, Hospital Clínico Universitario-INCLIVA; Department of Medicine, School of Medicine, University of Valencia, Valencia, Spain
| | - Irwin Walker
- Department of Medicine, McMaster University, Hamilton, ON, Canada
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16
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Marsh JCW, Risitano AM, Mufti GJ. The Case for Upfront HLA-Matched Unrelated Donor Hematopoietic Stem Cell Transplantation as a Curative Option for Adult Acquired Severe Aplastic Anemia. Biol Blood Marrow Transplant 2019; 25:e277-e284. [PMID: 31129354 DOI: 10.1016/j.bbmt.2019.05.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 05/07/2019] [Accepted: 05/16/2019] [Indexed: 12/20/2022]
Abstract
The improved success of HLA-matched unrelated donor (MUD) hematopoietic stem cell transplantation (HSCT) for severe aplastic anemia (SAA) in recent decades has had an impact on the indications for and timing of this treatment modality. In the absence of a matched sibling donor (MSD), historically MUD HSCT was reserved as an option after failure to respond to at least 2 courses of immunosuppressive therapy (IST) in adults with SAA, but with improved outcomes over time, it is now considered following failure to respond to 1 course of IST. Recent national and international studies and guidelines now recommend upfront MUD HSCT as an option for children for whom an MUD is readily available, because outcomes are similar to those for MSD HSCT. Fludarabine-based conditioning and the use of in vivo T cell depletion with antithymocyte globulin or alemtuzumab has been associated with a reported overall survival (OS) of >85% in adult patients undergoing MUD HSCT. However, the recent introduction of eltrombopag for patients with SAA has transformed the treatment landscape, and there is currently much interest in its use with IST as upfront treatment, which showed a high response rate in an early-phase study. The risks of HSCT, especially graft-versus-host disease (GVHD), need to be carefully balanced against the concerns of IST, namely relapse and later clonal evolution to myelodysplastic syndrome (MDS)/acute myelogenous leukemia (AML). In the absence of a current prospective randomized trial comparing these 2 approaches, in this review we examine the evidence supporting consideration of early MUD HSCT in adults with SAA who would have been considered for MSD HSCT but who lack a MSD and for whom an MUD is readily available, especially using an irradiation-free conditioning regimen, with a low risk of GVHD, as another treatment option. This option may be offered to patients to provide them with an informed choice, with the aim of curing disease rather than achieving freedom from disease, relapse-free survival, or OS. Furthermore, understanding the immune signature for the response to IST and the immunologic responses to somatic mutations and clonal progression to MDS/AML may help define the future indications for upfront HSCT and a more precise medical approach to therapy.
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Affiliation(s)
- Judith C W Marsh
- Department of Haematological Medicine, King's College Hospital/King's College London, London, UK.
| | | | - Ghulam J Mufti
- Department of Haematological Medicine, King's College Hospital/King's College London, London, UK
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Zeidan AM, Battiwalla M, Berlyne D, Winkler T. Aplastic Anemia and MDS International Foundation (AAMDSIF): Bone marrow failure disease scientific symposium 2016. Leuk Res 2017; 53:8-12. [PMID: 27923195 PMCID: PMC7731993 DOI: 10.1016/j.leukres.2016.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 11/21/2016] [Indexed: 11/20/2022]
Abstract
Patients with acquired and inherited bone marrow failure syndromes (BMFS) have ineffective hematopoiesis due to impairments of the hematopoietic stem cell compartment. Common manifestations of BMFS include varying degrees of peripheral blood cytopenias and, sometimes, progression to acute myelogenous leukemia. Research efforts have been made all over the world to improve understanding of the pathogenesis of these diseases and their clinical implications. The Aplastic Anemia and MDS International Foundation (AAMDSIF) is an independent nonprofit organization whose mission is to help patients and family members cope with BMFS. Here, we summarize recent scientific discoveries in several BMFS that were presented at the fifth International Bone Marrow Failure Disease Scientific Symposium 2016 that AAMDSIF sponsored on March 17-18, 2016, in Rockville, Maryland.
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Affiliation(s)
- Amer M Zeidan
- Section of Hematology, Department of Internal Medicine, Yale University, 333 Cedar Street, PO. Box 208028, New Haven, CT, 06520-8028, United States.
| | - Minoo Battiwalla
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, 10 Center Drive, Bethesda, MD, 20892, United States.
| | - Deborah Berlyne
- Aplastic Anemia and Myelodysplastic Syndrome International Foundation, 4330 East West Highway, Suite 230, Bethesda, MD, United States
| | - Thomas Winkler
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, 10 Center Drive, Bethesda, MD, 20892, United States.
