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Oravecz-Wilson K, Lauder E, Taylor A, Maneix L, Van Nostrand JL, Sun Y, Li L, Zhao D, Liu C, Reddy P. Autophagy differentially regulates tissue tolerance of distinct target organs in graft-versus-host disease models. J Clin Invest 2024; 134:e167369. [PMID: 38426503 PMCID: PMC10904048 DOI: 10.1172/jci167369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 01/11/2024] [Indexed: 03/02/2024] Open
Abstract
Tissue-intrinsic mechanisms that regulate severity of systemic pathogenic immune-mediated diseases, such as acute graft-versus-host disease (GVHD), remain poorly understood. Following allogeneic hematopoietic stem cell transplantation, autophagy, a cellular stress protective response, is induced in host nonhematopoietic cells. To systematically address the role of autophagy in various host nonhematopoietic tissues, both specific classical target organs of acute GVHD (intestines, liver, and skin) and organs conventionally not known to be targets of GVHD (kidneys and heart), we generated mice with organ-specific knockout of autophagy related 5 (ATG5) to specifically and exclusively inhibit autophagy in the specific organs. When compared with wild-type recipients, animals that lacked ATG5 in the gastrointestinal tract or liver showed significantly greater tissue injury and mortality, while autophagy deficiency in the skin, kidneys, or heart did not affect mortality. Treatment with the systemic autophagy inducer sirolimus only partially mitigated GVHD mortality in intestine-specific autophagy-deficient hosts. Deficiency of autophagy increased MHC class I on the target intestinal epithelial cells, resulting in greater susceptibility to damage by alloreactive T cells. Thus, autophagy is a critical cell-intrinsic protective response that promotes tissue tolerance and regulates GVHD severity.
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Affiliation(s)
- Katherine Oravecz-Wilson
- Department of Internal Medicine, Division of Hematology and Oncology, University of Michigan, Rogel Cancer Center, Ann Arbor, Michigan, USA
| | - Emma Lauder
- Department of Internal Medicine, Division of Hematology and Oncology, University of Michigan, Rogel Cancer Center, Ann Arbor, Michigan, USA
- Dan L. Duncan Comprehensive Cancer Center and
| | - Austin Taylor
- Department of Internal Medicine, Division of Hematology and Oncology, University of Michigan, Rogel Cancer Center, Ann Arbor, Michigan, USA
| | | | - Jeanine L. Van Nostrand
- Department of Molecular and Cellular Biology, Baylor College of Medicine, Houston, Texas, USA
| | - Yaping Sun
- Dan L. Duncan Comprehensive Cancer Center and
| | - Lu Li
- Dan L. Duncan Comprehensive Cancer Center and
| | | | - Chen Liu
- Department of Pathology, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Pavan Reddy
- Department of Internal Medicine, Division of Hematology and Oncology, University of Michigan, Rogel Cancer Center, Ann Arbor, Michigan, USA
- Dan L. Duncan Comprehensive Cancer Center and
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Esquirol A, Cadenas IG, Novelli S, Garrido A, Caballero AC, Oñate G, Lopez J, Redondo S, Argüello M, Saavedra S, Moreno C, Briones J, Sierra J, Martino R. Outcome improvement over time in reduced intensity conditioning hematopoietic transplantation: a 20-year experience. Ann Hematol 2024; 103:321-334. [PMID: 37971549 DOI: 10.1007/s00277-023-05530-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 10/29/2023] [Indexed: 11/19/2023]
Abstract
The current study includes all consecutive patients (N = 484) who received a reduced-intensity conditioning regimen (RIC) allogeneic hematopoietic stem cell transplantation in our center from 1999 to 2020. Conditioning regimens were based on fludarabine with melphalan or busulfan, with low-dose thiotepa and pharmacological GVHD prophylaxis consisted of cyclosporine A (CsA)-methotrexate (MTX)/mofetil (MMF) (n = 271), tacrolimus-sirolimus (n = 145), and post-transplantation cyclophosphamide (PTCy)-tacrolimus (n = 68). The median time of overall follow-up in survivors was 8 years (1-22 years) and was at least 3 years in all three GVHD prophylaxis groups. Thirty-three percent had a high or very high disease risk index, 56% ≥ 4 European bone marrow transplantation risk, and 65% ≥ 3 hematopoietic stem cell transplantation comorbidity index score-age score. Neutrophil and platelet engraftment was longer for PTCy-tacro (p 0.0001). Cumulative incidence of grade III-IV aGVHD was 17% at 200 days, and that of moderate-severe cGvHD was 36% at 8 years. GVHD prophylaxis was the only prognostic factor in the multivariable analyses for the development of aGVHD and moderate-severe cGVHD (p 0.0001). NRM and relapse incidences were 29% and 30% at 8 years, while OS and PFS rates were 43% and 39% at 8 years. At 3 years, OS was highest in the PTCy-tacro group (68%) than in the tacro-siro (61%) and CsA-MTX/MMF (49%) cohorts (p < 0.01). In the three groups, respectively, the 200-day incidence of grade III-IV aGvHD (6% vs. 12% vs. 23%) and 3-year moderate-severe cGVHD (8% vs. 40% vs. 38%) were lower in the PTCy cohort. These better outcomes were confirmed in multivariable analyses. Based on our recent results, the PTCy could be considered as a real GvHD prophylaxis in the RIC setting due to improve best 3-year GvHD and survival outcomes.
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Affiliation(s)
- Albert Esquirol
- Hematology Department, Hospital de La Santa Creu I Sant Pau, IIB-Sant Pau and Jose Carreras Leukemia Research Institutes, Universitat Autonoma of Barcelona, Mas Casanovas, 90, 08041, Barcelona, Spain.
