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Chevillon F, Rebotier M, Dhédin N, Bruno B, Cacciatore C, Charbonier A, Joseph L, Le Bourgeois A, Talouarn M, Magro L, Barraud Lange V. [Fertility preservation and hematopoietic stem cell transplantation (SFGM-TC)]. Bull Cancer 2024:S0007-4551(24)00185-1. [PMID: 38918137 DOI: 10.1016/j.bulcan.2024.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 04/20/2024] [Accepted: 04/22/2024] [Indexed: 06/27/2024]
Abstract
Conditioning regimen prior to hematopoietic stem cell transplantation have an impact on patient fertility through the use of gonadal irradiation and/or bifunctional alkylating agents. Their impact on fertility depends mainly on the dose used and, in women, on age at the time of treatment. All patients should benefit before treatment from a consultation informing them of the potential impact on fertility and of fertility preservation techniques. In the absence of contraindications, the major toxicity of myeloablative conditioning regimen justifies fertility preservation. There are few data concerning fertility after reduced-intensity conditioning. Despite lower theoretical gonadotoxicity, we also recommend fertility preservation, if possible before transplantation. The fertility preservation techniques used depend on the patient's age, pathology and conditioning. In the event of subsequent use of harvested gonadal tissue in the context of acute leukemia or aggressive lymphoma, it is advisable to assess the risk of reintroduction of tumor cells. Finally, it is recommended to assess gonadal function after transplant, especially after reduced conditioning. If there is persistent residual gonadal function, post-treatment fertility preservation should be discuss.
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Affiliation(s)
- Florian Chevillon
- Service hématologie adolescents jeunes adultes, hôpital Saint-Louis, AP-HP, 1, avenue Claude-Vellefaux, 75010 Paris, France.
| | - Marine Rebotier
- Service oncogynécologie, centre Leon-Berard et IHOPe, 28, promenade Léa et Napoléon Bullukian, 69008 Lyon, France
| | - Nathalie Dhédin
- Service hématologie adolescents jeunes adultes, hôpital Saint-Louis, AP-HP, 1, avenue Claude-Vellefaux, 75010 Paris, France
| | - Bénédicte Bruno
- Service hématologie pédiatrique, hôpital Jeanne-de-Flandre, avenue Eugène-Avinée, 59037 Lille, France
| | - Carlotta Cacciatore
- Service de médecine interne, hôpital Saint-Louis, AP-HP, 1, avenue Claude-Vellefaux, 75010 Paris, France
| | | | - Laure Joseph
- Service hématologie, département de biothérapie, hôpital Necker-enfants malades, AP-HP, 149, rue de Sèvres, 75015 Paris, France
| | - Amandine Le Bourgeois
- Service d'hématologie, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France
| | - Marie Talouarn
- Service d'hématologie, hôpital Saint-Antoine, AP-HP, 184, rue du faubourg Saint-Antoine, 75012 Paris, France
| | - Leonardo Magro
- Service d'hématologie, CHU de Lille, 2, avenue Oscar-Lambret, 59000 Lille, France
| | - Virginie Barraud Lange
- Service hématologie adolescents jeunes adultes, hôpital Saint-Louis, AP-HP, 1, avenue Claude-Vellefaux, 75010 Paris, France; Service biologie de la reproduction, hôpital Cochin Port Royal, AP-HP, 123, boulevard de Port Royal, 75014 Paris, France
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2
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Mouthon L. [Autologous peripheral stem cell transplantation in systemic sclerosis: An important step forward, but we must temper our enthusiasm!]. Rev Med Interne 2024; 45:100-103. [PMID: 38238136 DOI: 10.1016/j.revmed.2024.01.001] [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] [Indexed: 02/12/2024]
Abstract
Three prospective randomized studies have demonstrated the efficacy of autologous hematopoietic stem cell (HSC) transplantation in systemic sclerosis (SSc) on survival. These results encourage us to offer this therapy to patients who have a rapidly progressive disease and who have early symptoms but no advanced visceral involvement. HSC autograft can thus be discussed in patients with diffuse cutaneous SSc with a duration of the disease since the first visceral manifestations (cutaneous, cardiac, digestive, pulmonary, or renal) excluding Raynaud's phenomenon of less than 5 years. However, the indications for HSC autograft in SSc validated at European level and in the national diagnostic and care protocol (PNDS) are broader and some of these indications are debatable, in particular in patients with worsening diffuse interstitial lung disease. These indications are discussed in a reasoned way, taking into account the level of evidence and the toxicity of the HSC autograft.