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18
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Grimaldi F, Potter V, Perez-Abellan P, Veluchamy JP, Atif M, Grain R, Sen M, Best S, Lea N, Rice C, Pagliuca A, Mufti GJ, Marsh JCW, Barber LD. Mixed T Cell Chimerism After Allogeneic Hematopoietic Stem Cell Transplantation for Severe Aplastic Anemia Using an Alemtuzumab-Containing Regimen Is Shaped by Persistence of Recipient CD8 T Cells. Biol Blood Marrow Transplant 2016; 23:293-299. [PMID: 27816648 PMCID: PMC5270460 DOI: 10.1016/j.bbmt.2016.11.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Accepted: 11/01/2016] [Indexed: 01/08/2023]
Abstract
Clinical outcomes are excellent using an alemtuzumab-containing hematopoietic stem cell transplantation regimen for aplastic anemia. Outcomes are excellent despite prolonged abnormality of the T cell profile. Recipient-derived CD8 T cells shape persistent mixed chimerism.
Prevention of graft-versus-host disease (GVHD) is paramount for allogeneic hematopoietic stem cell transplantation (HSCT) to treat nonmalignant diseases. We previously reported that allogeneic HSCT for severe aplastic anemia (SAA) using the fludarabine, cyclophosphamide, and alemtuzumab (Campath-1H) (FCC) regimen is associated with a very low risk of GVHD and excellent clinical outcomes. We now report a single-center study of 45 patients with longer follow-up and investigation of lymphocyte recovery. Overall survival (OS) was 93%, and event-free survival (EFS) was 90.7%. Acute and chronic GVHD each occurred in 6 patients (13.3%), and only 1 case was severe. Mixed T cell chimerism was frequent and persisted after cessation of immunosuppression. T cells were extensively depleted, representing only 11.3% of lymphocytes at day 30 and rising to 43.8% by 1 year, but still significantly below normal levels (67.2%; P = .018), and deficiency persisted after immunosuppressive therapy (IST) withdrawal. Depletion of CD4 T cells was particularly profound, causing inversion of the normal CD4:CD8 T cell ratio. T cell subset composition was also abnormal, with memory and effector T cells predominating for at least 6 months after FCC HSCT. Analysis of T cell subset chimerism showed that CD4 T cells were predominantly donor-derived at 1 year, whereas recipient-derived CD8 T cells shaped mixed chimerism with a notable contribution of recipient effector CD8 T cells. The prolonged mixed T cell chimerism after IST withdrawal and low incidence of GVHD indicates the establishment of mutual tolerance, but the low incidence of viral disease suggests maintenance of antiviral immunity. Our study shows that despite the abnormal T cell profile after allogeneic HSCT for SAA using the FCC regimen, this regimen is conducive to an excellent clinical outcome.
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Affiliation(s)
- Francesco Grimaldi
- Department of Haematology, King's College Hospital NHS Foundation Trust, London, United Kingdom; Department of Clinical Medicine, Haematology Division, AOU Federico II, Naples, Italy
| | - Victoria Potter
- Department of Haematology, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | | | - John P Veluchamy
- Division of Cancer Studies, King's College London, London, United Kingdom
| | - Muhammad Atif
- Division of Cancer Studies, King's College London, London, United Kingdom
| | - Rosemary Grain
- Division of Cancer Studies, King's College London, London, United Kingdom
| | - Monica Sen
- Division of Cancer Studies, King's College London, London, United Kingdom
| | - Steven Best
- Department of Haematology, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Nicholas Lea
- Department of Haematology, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Carmel Rice
- Department of Haematology, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Antonio Pagliuca
- Department of Haematology, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Ghulam J Mufti
- Department of Haematology, King's College Hospital NHS Foundation Trust, London, United Kingdom; Division of Cancer Studies, King's College London, London, United Kingdom
| | - Judith C W Marsh
- Department of Haematology, King's College Hospital NHS Foundation Trust, London, United Kingdom; Division of Cancer Studies, King's College London, London, United Kingdom.
| | - Linda D Barber
- Division of Cancer Studies, King's College London, London, United Kingdom.
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