| | - Irene Garcia Cadenas
- Hematology Department, Hospital de La Santa Creu I Sant Pau, IIB-Sant Pau and Jose Carreras Leukemia Research Institutes, Universitat Autonoma of Barcelona, Mas Casanovas, 90, 08041, Barcelona, Spain
| | - Silvana Novelli
- Hematology Department, Hospital de La Santa Creu I Sant Pau, IIB-Sant Pau and Jose Carreras Leukemia Research Institutes, Universitat Autonoma of Barcelona, Mas Casanovas, 90, 08041, Barcelona, Spain
| | - Ana Garrido
- Hematology Department, Hospital de La Santa Creu I Sant Pau, IIB-Sant Pau and Jose Carreras Leukemia Research Institutes, Universitat Autonoma of Barcelona, Mas Casanovas, 90, 08041, Barcelona, Spain
| | - Ana Carolina Caballero
- Hematology Department, Hospital de La Santa Creu I Sant Pau, IIB-Sant Pau and Jose Carreras Leukemia Research Institutes, Universitat Autonoma of Barcelona, Mas Casanovas, 90, 08041, Barcelona, Spain
| | - Guadalupe Oñate
- Hematology Department, Hospital de La Santa Creu I Sant Pau, IIB-Sant Pau and Jose Carreras Leukemia Research Institutes, Universitat Autonoma of Barcelona, Mas Casanovas, 90, 08041, Barcelona, Spain
| | - Jordi Lopez
- Hematology Department, Hospital de La Santa Creu I Sant Pau, IIB-Sant Pau and Jose Carreras Leukemia Research Institutes, Universitat Autonoma of Barcelona, Mas Casanovas, 90, 08041, Barcelona, Spain
| | - Sara Redondo
- Hematology Department, Hospital de La Santa Creu I Sant Pau, IIB-Sant Pau and Jose Carreras Leukemia Research Institutes, Universitat Autonoma of Barcelona, Mas Casanovas, 90, 08041, Barcelona, Spain
| | - Miguel Argüello
- Hematology Department, Hospital de La Santa Creu I Sant Pau, IIB-Sant Pau and Jose Carreras Leukemia Research Institutes, Universitat Autonoma of Barcelona, Mas Casanovas, 90, 08041, Barcelona, Spain
| | - Silvana Saavedra
- Hematology Department, Hospital de La Santa Creu I Sant Pau, IIB-Sant Pau and Jose Carreras Leukemia Research Institutes, Universitat Autonoma of Barcelona, Mas Casanovas, 90, 08041, Barcelona, Spain
| | - Carolina Moreno
- Hematology Department, Hospital de La Santa Creu I Sant Pau, IIB-Sant Pau and Jose Carreras Leukemia Research Institutes, Universitat Autonoma of Barcelona, Mas Casanovas, 90, 08041, Barcelona, Spain
| | - Javier Briones
- Hematology Department, Hospital de La Santa Creu I Sant Pau, IIB-Sant Pau and Jose Carreras Leukemia Research Institutes, Universitat Autonoma of Barcelona, Mas Casanovas, 90, 08041, Barcelona, Spain
| | - Jorge Sierra
- Hematology Department, Hospital de La Santa Creu I Sant Pau, IIB-Sant Pau and Jose Carreras Leukemia Research Institutes, Universitat Autonoma of Barcelona, Mas Casanovas, 90, 08041, Barcelona, Spain
| | - Rodrigo Martino
- Hematology Department, Hospital de La Santa Creu I Sant Pau, IIB-Sant Pau and Jose Carreras Leukemia Research Institutes, Universitat Autonoma of Barcelona, Mas Casanovas, 90, 08041, Barcelona, Spain
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Amanam I, Otoukesh S, Al Malki MM, Salhotra A. Chronic GVHD: review advances in prevention, novel endpoints, and targeted strategies. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:164-170. [PMID: 38066845 PMCID: PMC10727045 DOI: 10.1182/hematology.2023000427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Allogeneic hematopoietic cell transplantation (allo-HCT) is a curative therapy for many malignant and non-malignant hematologic disorders. Chronic graft-versus-host (cGVHD) disease remains a significant hurdle for long-term survival in patients post allo-HCT, and it remains the leading cause of late non-relapse mortality. The risk factors for development of cGVHD include degree of human leukocyte antigen (HLA) disparity, increasing recipient age, use of peripheral blood stem cells as a source, myeloablative conditioning regimens, prior acute GVHD (aGVHD), and female donor to male recipient. Our biological understanding of cGVHD is mostly derived from transplantation mouse models and patient data. There are three distinct phases in the development of cGVHD. Approaches to prevent GVHD include pharmacologic strategies such as calcineurin inhibitors (cyclosporine, tacrolimus) combined with methotrexate or mTOR inhibitors (sirolimus), and IMP dehydrogenase inhibitors (mycophenolate mofetil). Increasingly, posttransplant cyclophosphamide is emerging as a promising strategy for GVCHD prevention especially in a setting of reduced intensity conditioning. Other approaches include serotherapy (ATG, Campath) and graft manipulation strategies. A significant obstacle to evaluating the response of novel GVHD-directed therapies has been standardized response assessments. This has functioned as a barrier to designing and interpreting clinical trials that are structured around the treatment of cGVHD. Novel endpoints including failure-free survival, Graft-versus-host disease-free, relapse-free survival (GRFS), and current GVHD-free, relapse-free survival (CGRFS) may create a clearer picture for post-HCT outcomes. Targeted therapies including Bruton's tyrosine kinase inhibition, JAK1/2 inhibition, and ROCK2 inhibitors have improved cGVHD therapy, especially in the steroid refractory setting. Continued improvement in prophylactic strategies for cGVHD, identification of accurate cGVHD treatment endpoints, and access to novel therapeutic agents are expected to improve cGVHD outcomes.
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Maurer K, Soiffer RJ. The delicate balance of graft versus leukemia and graft versus host disease after allogeneic hematopoietic stem cell transplantation. Expert Rev Hematol 2023; 16:943-962. [PMID: 37906445 PMCID: PMC11195539 DOI: 10.1080/17474086.2023.2273847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 10/18/2023] [Indexed: 11/02/2023]
Abstract
INTRODUCTION The curative basis of allogeneic hematopoietic stem cell transplantation (HSCT) relies in part upon the graft versus leukemia (GvL) effect, whereby donor immune cells recognize and eliminate recipient malignant cells. However, alloreactivity of donor cells against recipient tissues may also be deleterious. Chronic graft versus host disease (cGvHD) is an immunologic phenomenon wherein alloreactive donor T cells aberrantly react against host tissues, leading to damaging inflammatory symptoms. AREAS COVERED Here, we discuss biological insights into GvL and cGvHD and strategies to balance the prevention of GvHD with maintenance of GvL in modern HSCT. EXPERT OPINION/COMMENTARY Relapse remains the leading cause of mortality after HSCT with rates as high as 40% for some diseases. GvHD is a major cause of morbidity after HSCT, occurring in up to half of patients and responsible for 15-20% of deaths after HSCT. Intriguingly, the development of chronic GvHD may be linked to lower relapse rates after HSCT, suggesting that GvL and GvHD may be complementary sides of the immunologic foundation of HSCT. The ability to fine tune the balance of GvL and GvHD will lead to improvements in survival, relapse rates, and quality of life for patients undergoing HSCT.
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Affiliation(s)
- Katie Maurer
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Robert J Soiffer
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
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Haroun-Izquierdo A, Lanuza PM, Pfefferle A, Netskar H, Ask EH, Törlén J, Björklund A, Sohlberg E, Malmberg KJ. Effect of mTOR Inhibition with Sirolimus on Natural Killer Cell Reconstitution in Allogeneic Stem Cell Transplantation. Transplant Cell Ther 2023:S2666-6367(23)01201-0. [PMID: 36966873 DOI: 10.1016/j.jtct.2023.03.023] [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: 01/22/2023] [Revised: 03/09/2023] [Accepted: 03/20/2023] [Indexed: 04/25/2023]
Abstract
Sirolimus is an inhibitor of the mammalian target of rapamycin (mTOR) and is emerging as a promising component of graft-versus-host disease (GVHD) prophylaxis regimens in the context of allogeneic hematopoietic stem cell transplantation (HSCT). Multiple studies have explored the clinical benefits of adding sirolimus to GVHD prophylaxis; however, detailed immunologic studies have not yet been carried out in this context. Mechanistically, mTOR is at the center of metabolic regulation in T cells and natural killer (NK) cells and is critical for their differentiation to mature effector cells. Therefore, close evaluation of the inhibition of mTOR in the context of immune reconstitution post-HSCT is warranted. In this work, we studied the effect of sirolimus on immune reconstitution using a biobank of longitudinal samples from patients receiving either tacrolimus/sirolimus (TAC/SIR) or cyclosporin A/methotrexate (CSA/MTX) as conventional GVHD prophylaxis. Healthy donor controls, donor graft material, and samples from 28 patients (14 with TAC/SIR, 14 with CSA/MTX) at 3 to 4 weeks and 34 to 39 weeks post- HSCT were collected. Multicolor flow cytometry was used to perform broad immune cell mapping, with a focus on NK cells. NK cell proliferation was evaluated over a 6-day in vitro homeostatic proliferation protocol. Furthermore, in vitro NK cell responses to cytokine stimulation or tumor cells were evaluated. Systems-level assessment of the immune repertoire revealed a deep and prolonged suppression (weeks 34 to 39 post-HSCT) of the naïve CD4 T cell compartment with relative sparing of regulatory T cells and enrichment of CD69+Ki-67+HLA-DR+ CD8 T cells, independent of the type of GVHD prophylaxis. Early after transplantation (weeks 3 to 4), while patients were still on TAC/SIR or CSA/MTX, we found a relative increase in less-differentiated CD56bright NK cells and NKG2A+CD57-KIR- CD56dim NK cells and a distinct loss of CD16 and DNAM-1 expression. Both regimens led to suppressed proliferative responses ex vivo and functional impairment with preferential loss of cytokine responsiveness and IFN-γ production. Patients who received TAC/SIR as GVHD prophylaxis showed delayed NK cell reconstitution with lower overall NK cell counts and fewer CD56bright and NKG2A+ CD56dim NK cells. Treatment with sirolimus- containing regimens generated similar immune cell profiles as conventional prophylaxis; however, the NK cell compartment seemed to be composed of slightly more mature NK cells. These effects were also present after the completion of GVHD prophylaxis, suggesting that mTOR inhibition with sirolimus leaves a lasting imprint on homeostatic proliferation and NK cell reconstitution following HSCT.