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Affiliation(s)
- L Mouthon
- Service de médecine interne, centre de référence maladies autoimmunes et autoinflammatoires systémiques rares d'Ile de France, de l'Est et de l'Ouest, hôpital Cochin, Assistance Publique-hôpitaux de Paris (AP-HP), hôpital Cochin, 27, rue du Faubourg Saint-Jacques, 75014 Paris, France; Université Paris Cité, AP-HP-CUP, Hôpital Cochin, 75014 Paris, France.
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3
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Mouthon L. [Autologous peripheral stem cell transplantation in systemic sclerosis: An important step forward, but we must temper our enthusiasm!]. Rev Med Interne 2023:S0248-8663(23)01297-3. [PMID: 38057166 DOI: 10.1016/j.revmed.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
Three prospective randomized studies have demonstrated the efficacy of autologous hematopoietic stem cell (HSC) transplantation in systemic sclerosis (SSc) on survival. These results encourage us to offer this therapy to patients who have a rapidly progressive disease and who have early symptoms but no advanced visceral involvement. HSC autograft can thus be discussed in patients with diffuse cutaneous SSc with a duration of the disease since the first visceral manifestations (cutaneous, cardiac, digestive, pulmonary, or renal) excluding Raynaud's phenomenon of less than 5 years. However, the indications for HSC autograft in SSc validated at European level and in the national diagnostic and care protocol (PNDS) are broader and some of these indications are debatable, in particular in patients with worsening diffuse interstitial lung disease. These indications are discussed in a reasoned way, taking into account the level of evidence and the toxicity of the HSC autograft.
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Affiliation(s)
- L Mouthon
- Service de médecine interne, centre de référence maladies auto-immunes systémiques rares d'Île-de-France, hôpital Cochin, Assistance publique-Hôpitaux de Paris (AP-HP), 27, rue du Faubourg Saint-Jacques, 75014 Paris, France; Hôpital Cochin, université Paris Cité, AP-HP - CUP, 75014 Paris, France.
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4
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Chillon TS, Weiss G, Demircan K, Minich WB, Schenk M, Schomburg L. Antibodies to SARS-CoV-2 in follicular fluids and their association with assisted reproduction. Front Immunol 2023; 14:1120328. [PMID: 37006276 PMCID: PMC10064043 DOI: 10.3389/fimmu.2023.1120328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 03/07/2023] [Indexed: 03/19/2023] Open
Abstract
IntroductionEvery second woman suffering from infertility asks for medical help. There is public concern that vaccination-induced antibodies (Ab) are negatively associated with fertility. A recent study has demonstrated an association between SARS-CoV-2 vaccination and a lower pregnancy rate in the subsequent 60 days. Consequently, Ab could affect fertility success in assisted reproduction.MethodsTo address this question, we compared fertilization outcomes of vaccinated (n=35) and nonvaccinated (n=34) women. Paired serum samples and multiple follicular fluids (FF) (up to 10 from the same donor) were collected during the course of assisted reproduction and characterized for oocyte quality, the presence of Ab and trace element concentrations.ResultsThe results showed a positive correlation of vaccination-induced neutralizing activity of SARS-CoV-2-Ab in serum and FF. On average, Ab concentrations in serum were higher than in the corresponding FF. However, wide variations in SARS-CoV-2 Ab titers were observed between different FF, correlating to trace element levels, even when retrieved from the same donor.DiscussionOverall, FF contents are highly variable, but no negative association was observed between Ab in serum or FF and fertilization success and oocyte development, supporting the safety of SARS-CoV-2 vaccination during assisted reproduction.
