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Lendrum EC, Smart LR, Vukovic AA. Pancytopenia in the Emergency Department. J Pediatr 2024; 272:114111. [PMID: 38768892 DOI: 10.1016/j.jpeds.2024.114111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 05/07/2024] [Accepted: 05/15/2024] [Indexed: 05/22/2024]
Affiliation(s)
- Elizabeth C Lendrum
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
| | - Luke R Smart
- Division of Hematology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Global Health Center, Cincinnati Childrens Hospital Medical Center, Cincinnati, OH
| | - Adam A Vukovic
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
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Shimano KA, Rothman JA, Allen SW, Castillo P, de Jong JLO, Dror Y, Geddis AE, Lau BW, McGuinn C, Narla A, Overholt K, Pereda MA, Sharathkumar A, Sasa G, Nakano TA, Myers K, Gloude NJ, Broglie L, Boklan J. Treatment of newly diagnosed severe aplastic anemia in children: Evidence-based recommendations. Pediatr Blood Cancer 2024; 71:e31070. [PMID: 38757488 DOI: 10.1002/pbc.31070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 04/27/2024] [Accepted: 04/29/2024] [Indexed: 05/18/2024]
Abstract
Severe aplastic anemia (SAA) is a rare potentially fatal hematologic disorder. Although overall outcomes with treatment are excellent, there are variations in management approach, including differences in treatment between adult and pediatric patients. Certain aspects of treatment are under active investigation in clinical trials. Because of the rarity of the disease, some pediatric hematologists may have relatively limited experience with the complex management of SAA. The following recommendations reflect an up-to-date evidence-based approach to the treatment of children with newly diagnosed SAA.
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Affiliation(s)
- Kristin A Shimano
- Department of Pediatrics, Division of Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco Benioff Children's Hospital, San Francisco, California, USA
| | - Jennifer A Rothman
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Duke University Medical Center, Durham, North Carolina, USA
| | - Steven W Allen
- Department of Pediatrics, Pediatric Hematology/Oncology, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Paul Castillo
- Department of Pediatrics, Division of Pediatric Hematology Oncology, UF Health Shands Children's Hospital, Gainesville, Florida, USA
| | - Jill L O de Jong
- Department of Pediatrics, Section of Hematology/Oncology/Stem Cell Transplantation, University of Chicago, Chicago, Illinois, USA
| | - Yigal Dror
- Department of Pediatrics, Marrow Failure and Myelodysplasia Program, Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Canada
| | - Amy E Geddis
- Department of Pediatrics, Cancer and Blood Disorders Center, Seattle Children's Hospital, Seattle, Washington, USA
| | - Bonnie W Lau
- Department of Pediatrics, Pediatric Hematology-Oncology, Dartmouth-Hitchcock, Lebanon, New Hampshire, USA
| | - Catherine McGuinn
- Department of Pediatrics, Division of Pediatric Hematology Oncology, Weill Cornell Medicine, New York, New York, USA
| | - Anupama Narla
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Kathleen Overholt
- Department of Pediatrics, Pediatric Hematology/Oncology, Riley Hospital for Children at Indiana University, Indianapolis, Indiana, USA
| | - Maria A Pereda
- Department of Pediatrics, Center for Cancer and Blood Disorders, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Anjali Sharathkumar
- Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Ghadir Sasa
- Sarah Cannon Transplant and Cellular Therapy Network, San Antonio, Texas, USA
| | - Taizo A Nakano
- Department of Pediatrics, Center for Cancer and Blood Disorders, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Kasiani Myers
- Department of Pediatrics, University of Cincinnati College of Medicine, Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Nicholas J Gloude
- Department of Pediatrics, University of California San Diego, Rady Children's Hospital, San Diego, California, USA
| | - Larisa Broglie
- Department of Pediatric Hematology/Oncology/Blood and Marrow Transplantation, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jessica Boklan
- Department of Pediatrics, Center for Cancer and Blood Disorders, Phoenix Children's Hospital, Phoenix, Arizona, USA
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Sharathkumar A, Carr J, Claassen D, Syrbu S, Bhagavathi S, Al-Huniti A, Modi A, Bates M, Mott SL. Romiplostim for Treatment of Children and Young Adults With Severe Aplastic Anemia and Myelodysplastic Syndrome. J Pediatr Hematol Oncol 2024; 46:252-261. [PMID: 38787686 DOI: 10.1097/mph.0000000000002891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 04/23/2024] [Indexed: 05/26/2024]
Abstract
Thrombopoietin receptor agonists (TPO-RAs) induce trilineage hematopoiesis under conditions with acquired hematopoietic failure. We evaluated safety, tolerability, and preliminary efficacy of a TPO-RA, romiplostim (Nplate), with or without standard-of-care immunosuppressive therapy (±IST) for children (ages < 21 y) with newly diagnosed and relapsed/refractory severe aplastic anemia (SAA) and myelodysplastic syndrome (MDS). Data were collected from an observational study and a single arm interventional pilot study. The safety outcome was treatment-related adverse events (AEs). Efficacy was evaluated by complete hematopoietic response (CHR) at week 24. Romiplostim was commenced at 5 µg/kg/week, with dose escalation of 2.5 µg/kg/week (maximum, 20 µg/kg/dose) based on platelet response. Romiplostim was continued until CHR was observed. Ten subjects (SAA, 9 [IST, 4; without IST, 5]; MDS, 1) completed the study (median age: 9.2 y). Median romiplostim dose was 10 µg/kg/week (range: 5 to 17.5 µg/kg/week). The cumulative incidence of CHR was 70.4% (95% CI, 20.2%-92.6%). Among 21 AEs (Grade 1 to 3), 3 were attributed to romiplostim. At a median posttherapy follow-up of 10.9 months (range: 0.7 to 77.5), no clonal evolution, bone marrow fibrosis or mortality was reported. This proof-of-concept study provides data about short-term safety, tolerability, and preliminary efficacy of romiplostim (±IST) for treatment of pediatric SAA/MDS.