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Affiliation(s)
- Alvaro Haroun-Izquierdo
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Pilar M Lanuza
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Aline Pfefferle
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Herman Netskar
- Institute for Cancer Research, Department of Cancer Immunology, University of Oslo, Oslo University Hospital, Norway
| | - Eivind H Ask
- Institute for Cancer Research, Department of Cancer Immunology, University of Oslo, Oslo University Hospital, Norway
| | - Johan Törlén
- Department of Cellular Therapy and Allogeneic Stem Cell Transplantation, Karolinska University Hospital, Stockholm, Sweden
| | - Andreas Björklund
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden; Department of Cellular Therapy and Allogeneic Stem Cell Transplantation, Karolinska University Hospital, Stockholm, Sweden
| | - Ebba Sohlberg
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Karl-Johan Malmberg
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden; Institute for Cancer Research, Department of Cancer Immunology, University of Oslo, Oslo University Hospital, Norway.
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Yao JM, Yang D, Clark MC, Otoukesh S, Cao T, Ali H, Arslan S, Aldoss I, Artz A, Amanam I, Salhotra A, Pullarkat V, Sandhu K, Stein A, Marcucci G, Forman SJ, Nakamura R, Al Malki MM. Tacrolimus initial steady state level in post-transplant cyclophosphamide-based GvHD prophylaxis regimens. Bone Marrow Transplant 2021; 57:232-242. [PMID: 34802049 PMCID: PMC8825746 DOI: 10.1038/s41409-021-01528-y] [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: 05/14/2021] [Revised: 11/02/2021] [Accepted: 11/09/2021] [Indexed: 11/11/2022]
Abstract
Post-transplant cyclophosphamide (PTCy) combined with tacrolimus (TAC) as graft-versus-host disease (GvHD) prophylaxis post-hematopoietic cell transplantation (HCT) is safe and effective. Optimal serum levels of TAC in this combination remain undetermined. We hypothesized that TAC at initial steady state (TISS) of <10 ng/mL could promote optimal transplant outcomes and prevent TAC-associated toxicities. We retrospectively analyzed a consecutive case series of 210 patients who received PTCy/TAC-based prophylaxis post-HCT from 1/2013–6/2018. Patients received HCT from haploidentical (n=172) or mismatched donors (n=38), and flat dose (FD) or weight-based dose (WBD) TAC. Twenty-four-month overall survival (OS), disease free survival (DFS), and relapse rate (RR) were 61%, 56%, and 22%, respectively, in TISS <10 ng/mL cohort (n=176), and 50%, 43%, and 35%, respectively, in TISS ≥10 ng/mL cohort (n=34) (OS, P=0.71; DFS, P=0.097; RR, P=0.031). OS, DFS, RR, non-relapse mortality, acute GvHD grade II-IV, grade III-IV or chronic GvHD by TISS were similar in multivariable analysis. TISS ≥10 ng/mL conferred increased risk of viral infection (P=0.003). More patients receiving FD vs. WBD had TISS <10 ng/mL (P=0.001). Overall, TISS <10 ng/mL early post HCT conferred similar survival outcomes and lowered risk of viral infection and toxicities compared to TISS ≥10 ng/mL.
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Affiliation(s)
- Janny M Yao
- Department of Pharmacy, City of Hope National Medical Center, Duarte, CA, USA
| | - Dongyun Yang
- Department of Computational and Quantitative Medicine, Division of Biostatistics, City of Hope National Medical Center, Duarte, CA, USA
| | - Mary C Clark
- Department of Clinical and Translational Project Development, City of Hope National Medical Center, Duarte, CA, USA
| | - Salman Otoukesh
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
| | - Thai Cao
- Bone Marrow Transplant Department, Kaiser Permanente, Los Angeles, CA, USA
| | - Haris Ali
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
| | - Shukaib Arslan
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
| | - Ibrahim Aldoss
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
| | - Andrew Artz
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
| | - Idoroenyi Amanam
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
| | - Amandeep Salhotra
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
| | - Vinod Pullarkat
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
| | - Karamjeet Sandhu
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
| | - Anthony Stein
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
| | - Guido Marcucci
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
| | - Stephen J Forman
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
| | - Ryotaro Nakamura
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
| | - Monzr M Al Malki
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA.
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Garming Legert K, Ringdén O, Remberger M, Törlén J, Mattsson J, Dahllöf G. Oral mucositis after tacrolimus/sirolimus or cyclosporine/methotrexate as graft-versus-host disease prophylaxis. Oral Dis 2020; 27:1217-1225. [PMID: 33012083 PMCID: PMC8247364 DOI: 10.1111/odi.13663] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 09/02/2020] [Accepted: 09/17/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To determine whether treatment with tacrolimus plus sirolimus (Tac/Sir) as a prophylaxis for graft-versus-host disease worsens severe oral mucositis and delays healing compared to cyclosporine plus methotrexate (CsA/Mtx) following haematopoietic stem cell transplantation. SUBJECTS AND METHODS The study comprised 141 patients: 73 randomized to receive Tac/Sir and 68 to receive CsA/Mtx. The oral mucositis assessment scale and toxicity grading according to WHO were used to assess the severity, peak and duration of oral mucositis from the day -3 to day 24 post-transplant. RESULTS Eighty-seven patients developed oral mucositis in the first 24 days post-transplant. No significant difference in oral mucositis severity between the Tac/Sir and CsA/Mtx groups was observed. The peak oral mucositis score occurred on day 10 in both groups. Although oral mucositis scores had returned to baseline in the CsA/Mtx group on day 24 post-transplant, no significant difference compared with the Tac/Sir group was found. CONCLUSIONS The introduction of tacrolimus/sirolimus as a graft-versus-host disease prophylaxis in haematopoietic stem cell transplantation increased neither the incidence nor severity of oral mucositis compared with cyclosporine/methotrexate. Furthermore, oral mucositis healing was not prolonged and followed the same time pattern as cyclosporine/methotrexate.