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Affiliation(s)
- Thilo Samson Chillon
- Cardiovascular-Metabolic-Renal (CMR)-Research Center, Institute for Experimental Endocrinology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Gregor Weiss
- Das Kinderwunsch Institut Schenk GmbH, Dobl, Austria
| | - Kamil Demircan
- Cardiovascular-Metabolic-Renal (CMR)-Research Center, Institute for Experimental Endocrinology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Waldemar B. Minich
- Cardiovascular-Metabolic-Renal (CMR)-Research Center, Institute for Experimental Endocrinology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Michael Schenk
- Das Kinderwunsch Institut Schenk GmbH, Dobl, Austria
- Department of Obstetrics and Gynecology, Medical University of Graz, Graz, Austria
- *Correspondence: Michael Schenk, ; Lutz Schomburg,
| | - Lutz Schomburg
- Cardiovascular-Metabolic-Renal (CMR)-Research Center, Institute for Experimental Endocrinology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- *Correspondence: Michael Schenk, ; Lutz Schomburg,
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5
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Hematopoietic Stem Cell Transplantation for the Treatment of Autoimmune Neurological Diseases: An Update. Bioengineering (Basel) 2023; 10:bioengineering10020176. [PMID: 36829670 PMCID: PMC9952685 DOI: 10.3390/bioengineering10020176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 01/24/2023] [Accepted: 01/26/2023] [Indexed: 01/31/2023] Open
Abstract
Over the last two decades, haematopoietic stem cell transplantation (HSCT) has been explored as a potential therapeutic strategy for autoimmune diseases refractory to conventional treatments, including neurological disorders. Although both autologous (AHSCT) and allogeneic HSCT (allo-HSCT) were investigated, AHSCT was preferentially developed due to a more favourable safety profile compared to allo-HSCT. Multiple sclerosis (MS) represents the most frequent neurological indication for AHSCT, but increasing evidence on the potential effectiveness of transplant in other autoimmune neurological diseases is emerging, although with a risk-benefit ratio overall more uncertain than in MS. In the present work, the rationale for the use of HSCT in neurological diseases and the experimental models that prompted its clinical application will be briefly covered. Case series and prospective studies exploring the use of HSCT in autoimmune diseases other than MS will be discussed, covering both frequent and rare neurological disorders such as myasthenia gravis, myopathies, and stiff-person syndrome. Finally, an updated summary of ongoing and future studies focusing on this issue will be provided.
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6
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Hematopoietic Cell Transplantation for Systemic Sclerosis-A Review. Cells 2022; 11:cells11233912. [PMID: 36497169 PMCID: PMC9739132 DOI: 10.3390/cells11233912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 11/18/2022] [Accepted: 11/25/2022] [Indexed: 12/12/2022] Open
Abstract
Systemic sclerosis (SSc) is an autoimmune, multi-organ, connective tissue disease associated with significant morbidity and mortality. Conventional immunosuppressive therapies demonstrate limited efficacy. Autologous hematopoietic stem cell transplantation (HCT) is more efficacious but carries associated risks, including treatment-related mortality. Here, we review HCT as a treatment for SSc, its efficacy and toxicity in comparison to conventional therapies, and the proposed mechanisms of action. Furthermore, we discuss the importance of and recent developments in patient selection. Finally, we highlight the knowledge gaps and future work required to further improve patient outcomes.