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Affiliation(s)
- Anjali Sharathkumar
- Stead Family Department of Pediatrics, Carver College of Medicine
- Holden Comprehensive Cancer Center
| | - Jamie Carr
- Institute for Clinical and Translational Science
| | - David Claassen
- Stead Family Department of Pediatrics, Carver College of Medicine
| | - Sergei Syrbu
- Department of Pathology, University of Iowa, Iowa City, IA
| | | | - Ahmad Al-Huniti
- Department of Pediatrics, Mayo Clinic, Hematology, Rochester, MN
| | - Arunkumar Modi
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Melissa Bates
- Holden Comprehensive Cancer Center
- Department of Health and Human Physiology
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA
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Fox LC, McQuilten ZK, Firkin F, Fox V, Badoux X, Bajel A, Barbaro P, Cole-Sinclair MF, Forsyth C, Gibson J, Hiwase DK, Johnston A, Mills A, Roncolato F, Sutherland R, Szer J, Ting SB, Vilcassim S, Young L, Waters NA, Wood EM. The Australian Aplastic Anaemia and other Bone Marrow Failure Syndromes Registry. Best Pract Res Clin Haematol 2023; 36:101516. [PMID: 38092475 DOI: 10.1016/j.beha.2023.101516] [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: 08/14/2023] [Accepted: 09/14/2023] [Indexed: 12/18/2023]
Abstract
The bone marrow failure syndromes (BMFS) are a diverse group of acquired and inherited diseases which may manifest in cytopenias, haematological malignancy and/or syndromic multisystem disease. Patients with BMFS frequently experience poor outcomes, and improved treatment strategies are needed. Collation of clinical characteristics and patient outcomes in a national disease-specific registry represents a powerful tool to identify areas of need and support clinical and research collaboration. Novel treatment strategies such as gene therapy, particularly in rare diseases, will depend on the ability to identify eligible patients alongside the molecular genetic features of their disease that may be amenable to novel therapy. The Australian Aplastic Anaemia and other Bone Marrow Failure Syndromes Registry (AAR) aims to improve outcomes for all paediatric and adult patients with BMFS in Australia by describing the demographics, treatments (including supportive care) and outcomes, and serving as a resource for research and practice improvement.
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Affiliation(s)
- Lucy C Fox
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Peter MacCallum Cancer Centre, Melbourne, Australia; Austin Health, Melbourne, Australia
| | - Zoe K McQuilten
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Monash Health, Melbourne, Australia
| | | | - Vanessa Fox
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | | | - Ashish Bajel
- Peter MacCallum Cancer Centre, Melbourne, Australia; The Royal Melbourne Hospital, Melbourne, Australia
| | | | - Merrole F Cole-Sinclair
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; St Vincent's Hospital, Melbourne, Australia
| | | | - John Gibson
- Royal Prince Alfred Hospital, Sydney, Australia
| | | | | | | | | | - Robyn Sutherland
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Jeff Szer
- Peter MacCallum Cancer Centre, Melbourne, Australia; The Royal Melbourne Hospital, Melbourne, Australia
| | - Stephen B Ting
- Eastern Health, Melbourne, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Australia
| | - Shahla Vilcassim
- Monash Health, Melbourne, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Australia
| | - Lauren Young
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Neil A Waters
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Erica M Wood
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Peter MacCallum Cancer Centre, Melbourne, Australia; Monash Health, Melbourne, Australia.
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5
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Aplastic Anemia as a Roadmap for Bone Marrow Failure: An Overview and a Clinical Workflow. Int J Mol Sci 2022; 23:ijms231911765. [PMID: 36233062 PMCID: PMC9569739 DOI: 10.3390/ijms231911765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 09/27/2022] [Accepted: 09/28/2022] [Indexed: 11/27/2022] Open
Abstract
In recent years, it has become increasingly apparent that bone marrow (BM) failures and myeloid malignancy predisposition syndromes are characterized by a wide phenotypic spectrum and that these diseases must be considered in the differential diagnosis of children and adults with unexplained hematopoiesis defects. Clinically, hypocellular BM failure still represents a challenge in pathobiology-guided treatment. There are three fundamental topics that emerged from our review of the existing data. An exogenous stressor, an immune defect, and a constitutional genetic defect fuel a vicious cycle of hematopoietic stem cells, immune niches, and stroma compartments. A wide phenotypic spectrum exists for inherited and acquired BM failures and predispositions to myeloid malignancies. In order to effectively manage patients, it is crucial to establish the right diagnosis. New theragnostic windows can be revealed by exploring BM failure pathomechanisms.
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Hendricks CL, Naidoo A, Thejpal R, Rapiti N, Neethling B, Goga Y, Buldeo S. Childhood aplastic anaemia with paroxysmal nocturnal haemoglobinuria clones: A retrospective single-centre study in South Africa. Afr J Lab Med 2022; 11:1537. [PMID: 35811748 PMCID: PMC9257717 DOI: 10.4102/ajlm.v11i1.1537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 03/10/2022] [Indexed: 11/01/2022] Open
Abstract
Background: Paroxysmal nocturnal haemoglobinuria (PNH) clones in children are rare but commonly associated with aplastic anaemia (AA) and myelodysplasia.Objective: This study aimed to determine the prevalence of PNH clones in paediatric patients with idiopathic AA, identify differences in clinical and laboratory features and outcomes, and determine the impact of clone size on clinical presentation.Methods: Patients with confirmed idiopathic AA who were tested for PNH between September 2013 and January 2018 at the Inkosi Albert Luthuli Central Hospital, Durban, KwaZulu-Natal, South Africa, were included. PNH clones were detected in neutrophils and monocytes by flow cytometry using fluorescent aerolysin, CD24, CD66b and CD14.Results: Twenty-nine children with AA were identified and 11 were excluded. Ten patients (10/18, 55.6%) had PNH clones ranging from 0.11% to 24%. Compared to the PNH-negative group, these children were older (median: 10 years vs 4 years, p = 0.02) and had significantly lower total white cell counts (median 1.7 × 109/L vs 3.2 × 109/L; p = 0.04). There was no difference in median absolute neutrophil count or haemoglobin concentration. Four patients in each group received immunosuppressive therapy (IST). At six months, all four patients with PNH clones had responded, compared to one in the PNH-negative group.Conclusion: More than half of children with AA had a PNH clone. The size of the clone did not impact clinical severity; however, IST use may positively impact prognosis. We recommend early initiation of IST in patients with AA to avoid delays associated with human leukocyte antigen typing.