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Affiliation(s)
| | - Olle Ringdén
- Department of Clinical Sciences, Intervention and Technology, Translational cell therapy research group, Karolinska Institutet, Stockholm, Sweden
| | - Mats Remberger
- Department of Medical Sciences, Uppsala University and KFUE, Uppsala University Hospital, Uppsala, Sweden
| | - Johan Törlén
- Cell Therapy and Allogeneic Stem Cell Transplantation (CAST), Karolinska University Hospital, Stockholm, Sweden.,Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Jonas Mattsson
- Cell Therapy and Allogeneic Stem Cell Transplantation (CAST), Karolinska University Hospital, Stockholm, Sweden.,Gloria and Seymour Epstein Chair in Cell Therapy and Transplantation, University of Toronto, Toronto, Canada.,Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| | - Göran Dahllöf
- Department of Dental Medicine, Karolinska Institutet, Huddinge, Sweden.,Center for Oral Health Services and Research, Trondheim, Norway
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Effect of Sirolimus on Immune Reconstitution Following Myeloablative Allogeneic Stem Cell Transplantation: An Ancillary Analysis of a Randomized Controlled Trial Comparing Tacrolimus/Sirolimus and Tacrolimus/Methotrexate (Blood and Marrow Transplant Clinical Trials Network/BMT CTN 0402). Biol Blood Marrow Transplant 2019; 25:2143-2151. [PMID: 31271885 DOI: 10.1016/j.bbmt.2019.06.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 06/26/2019] [Accepted: 06/26/2019] [Indexed: 11/21/2022]
Abstract
Although allogeneic hematopoietic cell transplantation (HCT) is a potentially curative therapy for hematologic neoplasms, one of its limiting toxicities continues to be graft-versus-host disease, both acute (aGVHD) and chronic (cGVHD). Sirolimus is a mammalian target of rapamycin inhibitor that has proven effective in GVHD prophylaxis in combination with a calcineurin inhibitor, such as tacrolimus. The impact of sirolimus on immune reconstitution has not been comprehensively investigated in vivo thus far, however. Here we present an ancillary analysis of the randomized study BMT-CTN 0402 that examined the effect of sirolimus on immune subsets post-transplantation. We further examine the association between different lymphocyte subsets and outcomes post-transplantation in each arm. BMT-CTN 0402 was a randomized trial (n = 304) comparing 2 GVHD prophylaxis regimens, tacrolimus/sirolimus (Tac/Sir) and tacrolimus/methotrexate (Tac/MTX), in patients with acute myelogenous leukemia, acute lymphoblastic leukemia, or myelodysplastic syndrome undergoing myeloablative HLA-matched HCT. There were no differences in 114-day GVHD-free survival (primary endpoint), aGVHD, cGVHD, relapse, or overall survival (OS) between the 2 arms. Of the 304 patients, 264 had available samples for the current immune reconstitution analysis. Blood samples were collected at 1, 3, 6, 12, and 24 months post-HCT. Multiparameter flow cytometry was performed at the project laboratory (Esoterix Clinical Trials Services) in a blinded fashion, and results for the 2 arms were compared. Multivariable Cox regression models, treating each phenotypic parameter as a time-dependent variable, were constructed to study the impact of reconstitution on clinical outcomes. There were no significant differences in patient and transplantation characteristics between the Tac/Sir and Tac/MTX arms in this analysis. Absolute lymphocyte count and CD3+ cell, CD4+ cell, and conventional T cell (Tcon) counts were significantly decreased in the Tac/Sir arm for up to 3 months post-HCT, whereas CD8+ cells recovered even more slowly (up to 6 months) in this arm. Interestingly, there was no clear difference in the absolute number of regulatory T cells (Tregs, defined as CD4+CD25+ cells) between the 2 arms at any point post-HCT; however, the Treg:Tcon ratio was significantly greater in the Tac/Sir arm in the first 3 months after HCT. B lymphocyte recovery was significantly compromised in the Tac/Sir arm from 1 month to 6 months after HCT, whereas natural killer cell reconstitution was not affected in the Tac/Sir arm. In the outcomes analysis, higher numbers of CD3+ cells, CD4+ cells, CD8+ cells, and Tregs were associated with better OS. Neither Treg numbers nor the Treg:Tcon ratio was correlated with GVHD. Our findings indicate that Tac/Sir has a more profound T cell suppressive effect than the combination of Tac/MTX in the early post-transplantation period, and particularly compromises the recovery of CD8+ T cells, which have been implicated in aGVHD. Sirolimus used in vivo with tacrolimus does not appear to result in increased absolute numbers of Tregs, but might have a beneficial effect on the Treg:Tcon balance in the first 3 months after transplantation. Nonetheless, no differences in aGVHD or cGVHD between the 2 arms were observed in the parent randomized trial. Calcineurin-inhibitor free, sirolimus-containing GVHD prophylaxis strategies, incorporating other novel agents, should be investigated further to maximize the potential favorable effect of sirolimus on Treg:Tcon balance in the post-transplantation immune repertoire. Sirolimus significantly compromises B cell recovery in the first 6 months post-HCT, with potential complex effects on cGVHD that merit further study.
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9
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Guglieri-Lopez B, Perez-Pitarch A, Garcia-Cadenas I, Gimenez E, Barba P, Rabella N, Hernandez-Boluda JC, Fox L, Valcarcel D, Esquirol A, Ferriols-Lisart R, Sierra J, Solano C, Navarro D, Martino R, Piñana JL. Effect of Sirolimus Exposure on the Need for Preemptive Antiviral Therapy for Cytomeglovirus Infection after Allogeneic Hematopoietic Stem Cell Transplantation. Biol Blood Marrow Transplant 2019; 25:1022-1030. [DOI: 10.1016/j.bbmt.2019.01.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 01/04/2019] [Indexed: 11/16/2022]
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10
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Visweshwar N, Jaglal M, Sokol L, Djulbegovic B. Hematological Malignancies and Arterial Thromboembolism. Indian J Hematol Blood Transfus 2019; 35:611-624. [PMID: 31741612 PMCID: PMC6825093 DOI: 10.1007/s12288-019-01085-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 01/21/2019] [Indexed: 01/10/2023] Open
Abstract
Established guidelines exist for prevention and treatment of venous thromboembolism in hematological malignancies, but none for arterial thromboembolism. However, arterial and venous thromboembolism share the same provoking features—including altered procoagulant factors and defective fibrinolytic system. The morbidity for arterial thromboembolism is increasing in hematological malignancies, with the advent of immunomodulatory and targeted therapy. However, survival rate for hematological malignancy is improving. Consequently, as patients with hematological malignancies live longer, comorbidities including diabetes, hypertension and dyslipidemia, may accentuate arterial thrombosis. Thus far, the scientific literature on prophylaxis and treatment for arterial thromboembolism in hematological malignancies is limited. This review highlights the pathogenesis, incidence and clinical features of arterial thromboembolism in hematological malignancies.
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Affiliation(s)
- Nathan Visweshwar
- 1Division of Hematology, University of South Florida, Tampa, FL 33612 USA
| | - Michael Jaglal
- 2Division of Medical Oncology, Moffitt Cancer Center, Tampa, FL 35316 USA
| | - Lubomir Sokol
- 2Division of Medical Oncology, Moffitt Cancer Center, Tampa, FL 35316 USA
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11
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Piñana JL, Perez-Pitarch A, Guglieri-Lopez B, Giménez E, Hernandez-Boluda JC, Terol MJ, Ferriols-Lisart R, Solano C, Navarro D. Sirolimus exposure and the occurrence of cytomegalovirus DNAemia after allogeneic hematopoietic stem cell transplantation. Am J Transplant 2018; 18:2885-2894. [PMID: 29603596 DOI: 10.1111/ajt.14754] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 03/14/2018] [Accepted: 03/22/2018] [Indexed: 01/25/2023]
Abstract
Sirolimus appears to protect against cytomegalovirus (CMV) in organ transplant recipients. The effect of this drug in allogeneic hematopoietic stem cell transplantation recipients remains unexplored. By means of multivariate continuous-time Markov model analyses, we identified 3 independent covariates that significantly impacted the risk of CMV DNAemia: recipient/donor CMV serostatus, tacrolimus exposure, and sirolimus exposure. CMV-seropositive recipients with CMV-seronegative donors had a significantly higher probability of having detectable CMV DNAemia. Increasing the tacrolimus trough concentration from 0 to 16 ng/mL increased the probability of patients having detectable CMV DNAemia by 40% (from 40% to 80%), whereas this probability decreased by 25% (from 40% to 15%) when trough concentrations of sirolimus increased from 0 to 16 ng/mL. Sensitivity analysis showed that sirolimus exposure between 0 and 6 ng/mL has no or negligible effect on CMV DNAemia, but levels >8 ng/mL significantly decreased the number of detectable CMV DNAemia cases (the risk ratios decreased from 0.68 to 0.21 when whole blood sirolimus concentrations changed from 8 to 18 ng/mL, P < .01). In conclusion, we used a pharmacometric statistical tool to provide the first clinical evidence that fewer CMV DNAemia events become detectable as sirolimus exposure increases.