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7
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Autologous Haematopoietic Stem Cell Transplantation and Systemic Sclerosis: Focus on Interstitial Lung Disease. Cells 2022; 11:cells11050843. [PMID: 35269465 PMCID: PMC8909673 DOI: 10.3390/cells11050843] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 02/25/2022] [Accepted: 02/25/2022] [Indexed: 11/16/2022] Open
Abstract
Autologous hematopoietic stem cells transplantation (AHSCT) has been employed as treatment for severe systemic sclerosis (SSc) with high risk of organ failure. In the last 25 years overall survival and treatment-related mortality have improved, in accordance with a better patient selection and mobilization and conditioning protocols. This review analyzes the evidence from the last 5 years for AHSCT-treated SSc patients, considering in particular the outcomes related to interstitial lung disease. There are increasing data supporting the use of AHSCT in selected patients with rapidly progressive SSc. However, some unmet needs remain, such as an accurate patient selection, pre-transplantation analysis to identify subclinical conditions precluding the transplantation, and the alternatives for post-transplant ILD recurrence.
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8
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Moraes DA, Oliveira MC. Life after Autologous Hematopoietic Stem Cell Transplantation for Systemic Sclerosis. J Blood Med 2021; 12:951-964. [PMID: 34785969 PMCID: PMC8590726 DOI: 10.2147/jbm.s338077] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 10/26/2021] [Indexed: 12/29/2022] Open
Abstract
Stem cell transplantation has been investigated as treatment for severe and progressive systemic sclerosis (SSc) for the past 25 years. To date, more than 1000 SSc patients have been transplanted worldwide. Overall and event-free survival have increased over the years, reflecting stricter patient selection criteria and better clinical management strategies. This review addresses long-term outcomes of transplanted SSc patients, considering phase I/II and randomized clinical trials, as well as observational studies and those assessing specific aspects of the disease. Clinical outcomes are discussed comparatively between studies, highlighting advances, drawbacks and controversies in the field. Areas for future development are also discussed.
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Affiliation(s)
- Daniela A Moraes
- Division of Clinical Immunology, Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Maria Carolina Oliveira
- Center for Cell-Based Therapy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
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9
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AlOdhaibi KA, Varga J, Furst DE. Hematopoietic stem cell transplantation in systemic sclerosis: Yes!! BUT. . JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2021; 6:44-49. [PMID: 35382253 PMCID: PMC8922628 DOI: 10.1177/2397198320971967] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 10/18/2020] [Indexed: 12/12/2023]
Abstract
Systemic sclerosis is a chronic multisystem, autoimmune disease with high mortality, and to date, has no effective approved therapy. For patients with the most severe forms of systemic sclerosis, autologous hematopoietic stem cell therapy has been proven to be effective, as demonstrated by three randomized controlled clinical trials and at least two registry studies. In the controlled studies, autologous hematopoietic stem cell therapy was shown to improve mortality, skin involvement, quality-of-life, and function compared with patients treated with intravenous cyclophosphamide. There is significant transplant-related mortality associated with autologous hematopoietic stem cell therapy, as well as infectious and noninfectious serious adverse events, including cardiac and renal compromise. Although the results of autologous hematopoietic stem cell therapy clinical trials to date are highly encouraging, a number of important unanswered questions remain. These include the following: What is the optimal transplant regimen; can the spectrum of systemic sclerosis patients who respond to autologous hematopoietic stem cell therapy be expanded; how can disease relapse following autologous hematopoietic stem cell therapy be predicted and managed; can treatment-related toxicity and mortality be mitigated; can response or toxicity be predicted; and finally, is there a place for allogeneic stem cell transplants in systemic sclerosis? Systemic sclerosis is an autoimmune disease with multiple immunological, vascular, and fibrotic abnormalities. Immunosuppressive therapy is frequently used, but to date its efficacy has been generally modest. Stem cell transplantation is the most potent immunosuppressive therapy currently available, and as discussed below, may have an important role in the management of systemic sclerosis.