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Affiliation(s)
- Candice L Hendricks
- Department of Paediatric Haematology, Faculty of Health Sciences, School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- Department of Paediatric Haematology, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - Ashen Naidoo
- Department of Haematology, Faculty of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
- National Health Laboratory Service, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - Rajendra Thejpal
- Department of Paediatric Haematology, Faculty of Health Sciences, School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- Department of Paediatric Haematology, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - Nadine Rapiti
- Department of Haematology, Faculty of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
- National Health Laboratory Service, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - Beverley Neethling
- Department of Paediatric Haematology, Faculty of Health Sciences, School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- Department of Paediatric Haematology, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - Yasmin Goga
- Department of Paediatric Haematology, Faculty of Health Sciences, School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- Department of Paediatric Haematology, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - Suvarna Buldeo
- Department of Haematology, Faculty of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
- National Health Laboratory Service, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
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Shimano KA, Narla A, Rose MJ, Gloude NJ, Allen SW, Bergstrom K, Broglie L, Carella BA, Castillo P, Jong JLO, Dror Y, Geddis AE, Huang JN, Lau BW, McGuinn C, Nakano TA, Overholt K, Rothman JA, Sharathkumar A, Shereck E, Vlachos A, Olson TS, Bertuch AA, Wlodarski MW, Shimamura A, Boklan J. Diagnostic work-up for severe aplastic anemia in children: Consensus of the North American Pediatric Aplastic Anemia Consortium. Am J Hematol 2021; 96:1491-1504. [PMID: 34342889 DOI: 10.1002/ajh.26310] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 07/26/2021] [Accepted: 07/27/2021] [Indexed: 12/19/2022]
Abstract
The North American Pediatric Aplastic Anemia Consortium (NAPAAC) is a group of pediatric hematologist-oncologists, hematopathologists, and bone marrow transplant physicians from 46 institutions in North America with interest and expertise in aplastic anemia, inherited bone marrow failure syndromes, and myelodysplastic syndromes. The NAPAAC Bone Marrow Failure Diagnosis and Care Guidelines Working Group was established with the charge of harmonizing the approach to the diagnostic workup of aplastic anemia in an effort to standardize best practices in the field. This document outlines the rationale for initial evaluations in pediatric patients presenting with signs and symptoms concerning for severe aplastic anemia.
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Affiliation(s)
- Kristin A. Shimano
- Department of Pediatrics University of California San Francisco Benioff Children's Hospital San Francisco California USA
| | - Anupama Narla
- Department of Pediatrics Stanford University School of Medicine Stanford California USA
| | - Melissa J. Rose
- Division of Hematology, Oncology, and Bone Marrow Transplant Nationwide Children's Hospital, The Ohio State University College of Medicine Columbus Ohio USA
| | - Nicholas J. Gloude
- Department of Pediatrics University of California San Diego, Rady Children's Hospital San Diego California USA
| | - Steven W. Allen
- Pediatric Hematology/Oncology University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh Pittsburgh Pennsylvania USA
| | - Katie Bergstrom
- Cancer and Blood Disorders Center Seattle Children's Hospital Seattle Washington USA
| | - Larisa Broglie
- Department of Pediatric Hematology, Oncology, Blood and Marrow Transplantation Medical College of Wisconsin Milwaukee Wisconsin USA
| | - Beth A. Carella
- Department of Pediatrics Kaiser Permanente Washington District of Columbia USA
| | - Paul Castillo
- Division of Pediatric Hematology Oncology UF Health Shands Children's Hospital Gainesville Florida USA
| | - Jill L. O. Jong
- Section of Hematology‐Oncology, Department of Pediatrics University of Chicago Chicago Illinois USA
| | - Yigal Dror
- Marrow Failure and Myelodysplasia Program, Division of Hematology and Oncology, Department of Paediatrics The Hospital for Sick Children Toronto Ontario Canada
| | - Amy E. Geddis
- Cancer and Blood Disorders Center Seattle Children's Hospital Seattle Washington USA
| | - James N. Huang
- Department of Pediatrics University of California San Francisco Benioff Children's Hospital San Francisco California USA
| | - Bonnie W. Lau
- Pediatric Hematology‐Oncology Dartmouth‐Hitchcock Lebanon New Hampshire USA
| | - Catherine McGuinn
- Department of Pediatrics Weill Cornell Medicine New York New York USA
| | - Taizo A. Nakano
- Center for Cancer and Blood Disorders Children's Hospital Colorado Aurora Colorado USA
| | - Kathleen Overholt
- Pediatric Hematology and Oncology Riley Hospital for Children at Indiana University Indianapolis Indiana USA
| | - Jennifer A. Rothman
- Division of Pediatric Hematology and Oncology Duke University Medical Center Durham North Carolina USA
| | - Anjali Sharathkumar
- Stead Family Department of Pediatrics University of Iowa Carver College of Medicine Iowa City Iowa USA
| | - Evan Shereck
- Department of Pediatrics Oregon Health and Science University Portland Oregon USA
| | - Adrianna Vlachos
- Hematology, Oncology and Cellular Therapy Cohen Children's Medical Center New Hyde Park New York USA
| | - Timothy S. Olson
- Cell Therapy and Transplant Section, Division of Oncology and Bone Marrow Failure, Division of Hematology, Department of Pediatrics Children's Hospital of Philadelphia and University of Pennsylvania Philadelphia Pennsylvania USA
| | | | | | - Akiko Shimamura
- Cancer and Blood Disorders Center Boston Children's Hospital and Dana Farber Cancer Institute Boston Massachusetts USA
| | - Jessica Boklan
- Center for Cancer and Blood Disorders Phoenix Children's Hospital Phoenix Arizona USA
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Schneider KW, Suttman A, McKinney C, Giller R, Dollerschell K, Nakano TA. Incorporating genetic counseling into the evaluation of pediatric bone marrow failure. J Genet Couns 2021; 31:433-446. [PMID: 34570941 DOI: 10.1002/jgc4.1510] [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: 01/23/2021] [Revised: 08/30/2021] [Accepted: 09/04/2021] [Indexed: 11/10/2022]
Abstract
The timely identification of germline genetic causes of pediatric bone marrow failure (BMF) impacts medical screening practices, family counseling, therapeutic decision-making, and risk of progression to myelodysplastic syndrome (MDS) or acute myeloid leukemia (AML). At diagnosis, treatment decisions need to be made quickly to mitigate risks associated with profound cytopenias. As genetic testing options are rapidly evolving, an efficient multi-disciplinary approach and algorithm, including early involvement of a genetics team, is needed to expedite diagnosis and therapeutic decision-making. This process aids in the identification of appropriate candidates for molecular genetic testing. We present our single center experience reviewing the implementation of genetic counseling and a diagnostic and therapeutic algorithm used to guide genetic evaluation of pediatric BMF. Disease-specific next-generation sequencing (NGS) panels were most often pursued in patients who presented with a clinical phenotype consistent with a known inherited BMF syndrome and when trying to reduce incidental or uninformative results. Broader BMF NGS panels were most often utilized when unable to narrow the suspected etiology to a single disorder. Whole exome sequencing helped with optimizing treatment decision-making in higher risk children with BMF who required expedited hematopoietic stem cell transplantation. The experience has led to improvements to our process for evaluating patients with BMF.