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Affiliation(s)
- José Luis Piñana
- Department of Hematology, Fundación de investigación, INCLIVA, Hospital Clínico Universitario, Valencia, Spain.,Department of Hematology, Hospital Universitari i Politècnic la Fe, Valencia, Spain.,CIBERONC, Instituto Carlos III, Madrid, Spain
| | | | | | - Estela Giménez
- Microbiology Service, Hospital Clínico Universitario, Valencia, Spain
| | | | - María José Terol
- Department of Hematology, Fundación de investigación, INCLIVA, Hospital Clínico Universitario, Valencia, Spain
| | | | - Carlos Solano
- Department of Hematology, Fundación de investigación, INCLIVA, Hospital Clínico Universitario, Valencia, Spain.,Department of Medicine, School of Medicine, University of Valencia, Valencia, Spain
| | - David Navarro
- Microbiology Service, Hospital Clínico Universitario, Valencia, Spain.,Department of Microbiology, School of Medicine, University of Valencia, Valencia, Spain
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12
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Modi D, Al-Kadhimi Z, Chen W, Jang H, Deol A, Ayash L, Bhutani D, Alavi A, Ratanatharathorn V, Uberti JP. A phase II study of tacrolimus and thymoglobulin as graft-versus-host-disease prophylaxis in related donor allogeneic hematopoietic cell transplantation. Am J Hematol 2018; 93:E96-E98. [PMID: 29318650 DOI: 10.1002/ajh.25035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Revised: 12/26/2017] [Accepted: 01/05/2018] [Indexed: 11/10/2022]
Affiliation(s)
- Dipenkumar Modi
- Department of Oncology; Karmanos Cancer Institute/Wayne State University; Detroit Michigan
| | - Zaid Al-Kadhimi
- Department of Hematology and Medical Oncology; Winship Cancer Center and Emory University; Atlanta Georgia
| | - Wei Chen
- Biostatistics Core, Department of Oncology; Karmanos Cancer Institute, Wayne State University; Detroit Michigan
| | - Hyejeong Jang
- Biostatistics Core, Department of Oncology; Karmanos Cancer Institute, Wayne State University; Detroit Michigan
| | - Abhinav Deol
- Department of Oncology; Blood and Marrow Stem Cell Transplant Program, Karmanos Cancer Institute/Wayne State University; Detroit Michigan
| | - Lois Ayash
- Department of Oncology; Blood and Marrow Stem Cell Transplant Program, Karmanos Cancer Institute/Wayne State University; Detroit Michigan
| | - Divaya Bhutani
- Department of Oncology; Blood and Marrow Stem Cell Transplant Program, Karmanos Cancer Institute/Wayne State University; Detroit Michigan
| | - Asif Alavi
- Department of Oncology; Blood and Marrow Stem Cell Transplant Program, Karmanos Cancer Institute/Wayne State University; Detroit Michigan
| | - Voravit Ratanatharathorn
- Department of Oncology; Blood and Marrow Stem Cell Transplant Program, Karmanos Cancer Institute/Wayne State University; Detroit Michigan
| | - Joseph P. Uberti
- Department of Oncology; Blood and Marrow Stem Cell Transplant Program, Karmanos Cancer Institute/Wayne State University; Detroit Michigan
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13
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Kharfan-Dabaja MA, Sheets K, Kumar A, Murthy HS, Nishihori T, Tsalatsanis A, Mina A, Mathews J, Ayala E, Chavez J, Perez LE, Betts BC, Anasetti C, Pidala J. Hypoalbuminaemia segregates different prognostic subgroups within the refined standard risk acute graft-versus-host disease score. Br J Haematol 2018; 180:854-862. [DOI: 10.1111/bjh.15105] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 11/13/2017] [Indexed: 01/12/2023]
Affiliation(s)
- Mohamed A. Kharfan-Dabaja
- Department of Blood and Marrow Transplantation and Cellular Immunotherapy; Moffitt Cancer Center; Tampa FL USA
| | - Kyle Sheets
- Scholarly Concentrations Program; Biomedical Research; Morsani College of Medicine; University of South Florida; Tampa FL USA
| | - Ambuj Kumar
- Program for Comparative Effectiveness Research; Morsani College of Medicine; University of South Florida; Tampa FL USA
| | - Hemant S. Murthy
- Department of Blood and Marrow Transplantation and Cellular Immunotherapy; Moffitt Cancer Center; Tampa FL USA
| | - Taiga Nishihori
- Department of Blood and Marrow Transplantation and Cellular Immunotherapy; Moffitt Cancer Center; Tampa FL USA
| | - Athanasios Tsalatsanis
- Program for Comparative Effectiveness Research; Morsani College of Medicine; University of South Florida; Tampa FL USA
| | - Alain Mina
- Department of Blood and Marrow Transplantation and Cellular Immunotherapy; Moffitt Cancer Center; Tampa FL USA
| | - John Mathews
- Department of Blood and Marrow Transplantation and Cellular Immunotherapy; Moffitt Cancer Center; Tampa FL USA
| | - Ernesto Ayala
- Department of Blood and Marrow Transplantation and Cellular Immunotherapy; Moffitt Cancer Center; Tampa FL USA
| | - Julio Chavez
- Department of Malignant Hematology; Moffitt Cancer Center; Tampa FL USA
| | - Lia E. Perez
- Department of Blood and Marrow Transplantation and Cellular Immunotherapy; Moffitt Cancer Center; Tampa FL USA
| | - Brian C. Betts
- Department of Blood and Marrow Transplantation and Cellular Immunotherapy; Moffitt Cancer Center; Tampa FL USA
| | - Claudio Anasetti
- Department of Blood and Marrow Transplantation and Cellular Immunotherapy; Moffitt Cancer Center; Tampa FL USA
| | - Joseph Pidala
- Department of Blood and Marrow Transplantation and Cellular Immunotherapy; Moffitt Cancer Center; Tampa FL USA
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14
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Baygan A, Aronsson-Kurttila W, Moretti G, Tibert B, Dahllöf G, Klingspor L, Gustafsson B, Khoein B, Moll G, Hausmann C, Svahn BM, Westgren M, Remberger M, Sadeghi B, Ringden O. Safety and Side Effects of Using Placenta-Derived Decidual Stromal Cells for Graft-versus-Host Disease and Hemorrhagic Cystitis. Front Immunol 2017; 8:795. [PMID: 28744284 PMCID: PMC5504152 DOI: 10.3389/fimmu.2017.00795] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 06/22/2017] [Indexed: 11/13/2022] Open
Abstract
Mesenchymal stromal cells (MSCs) are increasingly used in regenerate medicine. Placenta-derived decidual stromal cells (DSCs) are a novel therapy for acute graft-versus-host-disease (GVHD) and hemorrhagic cystitis (HC) after allogeneic hematopoietic stem cell transplantation (HSCT). DSCs are more immunosuppressive than MSCs. We assessed adverse events and safety using DSCs among 44 treated patients and 40 controls. The median dose of infused cells was 1.5 (range 0.9–2.9) × 106 DSCs/kg. The patients were given 2 (1–5) doses, with a total of 82 infusions. Monitoring ended 3 months after the last DSC infusion. Three patients had transient reactions during DSC infusion. Laboratory values, hemorrhages, and transfusions were similar in the two groups. The frequency of leukemic relapse (2/2, DSC/controls) and invasive fungal infections (6/6) were the same in the two groups. Causes of death were those seen in HSCT patients: infections (5/3), respiratory failure (1/1), circulatory failure (3/1), thromboembolism (1/0), multiorgan failure (0/1), and GVHD and others (2/7). One-year survival for the DSC patients with GVHD was 67%, which was significantly better than achieved previously at our center. One-year survival was 90% in the DSC-treated HC group. DSC infusions appear safe. Randomized studies are required to prove efficacy.