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Affiliation(s)
| | - John Varga
- University of Michigan, Ann Arbor, MI, USA
| | - Daniel E Furst
- University of California-Los Angeles, Los Angeles, CA, USA
- University of Washington, Seattle, WA, USA
- University of Florence, Florence, Italy
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10
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Mariottini A, De Matteis E, Muraro PA. Haematopoietic Stem Cell Transplantation for Multiple Sclerosis: Current Status. BioDrugs 2021; 34:307-325. [PMID: 32166703 DOI: 10.1007/s40259-020-00414-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Autologous haematopoietic stem cell transplantation (AHSCT) is a treatment option for aggressive forms of multiple sclerosis (MS) that has been derived from haematological indications and repurposed for treatment of refractory autoimmune diseases. In the present review, a search for clinical studies on AHSCT was performed on the PubMed website and ClinicalTrials.gov databases. Papers were selected according to the following criteria: text written in English language, publication date between 2014 and August 2019, and reports including more than five patients. Prospective randomised and uncontrolled trials and retrospective case series were reviewed to examine the safety and efficacy of the procedure. Treatment protocols, pathological data and economic aspects of AHSCT were also succinctly covered. Growing evidence suggests that long-term suppression of inflammatory activity with stabilization or improvement of disability can be achieved in a high proportion of properly selected patients. More sophisticated outcome measures recently adopted, including effect on brain atrophy and disease biomarkers, are giving further insight into the effectiveness of transplant. The risks of the procedure have decreased to levels that can be considered acceptable for treatment of individuals with aggressive forms of MS. Careful selection of patients with an expected good benefit/risk profile, which is maximal when AHSCT is performed in early phases of the disease, and the expertise of transplant centres are critical to the success of treatment. Higher efficacy of AHSCT than with conventional treatments has recently been demonstrated by one randomised trial and further evidence is awaited from ongoing and planned trials comparing AHSCT with the most effective disease-modifying therapeutic agents.
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Affiliation(s)
- Alice Mariottini
- Department of Brain Sciences, Faculty of Medicine, Imperial College London, Burlington Danes Building, Du Cane Road, Hammersmith Hospital Campus, London, W12 0NN, UK.,Department of Neurosciences, Drug and Child Health, University of Florence, Florence, Italy
| | - Eleonora De Matteis
- Department of Brain Sciences, Faculty of Medicine, Imperial College London, Burlington Danes Building, Du Cane Road, Hammersmith Hospital Campus, London, W12 0NN, UK.,Department of Neurosciences, Mental Health and Sensory Organs, Faculty of Medicine and Psychology, Centre for Experimental Neurological Therapies, Sapienza University, Rome, Italy
| | - Paolo A Muraro
- Department of Brain Sciences, Faculty of Medicine, Imperial College London, Burlington Danes Building, Du Cane Road, Hammersmith Hospital Campus, London, W12 0NN, UK.
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11
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Gebel J, Tuppi M, Sänger N, Schumacher B, Dötsch V. DNA Damaged Induced Cell Death in Oocytes. Molecules 2020; 25:molecules25235714. [PMID: 33287328 PMCID: PMC7730327 DOI: 10.3390/molecules25235714] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 11/25/2020] [Accepted: 11/30/2020] [Indexed: 12/19/2022] Open
Abstract
The production of haploid gametes through meiosis is central to the principle of sexual reproduction. The genetic diversity is further enhanced by exchange of genetic material between homologous chromosomes by the crossover mechanism. This mechanism not only requires correct pairing of homologous chromosomes but also efficient repair of the induced DNA double-strand breaks. Oocytes have evolved a unique quality control system that eliminates cells if chromosomes do not correctly align or if DNA repair is not possible. Central to this monitoring system that is conserved from nematodes and fruit fly to humans is the p53 protein family, and in vertebrates in particular p63. In mammals, oocytes are stored for a long time in the prophase of meiosis I which, in humans, can last more than 50 years. During the entire time of this arrest phase, the DNA damage checkpoint remains active. The treatment of female cancer patients with DNA damaging irradiation or chemotherapeutics activates this checkpoint and results in elimination of the oocyte pool causing premature menopause and infertility. Here, we review the molecular mechanisms of this quality control system and discuss potential therapeutic intervention for the preservation of the oocyte pool during chemotherapy.