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Affiliation(s)
- Kami Wolfe Schneider
- Department of Pediatrics, Section of Hematology, Oncology and Bone Marrow Transplantation, University of Colorado, Aurora, CO, USA
| | - Alexandra Suttman
- Department of Pediatrics, Section of Hematology, Oncology and Bone Marrow Transplantation, University of Colorado, Aurora, CO, USA
| | - Christopher McKinney
- Department of Pediatrics, Section of Hematology, Oncology and Bone Marrow Transplantation, University of Colorado, Aurora, CO, USA
| | - Roger Giller
- Department of Pediatrics, Section of Hematology, Oncology and Bone Marrow Transplantation, University of Colorado, Aurora, CO, USA
| | - Kaylee Dollerschell
- Department of Pediatrics, Section of Hematology, Oncology and Bone Marrow Transplantation, University of Colorado, Aurora, CO, USA
| | - Taizo A Nakano
- Department of Pediatrics, Section of Hematology, Oncology and Bone Marrow Transplantation, University of Colorado, Aurora, CO, USA
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Lesmana H, Jacobs T, Boals M, Gray N, Lewis S, Ding J, Kang G, Hale M, Weiss M, Reiss U, Wang W, Wlodarski M. Eltrombopag in children with severe aplastic anemia. Pediatr Blood Cancer 2021; 68:e29066. [PMID: 33855784 DOI: 10.1002/pbc.29066] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 03/04/2021] [Accepted: 03/22/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND Immunosuppressive therapy with horse antithymocyte globulin and cyclosporine currently remains the standard therapy for children with severe aplastic anemia (SAA) who lack human leukocyte antigen (HLA)-identical sibling. The thrombopoietin receptor agonist eltrombopag has been recently approved for SAA patients 2 years and older. However, there are limited data on its safety and efficacy in pediatric cohorts. METHODS We conducted a retrospective study of patients ≤18 years old consecutively diagnosed with SAA between 2000 and 2018. Patients received either standard immunosuppressive therapy (IST-Std) or IST with eltrombopag (IST-Epag). The primary outcome was the objective response (OR), including partial and complete response (CR), at 6 and 12 months after starting therapy. RESULTS We identified 16 patients receiving IST-Std and nine IST-Epag treatment (seven of nine as upfront therapy and two of seven after previously failed IST). The OR at 6 and 12 months in IST-Std arm was 71% and 100%, with CR in 29% and 58%, respectively. Seven patients receiving upfront IST-Epag had OR at 6 and 12 months, with two of seven (29%) achieving CR at 6 and 12 months. Two patients who previously failed standard IST did not respond to eltrombopag. No significant differences were observed in both cohorts with regard to infections. One IST-Epag-treated patient developed transient grade 3 transaminitis. Finally, no changes in paroxysmal nocturnal hemoglobinuria (PNH) clone size and cytogenetic abnormalities were seen in either cohort. CONCLUSION The addition of eltrombopag to standard IST was well tolerated and resulted in satisfactory hematological response at 6 and 12 months in this single-institution experience. A larger cohort with longer follow-up is required to assess response durability.
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Affiliation(s)
- Harry Lesmana
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA.,Department of Pediatric Hematology, Oncology and Bone Marrow Transplantation, Cleveland Clinic, Cleveland, Ohio, USA
| | - Timothy Jacobs
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Michelle Boals
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Nathan Gray
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Sara Lewis
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Juan Ding
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Guolian Kang
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Melvanique Hale
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Mitchell Weiss
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Ulrike Reiss
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Winfred Wang
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Marcin Wlodarski
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
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10
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Atypical Outcomes for Hepatitis-associated Acquired Aplastic Anemia: 2 Case Studies and Review of the Literature. J Pediatr Hematol Oncol 2021; 43:195-199. [PMID: 32815884 DOI: 10.1097/mph.0000000000001916] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 07/09/2020] [Indexed: 11/26/2022]
Abstract
There is little data specifically dedicated to the long-term outcomes of the hepatitis-associated variant of aplastic anemia (HAAA). A majority of patients with nonsevere (moderate) aplastic anemia progress to severe aplastic anemia, and severe aplastic anemia typically results in death if left untreated. We present 2 unique cases of HAAA that contribute to our knowledge of the natural history of this disease variant. One patient had moderate HAAA that never progressed to severe disease. The second patient had severe HAAA that spontaneously resolved without treatment. The rare possibility of moderate HAAA failing to progress to fulfill severe criteria, or of severe HAAA spontaneously improving, may complicate early treatment decisions for some patients.