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Affiliation(s)
- Arjang Baygan
- Translational Cell Therapy Research Group (TCR), Division of Therapeutic Immunology, Department of LabMed, Karolinska Institutet, Stockholm, Sweden
| | - Wictor Aronsson-Kurttila
- Translational Cell Therapy Research Group (TCR), Division of Therapeutic Immunology, Department of LabMed, Karolinska Institutet, Stockholm, Sweden
| | - Gianluca Moretti
- Translational Cell Therapy Research Group (TCR), Division of Therapeutic Immunology, Department of LabMed, Karolinska Institutet, Stockholm, Sweden
| | - Babylonia Tibert
- Translational Cell Therapy Research Group (TCR), Division of Therapeutic Immunology, Department of LabMed, Karolinska Institutet, Stockholm, Sweden
| | - Göran Dahllöf
- Department of Dental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Lena Klingspor
- Department of Microbiology, Uppsala University Hospital, Uppsala, Sweden
| | - Britt Gustafsson
- Department of Pediatrics, Uppsala University Hospital, Uppsala, Sweden
| | - Bita Khoein
- Translational Cell Therapy Research Group (TCR), Division of Therapeutic Immunology, Department of LabMed, Karolinska Institutet, Stockholm, Sweden
| | - Guido Moll
- Translational Cell Therapy Research Group (TCR), Division of Therapeutic Immunology, Department of LabMed, Karolinska Institutet, Stockholm, Sweden.,Charité Universitätsmedizin, Berlin, Germany
| | - Charlotta Hausmann
- Center for Allogeneic Stem Cell Transplantation, Department of Pathology/Oncology, Karolinska University Hospital, Stockholm, Sweden
| | - Britt-Marie Svahn
- Translational Cell Therapy Research Group (TCR), Division of Therapeutic Immunology, Department of LabMed, Karolinska Institutet, Stockholm, Sweden
| | - Magnus Westgren
- Department of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden
| | - Mats Remberger
- Center for Allogeneic Stem Cell Transplantation, Department of Pathology/Oncology, Karolinska University Hospital, Stockholm, Sweden
| | - Behnam Sadeghi
- Translational Cell Therapy Research Group (TCR), Division of Therapeutic Immunology, Department of LabMed, Karolinska Institutet, Stockholm, Sweden
| | - Olle Ringden
- Translational Cell Therapy Research Group (TCR), Division of Therapeutic Immunology, Department of LabMed, Karolinska Institutet, Stockholm, Sweden
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15
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Piñana JL, Perez-Pitarch A, Garcia-cadenas I, Barba P, Hernandez-Boluda JC, Esquirol A, Fox ML, Terol MJ, Queraltó JM, Vima J, Valcarcel D, Ferriols-Lisart R, Sierra J, Solano C, Martino R. A Time-to-Event Model for Acute Kidney Injury after Reduced-Intensity Conditioning Stem Cell Transplantation Using a Tacrolimus- and Sirolimus-based Graft-versus-Host Disease Prophylaxis. Biol Blood Marrow Transplant 2017; 23:1177-1185. [DOI: 10.1016/j.bbmt.2017.03.035] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 03/30/2017] [Indexed: 10/19/2022]
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16
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Low incidence of severe cGvHD and late NRM in a phase II trial of thymoglobulin, tacrolimus and sirolimus for GvHD prevention. Bone Marrow Transplant 2017; 52:1304-1310. [PMID: 28581472 DOI: 10.1038/bmt.2017.95] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2016] [Revised: 03/17/2017] [Accepted: 04/14/2017] [Indexed: 12/22/2022]
Abstract
Chronic GvHD (cGvHD) is the leading cause of late non-relapse mortality (NRM) and morbidity after allogeneic hematopoietic stem cell transplant (AHSCT). We analyzed the late effects of a phase II trial testing the efficacy of intermediate dose rabbit anti-thymocyte globulin (Thymoglobulin Thymo) in combination with tacrolimus and sirolimus (TTS) in 47 patients (pts) for the prevention of acute and chronic GvHD after unrelated AHSCT. The median follow-up was 45.2 months. The cumulative incidence of NIH severe cGvHD at 48 months was 6.4% with no new occurrences past 6 months for the entire follow-up period. The overall cumulative incidence of cGvHD was 44.7%. Out of 20 pts who are alive and disease-free at the last follow-up, only 4 pts continue to need systemic immune suppression. We observed low late NRM with only 3 transplant-related deaths after 6 months post transplant. At 4 years of follow-up, the overall cumulative incidence of NRM and disease relapse was 27.7% and 30.0%, respectively. PFS and overall survival (OS) at 4 years were 42 and 47%. At long term follow-up, TTS was associated with low incidence of severe cGvHD and late NRM.
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17
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Sensing danger: toll-like receptors and outcome in allogeneic hematopoietic stem cell transplantation. Bone Marrow Transplant 2016; 52:499-505. [PMID: 27941769 DOI: 10.1038/bmt.2016.263] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 07/21/2016] [Accepted: 07/22/2016] [Indexed: 12/18/2022]
Abstract
Pattern recognition receptors (PRRs) such as Toll-like receptors (TLRs) play key roles in initiating innate and adaptive immune responses. Based mainly on animal studies there is growing evidence to suggest that TLRs are involved in the development of chemotherapy-induced mucositis and in the propagation of graft versus host reactions as well as graft versus tumor effects in allogeneic hematopoietic stem cell transplantation (HSCT). In this review we discuss these findings along with the emerging, although still preliminary, clinical evidence, that points to a role of PRRs in determining the outcome of HSCT and new therapeutic perspectives that may be related to this development.
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18
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Kharfan-Dabaja MA, Parody R, Perkins J, Lopez-Godino O, Lopez-Corral L, Vazquez L, Caballero D, Falantes J, Shapiro J, Ortí G, Barba P, Valcárcel D, Esquirol A, Martino R, Piñana JL, Solano C, Tsalatsanis A, Pidala J, Anasetti C, Perez-Simón JA. Tacrolimus plus sirolimus with or without ATG as GVHD prophylaxis in HLA-mismatched unrelated donor allogeneic stem cell transplantation. Bone Marrow Transplant 2016; 52:438-444. [PMID: 27819684 DOI: 10.1038/bmt.2016.269] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Revised: 08/23/2016] [Accepted: 08/24/2016] [Indexed: 12/28/2022]
Abstract
HLA-matched related or unrelated donors are not universally available. Consequently, patients can be offered hematopoietic stem cell transplantation (HSCT) from alternative donors, including mismatched unrelated donors (MMURD), known to cause a higher incidence of acute GVHD (aGVHD) and chronic GVHD. In vivo T-cell-depletion strategies, such as antithymocyte globulin (ATG) therapy, significantly decrease the risk of GVHD. We performed a multicenter, retrospective study comparing tacrolimus (TAC) and sirolimus (SIR) with or without ATG in 104 patients (TAC-SIR=45, TAC-SIR-ATG=59) who underwent MMURD HSCT. Use of ATG was associated with a lower incidence, albeit not statistically significant, of grades 2-4 aGVHD (46% vs 64%, P=0.09), no difference in grades 3-4 aGVHD (10% vs 15%, P=0.43), a trend for a lower incidence of moderate/severe chronic GVHD (16% vs 37%, P=0.09) and more frequent Epstein-Barr virus reactivation (54% vs 18%, P=0.0002). There were no statistically significant differences in 3-year overall survival (OS) (TAC-SIR-ATG=40% (95% confidence interval (CI)=24-56%) vs TAC-SIR=54% (95% CI=37-70%), P=0.43) or 3-year cumulative incidence of relapse/progression (TAC-SIR-ATG=40% (95% CI=28-58%) vs TAC-SIR=22% (95% CI=13-39%), P=0.92). An intermediate Center for International Blood & Marrow Transplant Research disease risk resulted in a significantly lower non-relapse mortality and better OS at 3 years. Our study suggests that addition of ATG to TAC-SIR in MMURD HSCT does not affect OS when compared with TAC-SIR alone.