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Affiliation(s)
- Jakob Gebel
- Institute of Biophysical Chemistry and Center for Biomolecular Magnetic Resonance, Goethe University, 60438 Frankfurt, Germany; (J.G.); (M.T.)
| | - Marcel Tuppi
- Institute of Biophysical Chemistry and Center for Biomolecular Magnetic Resonance, Goethe University, 60438 Frankfurt, Germany; (J.G.); (M.T.)
| | - Nicole Sänger
- Department for Gynecological Endocrinology and Reproductive Medicine, University Hospital of Bonn, Venusberg-Campus 1, 53217 Bonn, Germany;
| | - Björn Schumacher
- Institute for Genome Stability in Aging and Disease, Cologne Cluster of Excellence in Cellular Stress Responses in Aging-Associated Diseases (CECAD) Research Center, and Center for Molecular Medicine, University of Cologne, Joseph-Stelzmann-Str. 26, 50931 Cologne, Germany;
| | - Volker Dötsch
- Institute of Biophysical Chemistry and Center for Biomolecular Magnetic Resonance, Goethe University, 60438 Frankfurt, Germany; (J.G.); (M.T.)
- Correspondence: ; Tel.: +49-69-798-29631
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12
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Bruni C, Furst DE. The burning question: To use or not to use cyclophosphamide in systemic sclerosis. Eur J Rheumatol 2020; 7:S237-S241. [PMID: 33164737 PMCID: PMC7647679 DOI: 10.5152/eurjrheum.2020.19104] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 03/06/2020] [Indexed: 02/04/2023] Open
Abstract
Fibrosis, inflammation, and vasculopathy are the main determinants of systemic sclerosis (SSc) pathogenesis. Cyclophosphamide (CYC), an alkylating agent, has been used to treat skin fibrosis and interstitial lung diseases in SSc for many years and still represents a mainstay in hematopoietic stem cell transplantation. Despite significant effect in reducing lung functional impairment and skin tightness, CYC has a significant safety burden, including infection risk and bone marrow and bladder toxicity. Moreover, it can affect fertility and also cause a predisposition for cancer development in the future, particularly in the bladder. This review summarizes the current evidences regarding the use of CYC to treat SSc, its efficacy and safety profile, and currently available or tested alternative drugs for lung and skin involvement in SSc.
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Affiliation(s)
- Cosimo Bruni
- Division of Rheumatology, Department of Experimental and Clinical Medicine, University of Firenze, Firenze, Italy
| | - Daniel E. Furst
- Division of Rheumatology, Department of Experimental and Clinical Medicine, University of Firenze, Firenze, Italy
- Division of Rheumatology, Department of Medicine, University of California Los Angeles, Los Angeles, CA, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
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13
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Luong SN, Isaacs A, Liu Z, Sin FE, Giles I. A systematic review and meta-analysis of the gonadotoxic effects of cyclophosphamide and benefits of gonadotropin releasing hormone agonists (GnRHa) in women of child-bearing age with autoimmune rheumatic disease. Expert Rev Clin Immunol 2020; 16:321-333. [PMID: 32005081 DOI: 10.1080/1744666x.2020.1724091] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Objectives: To systematically review risk of sustained amenorrhea with intravenous (IV) cyclophosphamide in autoimmune rheumatic disease (ARD), and evaluate efficacy of gonadotropin-releasing hormone agonists (GnRHa) to reduce this risk.Methods: Systematic search for papers reporting incidence of sustained amenorrhea ≥12 months in ARD following: IV cyclophosphamide; or GnRHa and IV cyclophosphamide compared to IV cyclophosphamide alone.Results: From 31 articles and 1388 patients (mean age 27.7 years) sustained amenorrhea occurred in 273 patients (19.7%). Of 56 patients (mean age range 23.9-25.6 years) receiving GnRHa and IV cyclophosphamide, and 37 controls (mean age range 25-30.1 years) given IV cyclophosphamide only, sustained amenorrhea occurred in 2/56 (3.6%) patients treated with GnRHa, compared to 15/37 (40.5%) controls. Pooled odds ratio of sustained amenorrhea with GnRHa and cyclophosphamide versus cyclophosphamide alone was 0.054 (95% CI 0.0115-0.2576 p < 0.001), corresponding to a number needed to treat of 2.7 (95% CI 1.955-4.388) and absolute risk reduction of 36.95% (95% CI 35.6-38.4%).Conclusion: Sustained amenorrhea with IV cyclophosphamide was observed in patients with ARD, especially with increasing age and cumulative doses >5 g. GnRHa reduced this risk and should be considered with IV cyclophosphamide in women of childbearing age with ARD.