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11
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Efficacy of Rabbit Antithymocyte Globulin as a First-line Therapy in Children With Aplastic Anemia. J Pediatr Hematol Oncol 2020; 42:e702-e706. [PMID: 32969848 DOI: 10.1097/mph.0000000000001885] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND The efficacy, safety, and outcome of rabbit antihuman thymocyte globulin (rATG) as initial therapy for children aplastic anemia (AA) were evaluated. PATIENTS AND METHODS Sixty-one children with AA were retrospectively analyzed, including 43 patients with severe AA and 18 patients with transfusion-dependent nonsevere AA. All patients received rATG in combination with cyclosporine A between September 2005 and January 2015. RESULTS The overall response rates were 55.7%, 68.9%, and 68.9% at 6, 12, and 18 months, respectively. Surprisingly, the overall complete response rate kept increasing from 9.8% at 12 months to 39.3% at 18 months, indicating a delayed response for rATG. Overall survival at 5 and 10 years was 72.1% and 67.2%, respectively. The overall survival of patients who responded between 3 and 12 months was significantly higher than that of nonresponders (71.4% vs. 47.4%).Antithymocyte globulin-related adverse reactions were significantly higher in severe AA (83.7%) than in nonsevere AA (55.6%) and these reactions were controllable and not life threatening with comprehensive measures. CONCLUSIONS This retrospective study shows an encouraging response and survival results in children with AA treated with rATG. Prolonged assessments were needed to evaluate the delayed responses to rATG. rATG could be used as an alternative in the first-line treatment of childhood AA.
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12
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Pulsipher MA, Lehmann LE, Bertuch AA, Sasa G, Olson T, Nakano T, Gilio A, Burroughs LM, Lipton JM, Huang JN, Dickerson KE, Bertaina A, Zhuang C, Malsch M, Fleming M, Weller E, Shimamura A, Williams DA. A study assessing the feasibility of randomization of pediatric and young adult patients between matched unrelated donor bone marrow transplantation and immune-suppressive therapy for newly diagnosed severe aplastic anemia: A joint pilot trial of the North American Pediatric Aplastic Anemia Consortium and the Pediatric Transplantation and Cellular Therapy Consortium. Pediatr Blood Cancer 2020; 67:e28444. [PMID: 32776425 PMCID: PMC9533334 DOI: 10.1002/pbc.28444] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 05/07/2020] [Accepted: 05/13/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Recent data show survival after matched unrelated donor (MUD) bone marrow transplantation (BMT) is similar to matched sibling procedures for young patients with severe aplastic anemia (SAA). Donor delays, risk of transplant-related mortality (TRM), and concern about chronic graft versus host disease raise questions about whether MUD BMT or immune suppression therapy (IST) should be preferred initial therapy for young patients lacking matched sibling donors. PROCEDURE We performed a pilot trial to assess the feasibility of randomizing patients under age 26 with newly diagnosed SAA to receive IST versus MUD BMT. Primary aims assessed the acceptability of randomization and timing of BMT. Secondary aims measured toxicities, response, and survival. RESULTS Sixty-seven patients with possible SAA were screened at nine centers. Of 57 with confirmed SAA, 23 underwent randomization and received therapy with a median follow-up of 18 months. Of 12 randomized to BMT, 10 started BMT as initial therapy at a median of 36 days after randomization. One BMT recipient experienced secondary graft failure, requiring a second procedure. Six of 11 randomized to IST responded, whereas five with refractory disease underwent successful salvage BMT. One patient achieving complete response relapsed after discontinuation of immune suppression and died of infection after salvage BMT. CONCLUSIONS This feasibility study showed that a high percentage of patients underwent randomization and received up-front MUD BMT. Our study lays the groundwork for a larger randomized trial that will define best initial therapy for young patients with SAA who have an available MUD.
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Affiliation(s)
- Michael A. Pulsipher
- Cancer and Blood Disease Institute, Children’s Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Leslie E. Lehmann
- Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Alison A. Bertuch
- Baylor College of Medicine, Center for Cell and Gene Therapy and Texas Children’s Hospital, Houston, Texas
| | - Ghadir Sasa
- Baylor College of Medicine, Center for Cell and Gene Therapy and Texas Children’s Hospital, Houston, Texas
| | - Timothy Olson
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | | | - Lauri M. Burroughs
- Fred Hutchinson Cancer Research Center and the University of Washington School of Medicine, Seattle, Washington
| | - Jeffrey M. Lipton
- Division of Hematology/Oncology and Cellular Therapy, Cohen Children’s Medical Center of New York, New York
| | - James N. Huang
- UCSF Benioff Children’s Hospital and University of California, San Francisco, California
| | | | - Alice Bertaina
- Division of Stem Cell Transplantation and Regenerative Medicine, Department of Pediatrics, Stanford School of Medicine, Stanford, California
| | - Cindy Zhuang
- Cancer and Blood Disease Institute, Children’s Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Maggie Malsch
- Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Mark Fleming
- Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Edie Weller
- Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Akiko Shimamura
- Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - David A. Williams
- Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts
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13
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Zhao J, Song Y, Liu L, Yang S, Fang B. Effect of arsenic trioxide on the Tregs ratio and the levels of IFN-γ, IL-4, IL-17 and TGF-β1 in the peripheral blood of severe aplastic anemia patients. Medicine (Baltimore) 2020; 99:e20630. [PMID: 32590737 PMCID: PMC7329005 DOI: 10.1097/md.0000000000020630] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Previous studies have suggested that the anticancer agent, arsenic trioxide (ATO), could attenuate T cell mediated immunity by not only inhibiting the proliferative response of T cells but by also increasing the frequency of regulatory T cells (Tregs). Furthermore, ATO represents a reasonable salvage treatment in some patients with refractory severe aplastic anemia (SAA). The current study aimed to evaluate the function of ATO on the Tregs percentage and cytokines changes in the peripheral blood mononuclear cells (PBMCs) of SAA patients.PBMCs were collected from 20 newly diagnosed SAA patients in Henan Cancer Hospital and treated with different concentrations of ATO (0, 1, 2.5, and 5 μmol/L). Then we investigated the efficacy of ATO on Tregs ratio and the levels of interferon (IFN)-γ, interleukin (IL)-4, IL-17 and transforming growth factor (TGF)-β1 in the peripheral blood of SAA patients in vitro.The results showed that ATO significantly increased the proportion of Tregs (P < .001) at 2.5 and 5 μmol/L concentrations, and the proportion of Tregs was increased with increasing ATO concentration (r = 0.524). At 1 (P = .03), 2.5 (P < .001) and 5 μmol/L (P < .001), ATO significantly up-regulated the expression levels of Foxp3 mRNA, which was positively and linearly correlated with the increase of Tregs cell-frequency (r = 0.52, 95%CI, 0.37-0.67). In addition, ATO significantly reduced the levels of IFN-γ (at 1, 2.5 and 5 μmol/L, P < .001), IL-4 (at 2.5 μmol/L, P = .009; at 5 μmol/L, P < .001), and IL-17 (at 2.5, P = .016; at 5 μmol/L, P < .001). ATO significantly reduced the levels of TGF-β1 at 5 μmol/L (P = .03), but showed no significant effects at 1 and 2.5 μmol/L (P > .05).ATO could mediate the immune regulation, which might contribute to improve hematopoietic recovery in SAA patients.