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Affiliation(s)
- M A Kharfan-Dabaja
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - R Parody
- Department of Hematology, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla (IBIS)/CSIC, Sevilla, Spain
| | - J Perkins
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA.,College of Pharmacy, University of South Florida, Tampa, FL, USA
| | | | | | - L Vazquez
- Hospital Universitario de Salamanca, Salamanca, Spain
| | - D Caballero
- Hospital Universitario de Salamanca, Salamanca, Spain
| | - J Falantes
- Department of Hematology, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla (IBIS)/CSIC, Sevilla, Spain
| | - J Shapiro
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - G Ortí
- Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - P Barba
- Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - D Valcárcel
- Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - A Esquirol
- Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - R Martino
- Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - J L Piñana
- Hospital Clínico de Valenci, Valencia, Spain
| | - C Solano
- Hospital Clínico de Valenci, Valencia, Spain
| | - A Tsalatsanis
- Center for Evidence-Based Medicine, University of South Florida College of Medicine, Tampa, FL, USA
| | - J Pidala
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - C Anasetti
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - J A Perez-Simón
- Department of Hematology, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla (IBIS)/CSIC, Sevilla, Spain
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19
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Bejanyan N, Rogosheske J, DeFor TE, Lazaryan A, Arora M, Holtan SG, Jacobson PA, MacMillan ML, Verneris MR, Blazar BR, Weisdorf DJ, Wagner JE, Brunstein CG. Sirolimus and Mycophenolate Mofetil as Calcineurin Inhibitor-Free Graft-versus-Host Disease Prophylaxis for Reduced-Intensity Conditioning Umbilical Cord Blood Transplantation. Biol Blood Marrow Transplant 2016; 22:2025-2030. [PMID: 27519278 DOI: 10.1016/j.bbmt.2016.08.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 08/05/2016] [Indexed: 11/25/2022]
Abstract
The use of calcineurin inhibitors (CNIs) to reduce the risk of graft-versus-host disease (GVHD) after hematopoietic cell transplantation (HCT) requires intensive post-transplantation toxicity monitoring. Sirolimus-based GVHD prophylaxis is associated with a favorable toxicity profile and requires less intensive monitoring. However, the efficacy of sirolimus-based regimen compared with CNI-based regimen has not been evaluated in the setting of reduced-intensity conditioning (RIC) double umbilical cord blood (UCB) HCT. We compared outcomes of patients receiving sirolimus/mycophenolate mofetil (MMF) (n = 37) or cyclosporine (CSA)/MMF (n = 123) in an ongoing phase II study of RIC UCB transplantation. In multiple regression analysis, sirolimus/MMF did not influence the risk of grades II to IV or grades III and IV acute GVHD. In addition, there was no association between type of GVHD prophylaxis and hematopoietic engraftment. Infection density analysis found a significantly lower risk of infections with sirolimus/MMF between days +46 and +180 after HCT compared with CSA/MMF (3.4 versus 6.3 per 1000 patient-days, P = .03); however, no difference was observed before day +45. Sirolimus/MMF use resulted in no thrombotic microangiopathy, fewer instances of elevated serum creatinine >2 mg/dL (14% versus 45%; P <.01), and similar rates of sinusoidal obstruction syndrome (2.7% versus 4%; P = .68), compared with CSA/MMF. Disease-free survival at 1 year was 51% for sirolimus/MMF and 41% for CSA/MMF (P = .41), and sirolimus/MMF use did not influence the risk of nonrelapse mortality or survival. In conclusion, sirolimus/MMF GVHD prophylaxis was better tolerated and resulted in similar rates of GVHD and survival as compared to CSA/MMF after RIC double UCB transplantation.
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Affiliation(s)
- Nelli Bejanyan
- Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota.
| | - John Rogosheske
- Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, Minnesota
| | - Todd E DeFor
- Adult and Pediatric Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | - Aleksandr Lazaryan
- Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Mukta Arora
- Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Shernan G Holtan
- Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Pamala A Jacobson
- Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, Minnesota
| | - Margaret L MacMillan
- Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Michael R Verneris
- Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Bruce R Blazar
- Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Daniel J Weisdorf
- Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - John E Wagner
- Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Claudio G Brunstein
- Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
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20
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Törlén J, Ringdén O, Garming-Legert K, Ljungman P, Winiarski J, Remes K, Itälä-Remes M, Remberger M, Mattsson J. A prospective randomized trial comparing cyclosporine/methotrexate and tacrolimus/sirolimus as graft-versus-host disease prophylaxis after allogeneic hematopoietic stem cell transplantation. Haematologica 2016; 101:1417-1425. [PMID: 27662016 DOI: 10.3324/haematol.2016.149294] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 08/01/2016] [Indexed: 12/29/2022] Open
Abstract
Improvement of graft-versus-host disease prophylaxis remains an important goal in allogeneic hematopoietic stem cell transplantation. Based on reports of possibly preferential properties of sirolimus, we compared the standard regimen of cyclosporine and methotrexate (n=106) with a combination of tacrolimus and sirolimus (n=103) as graft-versus-host disease prophylaxis after allogeneic hematopoietic stem cell transplantation in a prospective, open, randomized trial. The hypothesis was that the tacrolimus/sirolimus regimen would lead to less acute graft-versus-host disease and reduced transplant-related mortality. There was no significant difference in the cumulative incidence of acute graft-versus-host disease of grades II-IV (41% vs. 51%; P=0.19) or grades III-IV (13% vs. 7%; P=0.09) between the groups. Time to neutrophil engraftment (18 days vs. 17 days; P=0.24) was similar, but time to platelet engraftment was longer in cyclosporine/methotrexate patients (14 vs. 12 days; P<0.01). No significant differences in incidence of oropharyngeal mucositis, time to full donor chimerism, or number of cytomegalovirus infections were seen between the two treatment arms, and transplant-related toxicities were equally distributed. Triglyceride (P=0.005) and cholesterol (P=0.009) levels were higher in tacrolimus/sirolimus patients. Transplant-related mortality (18% vs. 12%; P=0.40) and 5-year overall survival (72% vs. 71%; P=0.71) were similar. Five-year relapse-free survival in patients with malignant diagnoses was 65% in the cyclosporine/methotrexate group and 63% in the tacrolimus/sirolimus group (P=0.73). We conclude that tacrolimus/sirolimus remains a valid and safe alternative to cyclosporine/methotrexate as graft-versus-host disease prophylaxis after allogeneic hematopoietic stem cell transplantation, with comparable transplant-related outcomes. The trial was registered at clinicaltrials.gov identifier: 00993343.
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Affiliation(s)
- Johan Törlén
- Center for Allogeneic Stem Cell Transplantation, Karolinska University Hospital, Stockholm, Sweden .,Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Olle Ringdén
- Center for Allogeneic Stem Cell Transplantation, Karolinska University Hospital, Stockholm, Sweden
| | - Karin Garming-Legert
- Division of Oral and Maxillofacial Surgery, Department of Dental Medicine, Karolinska Institutet, Huddinge, Sweden
| | - Per Ljungman
- Center for Allogeneic Stem Cell Transplantation, Karolinska University Hospital, Stockholm, Sweden.,Department of Hematology, Karolinska University Hospital and Division of Hematology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Jacek Winiarski
- Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Kari Remes
- Department of Internal Medicine, Turku University Hospital, Finland.,Turku University, Finland
| | | | - Mats Remberger
- Center for Allogeneic Stem Cell Transplantation, Karolinska University Hospital, Stockholm, Sweden.,Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Jonas Mattsson
- Center for Allogeneic Stem Cell Transplantation, Karolinska University Hospital, Stockholm, Sweden.,Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
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21
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Mayer S, Pastores SM, Riedel E, Maloy M, Jakubowski AA. Short- and long-term outcomes of adult allogeneic hematopoietic stem cell transplant patients admitted to the intensive care unit in the peritransplant period. Leuk Lymphoma 2016; 58:382-390. [PMID: 27347608 DOI: 10.1080/10428194.2016.1195499] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Survival of allogeneic hematopoietic stem cell transplant (aHSCT) recipients in the intensive care unit (ICU) has been poor. We retrospectively analyzed the short- and long-term outcomes of aHSCT patients admitted to the ICU over a 12-year period. Of 1235 adult patients who had aHSCT between 2002 and 2013, 161 (13%) were admitted to the ICU. The impact of clinical parameters was assessed and outcomes were compared for the periods 2002-2007 and 2008-2013. The ICU, in-hospital, 1- and 5-year survival rates were 64.6%, 46%, 33% and 20%, respectively. Mechanical ventilation and vasopressor use predicted for worse hospital- and overall survival (OS). After 2008, the requirement for mechanical ventilation and vasopressors, and the diagnosis of sepsis were reduced. While hospital mortality decreased from 69% to 44%, long-term survival (LTS) remained unchanged. Late deaths, due to causes not associated with the ICU such as relapse and graft-versus-host disease, increased. As thresholds for transplant are lowered, improvements in ICU outcomes for aHSCT recipients may be limited.