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Affiliation(s)
- Shi-Nan Luong
- Department of Rheumatology, University College London Hospital, London, UK.,Centre for Rheumatology, Division of Medicine, Rayne Institute, University College London, London, UK.,South Western Sydney Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Anthony Isaacs
- Department of Rheumatology, University College London Hospital, London, UK
| | - Zhixin Liu
- Stats Central, Mark Wainwright Analytical Centre, University of New South Wales, Sydney, Australia
| | - Fang E Sin
- Department of Rheumatology, University College London Hospital, London, UK
| | - Ian Giles
- Department of Rheumatology, University College London Hospital, London, UK.,Centre for Rheumatology, Division of Medicine, Rayne Institute, University College London, London, UK
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14
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Kvistad SAS, Lehmann AK, Trovik LH, Kristoffersen EK, Bø L, Myhr KM, Torkildsen Ø. Safety and efficacy of autologous hematopoietic stem cell transplantation for multiple sclerosis in Norway. Mult Scler 2019; 26:1889-1897. [DOI: 10.1177/1352458519893926] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background: Hematopoietic stem cell treatment (HSCT) is a promising treatment option for multiple sclerosis (MS), but detailed safety and efficacy measures are still scarce. Objective: To evaluate the efficacy and safety of HSCT in MS. Methods: Retrospective single-center observational study of all MS patients that underwent HSCT in Norway during January 2015 to January 2018. The primary outcome was no evidence of disease activity (NEDA-3) status. Results: A total of 30 patients with a median follow-up time of 26 months (range: 11–48) were evaluated. In total, 25 (83%) achieved NEDA-3 status, and none received disease-modifying treatment after HSCT. For 13 (43%) of the patients, there were sustained improvement in Expanded Disability Status Scale (EDSS) score, and 10 (33%) were working full time after the treatment, compared to only 1 (3%) before treatment. There were no serious treatment-related complications and was no mortality. Five patients (17%) were diagnosed with an autoimmune thyroid disease after the procedure, and 10 (43%) of the women had amenorrhea lasting >12 months and symptoms of ovarian failure. Conclusion: HSCT in MS is an effective and relatively safe treatment option, with few serious complications and no mortality in Norway, so far. However, long-term adverse event with amenorrhea is a common problem.