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14
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Fox LC, Ritchie DS. Pediatric aplastic anemia treatment patterns and responses; power in the numbers. Haematologica 2020; 104:1909-1912. [PMID: 31575670 DOI: 10.3324/haematol.2019.225870] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- Lucy C Fox
- Diagnostic Haematology, Peter MacCallum Cancer Centre.,University of Melbourne
| | - David S Ritchie
- University of Melbourne.,Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, Australia
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15
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Fox LC, Wood EM, Ritchie DS, Blombery P. Diagnostic evaluation and considerations in hypocellular bone marrow failure—A focus on genomics. Int J Lab Hematol 2020; 42 Suppl 1:82-89. [DOI: 10.1111/ijlh.13179] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 02/09/2020] [Accepted: 02/11/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Lucy C. Fox
- Peter MacCallum Cancer Centre Melbourne Vic. Australia
- University of Melbourne Melbourne Vic. Australia
- Transfusion Research Unit Monash University Melbourne Vic. Australia
| | - Erica M. Wood
- Transfusion Research Unit Monash University Melbourne Vic. Australia
- Monash Health Melbourne Vic. Australia
| | - David S. Ritchie
- Peter MacCallum Cancer Centre Melbourne Vic. Australia
- University of Melbourne Melbourne Vic. Australia
| | - Piers Blombery
- Peter MacCallum Cancer Centre Melbourne Vic. Australia
- University of Melbourne Melbourne Vic. Australia
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16
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Alqahtany FS. Idiopathic Aplastic Anemia in Children and Adults: Diagnosis, Treatments, and Management - A Review. Curr Pharm Biotechnol 2019; 21:1282-1288. [PMID: 31820683 DOI: 10.2174/1389201021666191210141426] [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: 06/11/2019] [Revised: 07/12/2019] [Accepted: 07/18/2019] [Indexed: 11/22/2022]
Abstract
Aplastic Anemia (AA) is also known as idiopathic aplastic anemia (IAA) and the production of new blood cells ceases in AA, which leads to an abnormal hematological syndrome such as pancytopenia and suppression of hypo-cellular bone marrow. The pathophysiology of AA in most cases is immune-mediated and is stimulated by type 1 cytotoxic T cells. Reliable early diagnostic tests of IAA are not yet available, therefore most of the cases are identified in advanced stages. Recently, abnormal immune response and hematopoietic cell deficiencies are defined genetically, such as in target cells of telomere repair gene mutations and by the dysregulation of T-cell activation pathways. Importantly, anti-thymocyte globulins and cyclosporine-associated immunosuppression are successful treatments for restoring blood cell production in most of the cases, however, clonal hematologic diseases remain challenging. In the current review, we have discussed the common practices in the treatment, pathophysiology, diagnosis, and management of AA.
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Affiliation(s)
- Fatmah S Alqahtany
- Department of Pathology, Hematopathology Unit, College of Medicine, King Saud University, King Saud University Medical City, Riyadh, Saudi Arabia
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17
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Zhu XF, He HL, Wang SQ, Tang JY, Han B, Zhang DH, Wu LQ, Wu DP, Li W, Xia LH, Zhu HL, Liu F, Shi HX, Zhang X, Zhou F, Hu JD, Fang JP, Chen XQ, Ye TZ, Liang YM, Jin J, Zhang FK. Current Treatment Patterns of Aplastic Anemia in China: A Prospective Cohort Registry Study. Acta Haematol 2019; 142:162-170. [PMID: 31091521 DOI: 10.1159/000499065] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 12/14/2018] [Indexed: 02/05/2023]
Abstract
Aplastic anemia (AA) is a hematologic disease characterized by pancytopenia and hypocellular bone marrow, potentially leading to chronic anemia, hemorrhage, and infection. The China Aplastic Anemia Committee and British Committee for Standards in Haematology guidelines recommend hematopoietic stem-cell transplantation (HSCT) or immunosuppressive therapy (IST) comprising antithymocyte globulin (ATG) with cyclosporine (CsA) as initial treatment for AA patients. With limited epidemiological data on the clinical management of AA in Asia, a prospective cohort registry study involving 22 AA treatment centers in China was conducted to describe the disease characteristics of newly diagnosed AA patients and investigate real-world treatment patterns and patient outcomes. Of 340 AA patients, 72.9, 12.6, and 3.5% were receiving IST, traditional Chinese medicine, and HSCT, respectively, at baseline; only 22.2% of IST-treated patients received guideline-recommended ATG with CsA initially. Almost all patients received supportive care (95.6%) as blood transfusion (97.8%), antibiotics (63.7%), and/or hematopoietic growth factors (58.2%). Overall, 64.8% achieved a partial or complete response, and 0.9% experienced relapse. No new safety concerns were identified; serious adverse events were largely unrelated to the treatment regimen. These results demonstrate the need to identify and minimize treatment barriers to standardize and align AA management in China with treatment guideline recommendations and further improve patient outcomes.