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Affiliation(s)
- Silje Agnethe Stokke Kvistad
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway/Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | | | | | | | - Lars Bø
- Norwegian Multiple Sclerosis Registry and Biobank, Department of Neurology, Haukeland University Hospital, Bergen, Norway/Norwegian Multiple Sclerosis Competence Centre, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Kjell-Morten Myhr
- Department of Clinical Medicine, University of Bergen, Bergen, Norway/Norwegian Multiple Sclerosis Registry and Biobank, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Øivind Torkildsen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway/Norwegian Multiple Sclerosis Competence Centre, Department of Neurology, Haukeland University Hospital, Bergen, Norway
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15
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Is There a Place for Hematopoietic Stem Cell Transplantation in Rheumatology? Rheum Dis Clin North Am 2019; 45:399-416. [DOI: 10.1016/j.rdc.2019.04.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Fertility preservation in patients with hematologic malignancies and recipients of hematopoietic cell transplants. Blood 2019; 134:746-760. [PMID: 31292116 DOI: 10.1182/blood.2018846790] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Accepted: 05/30/2019] [Indexed: 02/07/2023] Open
Abstract
Patients with hematologic malignancies and those undergoing hematopoietic cell transplantation (HCT) face a complex set of challenges when considering options for fertility preservation (FP). There are no standard options for prepubertal children, and women with hematologic malignancies may not be eligible for standard FP options. Fortunately, initial therapies for most blood cancers are not highly gonadotoxic, affording an important opportunity for postremission counseling and referrals to fertility specialists. These patients face a high risk of relapse, and many will be referred for autologous or allogeneic HCT, which carries an extremely high risk of infertility. The expanding indications for HCT to include benign hematologic disorders as well as autoimmune diseases mandate that all hematologists are familiar with these risks. Oncofertility researchers are continually pushing the boundaries of what may be possible for our patients; in the meantime, communication and shared decision-making between hematologists and patients, as well as program-building, education, and outreach are essential to ensure that these patients, many of whom will be cured, maintain all of their options for a fulfilling life after intensive therapy.
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Abstract
Improved understanding of the pathogenesis and natural history of many urologic disorders, as well as advances in fertility preservation techniques, has increased the awareness of and options for management of fertility threats in pediatric patients. In children, fertility may be altered by oncologic conditions, by differences in sexual differentiation, by gonadotoxic drugs and other side effects of treatment for nonurologic disorders, and by urologic conditions, such as varicocele and cryptorchidism. Although fertility concerns are best addressed in a multidisciplinary setting, pediatric urologists should be aware of the underlying pathophysiology and management options to properly counsel and advocate for patients.
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Affiliation(s)
- Kathleen Kieran
- Division of Urology, Seattle Children's Hospital, 4800 Sand Point Way Northeast, OA.9.220, Seattle, WA 98105, USA.
| | - Margarett Shnorhavorian
- Division of Urology, Seattle Children's Hospital, 4800 Sand Point Way Northeast, OA.9.220, Seattle, WA 98105, USA
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Walker UA, Saketkoo LA, Distler O. Haematopoietic stem cell transplantation in systemic sclerosis. RMD Open 2018; 4:e000533. [PMID: 30018796 PMCID: PMC6045702 DOI: 10.1136/rmdopen-2017-000533] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 05/23/2018] [Accepted: 06/04/2018] [Indexed: 12/29/2022] Open
Abstract
Three randomised controlled trials of haematopoietic stem cell transplantation (HSCT) in systemic sclerosis (SSc) demonstrated long-term survival benefits, induction of clinically meaningful, sustained improvement of forced vital capacity with improvements in skin thickening, vasculopathy and health-related quality of life, in contrast to a clinical decline in standard of care control groups. These benefits, however, must be weighed against the increased risk of transplant-related mortality. Further, with disease progression, severe extensive internal organ involvement and damage ensues, constituting an exclusion criterion for safety reasons, leaving a limited window whereby patients with SSc are eligible for HSCT. Although autologous HSCT offers the possibility of drug-free remission, relapse can occur, requiring re-initiation of disease modifying antirheumatic drugs. HSCT is also associated with secondary autoimmune diseases and gonadal failure. HSCT should be proposed for carefully selected patients with early rapidly progressive diffuse SSc whose clinical picture portends a poor prognosis for survival, but yet lacks advanced organ involvement.
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Affiliation(s)
- Ulrich A Walker
- Department of Rheumatology, University Hospital Basel, Basel, Switzerland
| | - Lesley Ann Saketkoo
- Tulane University School of Medicine Lung Center, New Orleans Scleroderma and Sarcoidosis Patient Care and Research Center, University Medical Center - Comprehensive Pulmonary Hypertension Center, New Orleans, Louisiana, USA
| | - Oliver Distler
- Department of Rheumatology, University Hospital Zurich, Zurich, Switzerland
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