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Affiliation(s)
- Xiao-Fan Zhu
- Center for Pediatric Blood Disease, State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Hai-Long He
- Department of Hematology and Oncology, Soochow University Affiliated Children's Hospital, Suzhou, China
| | - Shun-Qing Wang
- Department of Hematology, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, China
| | - Jing-Yan Tang
- Department of Hematology and Oncology, Shanghai Children's Medical Center Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Bing Han
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Dong-Hua Zhang
- Department of Hematology, Tongji Hospital, Tongji Medical College Huazhong University of Science and Technology, Wuhan, China
| | - Li-Qiang Wu
- Department of Hematology, Zhejiang Provincial Hospital of Traditional Chinese Medicine, Hangzhou, China
| | - De-Pei Wu
- Department of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Wei Li
- Department of Hematology, The First Hospital of Jilin University, Changchun, China
| | - Ling-Hui Xia
- Department of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Huan-Ling Zhu
- Department of Hematology, West China Hospital, Sichuan University, Chengdu, China
| | - Feng Liu
- Department of Hematology, Xiyuan Hospital, Chinese Academy of Chinese Medicine Sciences, Beijing, China
| | - Hong-Xia Shi
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Xi Zhang
- Department of Hematology, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Fang Zhou
- Department of Hematology, Jinan Military General Hospital, Jinan, China
| | - Jian-Da Hu
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory on Hematology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Jian-Pei Fang
- Department of Pediatric Hematology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Xie-Qun Chen
- Department of Hematology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Tie-Zhen Ye
- Department of Pediatric Hematology, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Ying-Min Liang
- Department of Hematology, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Jie Jin
- Department of Hematology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Feng-Kui Zhang
- Department of Anemia Therapeutic Centre, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Tianjin, China,
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18
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Rogers ZR, Nakano TA, Olson TS, Bertuch AA, Wang W, Gillio A, Coates TD, Chawla A, Castillo P, Kurre P, Gamper C, Bennett CM, Joshi S, Geddis AE, Boklan J, Nalepa G, Rothman JA, Huang JN, Kupfer GM, Cada M, Glader B, Walkovich KJ, Thompson AA, Hanna R, Vlachos A, Malsch M, Weller EA, Williams DA, Shimamura A. Immunosuppressive therapy for pediatric aplastic anemia: a North American Pediatric Aplastic Anemia Consortium study. Haematologica 2019; 104:1974-1983. [PMID: 30948484 PMCID: PMC6886407 DOI: 10.3324/haematol.2018.206540] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 03/28/2019] [Indexed: 12/21/2022] Open
Abstract
Quality of response to immunosuppressive therapy and long-term outcomes for pediatric severe aplastic anemia remain incompletely characterized. Contemporary evidence to inform treatment of relapsed or refractory severe aplastic anemia for pediatric patients is also limited. The clinical features and outcomes for 314 children treated from 2002 to 2014 with immunosuppressive therapy for acquired severe aplastic anemia were analyzed retrospectively from 25 institutions in the North American Pediatric Aplastic Anemia Consortium. The majority of subjects (n=264) received horse anti-thymocyte globulin (hATG) plus cyclosporine (CyA) with a median 61 months follow up. Following hATG/CyA, 71.2% (95%CI: 65.3,76.6) achieved an objective response. In contrast to adult studies, the quality of response achieved in pediatric patients was high, with 59.8% (95%CI: 53.7,65.8) complete response and 68.2% (95%CI: 62.2,73.8) achieving at least a very good partial response with a platelet count ≥50×109L. At five years post-hATG/CyA, overall survival was 93% (95%CI: 89,96), but event-free survival without subsequent treatment was only 64% (95%CI: 57,69) without a plateau. Twelve of 171 evaluable patients (7%) acquired clonal abnormalities after diagnosis after a median 25.2 months (range: 4.3-71 months) post treatment. Myelodysplastic syndrome or leukemia developed in 6 of 314 (1.9%). For relapsed/refractory disease, treatment with a hematopoietic stem cell transplant had a superior event-free survival compared to second immunosuppressive therapy treatment in a multivariate analysis (HR=0.19, 95%CI: 0.08,0.47; P=0.0003). This study highlights the need for improved therapies to achieve sustained high-quality remission for children with severe aplastic anemia.
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Affiliation(s)
- Zora R Rogers
- Pediatric Hematology/Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Taizo A Nakano
- Center for Cancer and Blood Disorders, Department of Pediatrics, Children's Hospital Colorado and the University of Colorado School of Medicine, Aurora, CO, USA
| | | | | | - Winfred Wang
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Alfred Gillio
- Hackensack University Medical Center, Hackensack, NJ, USA
| | | | | | | | - Peter Kurre
- Oregon Health and Science University, Portland, OR, USA
| | | | | | - Sarita Joshi
- Nationwide Childrens Hospital, Columbus, OH, USA
| | | | - Jessica Boklan
- Center for Cancer and Blood Disorders, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Grzegorz Nalepa
- Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - James N Huang
- UCSF Benioff Children's Hospital, San Francisco, CA, USA
| | | | | | - Bertil Glader
- Stanford University School of Medicine, Palo Alto, CA, USA
| | | | | | | | | | - Maggie Malsch
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, MA, USA
| | - Edie A Weller
- Division of Hematology and Oncology and Biostatistics and Research Design Center of the Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, MA, USA
| | - David A Williams
- Boston Children's Hospital and Dana Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA, USA
| | - Akiko Shimamura
- Boston Children's Hospital and Dana Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA, USA
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19
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Noronha SA. Aplastic and Hypoplastic Anemias. Pediatr Rev 2018; 39:601-611. [PMID: 30504252 DOI: 10.1542/pir.2017-0250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Suzie A Noronha
- Division of Pediatric Hematology/Oncology, University of Rochester, Rochester, NY
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20
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Bercovitz RS, Josephson CD. Transfusion Considerations in Pediatric Hematology and Oncology Patients. Hematol Oncol Clin North Am 2016; 30:695-709. [DOI: 10.1016/j.hoc.2016.01.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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21
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Corey SJ. The Highs and Lows of Measuring Thrombopoietin in Aplastic Anemia. Pediatr Blood Cancer 2016; 63:585-6. [PMID: 26740061 DOI: 10.1002/pbc.25885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 11/12/2015] [Accepted: 11/12/2015] [Indexed: 11/09/2022]
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Affiliation(s)
- Richa Sharma
- Department of Pediatrics, Division of Pediatric Hematology-Oncology, Indiana University School of Medicine, Indianapolis, IN
| | - Grzegorz Nalepa
- Department of Pediatrics, Division of Pediatric Hematology-Oncology, Indiana University School of Medicine, Indianapolis, IN. Department of Medical and Molecular Genetics and Department of Biochemistry, Indiana University School of Medicine; Bone Marrow Failure Program, Riley Hospital for Children at IU Health, Indianapolis, IN
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23
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Babushok DV, Grignon A, Li Y, Atienza J, Xie HM, Lam H, Hartung H, Bessler M, Olson TS. Disrupted lymphocyte homeostasis in hepatitis-associated acquired aplastic anemia is associated with short telomeres. Am J Hematol 2016; 91:243-7. [PMID: 26615915 PMCID: PMC4724330 DOI: 10.1002/ajh.24256] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 11/24/2015] [Indexed: 12/13/2022]
Abstract
Hepatitis‐associated aplastic anemia (HAA) is a variant of acquired aplastic anemia (AA) in which immune‐mediated bone marrow failure (BMF) develops following an acute episode of seronegative hepatitis. Dyskeratosis congenita (DC) is an inherited BMF syndrome characterized by the presence of short telomeres, mucocutaneous abnormalities, and cancer predisposition. While both conditions may cause BMF and hepatic impairment, therapeutic approaches are distinct, making it imperative to establish the correct diagnosis. In clinical practice, lymphocyte telomere lengths (TL) are used as a first‐line screen to rule out inherited telomeropathies before initiating treatment for AA. To evaluate the reliability of TL in the HAA population, we performed a retrospective analysis of TL in 10 consecutively enrolled HAA patients compared to 19 patients with idiopathic AA (IAA). HAA patients had significantly shorter telomeres than IAA patients (P = 0.009), including four patients with TL at or below the 1st percentile for age‐matched controls. HAA patients had no clinical features of DC and did not carry disease‐causing mutations in known genes associated with inherited telomere disorders. Instead, short TLs were significantly correlated with severe lymphopenia and skewed lymphocyte subsets, features characteristic of HAA. Our results indicate the importance of caution in the interpretation of TL measurements in HAA, because, in this patient population, short telomeres have limited specificity. Am. J. Hematol. 91:243–247, 2016. © 2015 The Authors. American Journal of Hematology Published by Wiley Periodicals, Inc.
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Affiliation(s)
- Daria V. Babushok
- Comprehensive Bone Marrow Failure Center, Division of Hematology, Department of PediatricsChildren's Hospital of PhiladelphiaPhiladelphia Pennsylvania
- Division of Hematology–Oncology, Department of MedicineHospital of the University of PennsylvaniaPhiladelphia Pennsylvania
| | - Anne‐Laure Grignon
- Comprehensive Bone Marrow Failure Center, Division of Hematology, Department of PediatricsChildren's Hospital of PhiladelphiaPhiladelphia Pennsylvania
| | - Yimei Li
- Department of Biostatistics and EpidemiologyPerelman School of Medicine at the University of PennsylvaniaPhiladelphia Pennsylvania
| | - Jamie Atienza
- Comprehensive Bone Marrow Failure Center, Division of Hematology, Department of PediatricsChildren's Hospital of PhiladelphiaPhiladelphia Pennsylvania
| | - Hongbo M. Xie
- Division of Health and Biomedical InformaticsChildren's Hospital of PhiladelphiaPhiladelphia Pennsylvania
| | - Ho‐Sun Lam
- Comprehensive Bone Marrow Failure Center, Division of Hematology, Department of PediatricsChildren's Hospital of PhiladelphiaPhiladelphia Pennsylvania
| | - Helge Hartung
- Comprehensive Bone Marrow Failure Center, Division of Hematology, Department of PediatricsChildren's Hospital of PhiladelphiaPhiladelphia Pennsylvania
| | - Monica Bessler
- Comprehensive Bone Marrow Failure Center, Division of Hematology, Department of PediatricsChildren's Hospital of PhiladelphiaPhiladelphia Pennsylvania
| | - Timothy S. Olson
- Comprehensive Bone Marrow Failure Center, Division of Hematology, Department of PediatricsChildren's Hospital of PhiladelphiaPhiladelphia Pennsylvania
- Division of Oncology, Department of PediatricsChildren's Hospital of Philadelphia and University of PennsylvaniaPhiladelphia Pennsylvania
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Abstract
Fanconi anemia (FA) is a genetically and phenotypically heterogeneous disorder characterized by congenital malformations, progressive bone marrow failure, and predisposition to cancer, particularly hematological malignancies and solid tumors of the head and neck. The main role of FA proteins is in the repair of DNA interstrand crosslinks (ICLs). FA results from pathogenic variants in at least sixteen distinct genes, causing genomic instability. Although the highly variable phenotype makes accurate diagnosis on the basis of clinical manifestations difficult in some patients, diagnosis based on a profound sensitivity to DNA-crosslinking agents can be used to identify the pre-anemia patient as well as patients with aplastic anemia or leukemia who may or may not have the physical stigmata associated with the syndrome. Diepoxybutane (DEB) analysis is the preferred test for FA because other agents have higher rates of false-positive and false-negative results.
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Affiliation(s)
- Arleen D Auerbach
- Program in Human Genetics and Hematology, The Rockefeller University, New York, New York
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25
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Moderate-dose cyclophosphamide for severe aplastic anemia has significant toxicity and does not prevent relapse and clonal evolution. Blood 2014; 124:2820-3. [PMID: 25185712 DOI: 10.1182/blood-2014-05-573642] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
First-line therapy of severe aplastic anemia (SAA) with high-dose cyclophosphamide causes toxicity and increased short-term mortality. We investigated cyclophosphamide at a lower, more moderate dose in combination with aggressive supportive care to determine whether severe infections might be avoided and hematologic outcomes defined for this regimen. From 2010 to 2012, 22 patients received cyclophosphamide at 120 mg/kg plus cyclosporine and antibacterial, antiviral, and antifungal prophylaxis. Toxicity was considerable, mainly due to prolonged absolute neutropenia, which occurred regardless of pretherapy blood counts, and persisted an average of 2 months. Granulocyte transfusions for uncontrolled infection were required in 5 patients, confirmed fungal infections were documented in 6, and 9 patients died. Nine patients (41%) responded at 6 months. After a median follow-up of 2.2 years, relapse occurred in 2 patients, and cytogenetic abnormalities (including monosomy 7) were observed in 4 patients. Although cyclophosphamide has activity in SAA, its toxicity is not justified when far less dangerous alternatives are available. This trial was registered at www.clinicaltrials.gov as #NCT01193283.
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26
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Zierhut H, Schneider KW. Stem Cell Transplantation: Genetic Counselors as a Critical Part of the Process. CURRENT GENETIC MEDICINE REPORTS 2014. [DOI: 10.1007/s40142-014-0038-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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