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Affiliation(s)
- Sebastian Mayer
- a Department of Medicine , New York Presbyterian Hospital, Joan and Sanford I Weill Medical College, Cornell University , New York , USA
| | - Stephen M Pastores
- a Department of Medicine , New York Presbyterian Hospital, Joan and Sanford I Weill Medical College, Cornell University , New York , USA.,b Departments of Anesthesiology and Critical Care Medicine , Memorial Sloan-Kettering Cancer Center , New York , USA
| | - Elyn Riedel
- c Epidemiology and Biostatistics , Memorial Sloan-Kettering Cancer Center , New York , USA
| | - Molly Maloy
- d Memorial Sloan Kettering Cancer Center , New York , USA
| | - Ann A Jakubowski
- e Department of Medicine , Memorial Sloan Kettering Cancer Center , New York , USA.,f Joan and Sanford I Weill Cornell Medical College, Cornell University , New York , New York , USA
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22
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Armand P, Kim HT, Sainvil MM, Lange PB, Giardino AA, Bachanova V, Devine SM, Waller EK, Jagirdar N, Herrera AF, Cutler C, Ho VT, Koreth J, Alyea EP, McAfee SL, Soiffer RJ, Chen YB, Antin JH. The addition of sirolimus to the graft-versus-host disease prophylaxis regimen in reduced intensity allogeneic stem cell transplantation for lymphoma: a multicentre randomized trial. Br J Haematol 2016; 173:96-104. [PMID: 26729448 DOI: 10.1111/bjh.13931] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Accepted: 11/18/2015] [Indexed: 11/28/2022]
Abstract
Inhibition of the mechanistic target of rapamycin (mTOR) pathway has clinical activity in lymphoma. The mTOR inhibitor sirolimus has been used in the prevention and treatment of graft-versus-host disease (GVHD) after allogeneic haematopoietic stem cell transplantation (HSCT). A retrospective study suggested that patients with lymphoma undergoing reduced intensity conditioning (RIC) HSCT who received sirolimus as part of their GVHD prophylaxis regimen had a lower rate of relapse. We therefore performed a multicentre randomized trial comparing tacrolimus, sirolimus and methotrexate to standard regimens in adult patients undergoing RIC HSCT for lymphoma in order to assess the possible benefit of sirolimus on HSCT outcome. 139 patients were randomized. There was no difference overall in 2-year overall survival, progression-free survival, relapse, non-relapse mortality or chronic GVHD. However, the sirolimus-containing arm had a significantly lower incidence of grade II-IV acute GVHD (9% vs. 25%, P = 0·015), which was more marked for unrelated donor grafts. In conclusion, the addition of sirolimus for GVHD prophylaxis in RIC HSCT is associated with no increased overall toxicity and a lower risk of acute GVHD, although it does not improve survival; this regimen is an acceptable option for GVHD prevention in RIC HSCT. This trial is registered at clinicaltrials.gov (NCT00928018).
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Affiliation(s)
- Philippe Armand
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Haesook T Kim
- Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, MA, USA
| | | | - Paulina B Lange
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Angela A Giardino
- Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA
| | - Veronika Bachanova
- Department of Medical Oncology, University of Minnesota, Minneapolis, MN, USA
| | - Steven M Devine
- Department of Medicine, The Ohio State University Comprehensive Cancer Center Ohio State University, Columbus, OH, USA
| | - Edmund K Waller
- Department of Hematology/Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Neera Jagirdar
- Department of Hematology/Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | | | - Corey Cutler
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Vincent T Ho
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - John Koreth
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Edwin P Alyea
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Steven L McAfee
- Bone Marrow Transplant Unit, Division of Hematology/Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Robert J Soiffer
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Yi-Bin Chen
- Bone Marrow Transplant Unit, Division of Hematology/Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Joseph H Antin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
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23
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Khaled SK, Palmer JM, Herzog J, Stiller T, Tsai NC, Senitzer D, Liu X, Thomas SH, Shayani S, Weitzel J, Forman SJ, Nakamura R. Influence of Absorption, Distribution, Metabolism, and Excretion Genomic Variants on Tacrolimus/Sirolimus Blood Levels and Graft-versus-Host Disease after Allogeneic Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2015; 22:268-276. [PMID: 26325438 DOI: 10.1016/j.bbmt.2015.08.027] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 08/19/2015] [Indexed: 01/23/2023]
Abstract
Allelic variants of genes implicated in drug absorption, distribution, metabolism, and excretion (ADME) determine the pharmacokinetic variability of many medications and are increasingly recognized as important factors determining the success or failure of medical treatments. Both tacrolimus and sirolimus have narrow therapeutic ranges maintained by therapeutic drug monitoring (TDM). Using an ADME panel that covers >99% of the PharmaADME working group core list (188 single nucleotide polymorphism [SNP] and 12 copy number variant [CNV] assays in 36 pharmacogenetically relevant genes), we studied 177 patients who underwent allogeneic hematopoietic cell transplantation (HCT) using tacrolimus/sirolimus-based graft-versus-host disease (GVHD) prophylaxis. We tested for possible associations between ADME variants and tacrolimus/sirolimus drug levels, concentration/dose (C/D) ratio, and clinical endpoints, including acute GVHD. A total of 62 SNP and 6 CNV assays were evaluable after removing the variants, which were homozygous in (nearly) all samples. For sirolimus, rs2032582 (ABCB1) T-carriers versus non-T-carriers were associated with higher blood levels (P = .01), with similar results for C/D ratio. Generalized estimating equation analysis supported these findings. For tacrolimus, rs776746 CYP3A5*3/*3 and CYP3A5*3/*1 were associated with higher blood levels than CYP3A5*1/*1 (P = .002). By multivariable analysis, rs776746 CYP3A5*3/*3 and CYP3A5*3/*1 were independently associated with decreased acute GVHD compared with CYP3A5*1/*1, after adjustment for conditioning, donor type, race/ethnicity, and age. We demonstrated association of specific ADME genetic polymorphisms with blood levels of tacrolimus/sirolimus, and incidence of acute GVHD after HCT, in spite of TDM and dose adjustment. A larger ongoing study will determine whether these associations have clinical utility beyond TDM.
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Affiliation(s)
- Samer K Khaled
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California; Gehr Family Center for Leukemia Research of the Hematologic Malignancies and Stem Cell Transplantation Institute of the City of Hope, Duarte, CA.
| | | | - Josef Herzog
- Division of Clinical Cancer Genetics, City of Hope, Duarte, California
| | - Tracey Stiller
- Division of Biostatistics, City of Hope, Duarte, California
| | - Ni-Chun Tsai
- Division of Biostatistics, City of Hope, Duarte, California
| | - David Senitzer
- Division of Histocompatibility (HLA Laboratory), City of Hope, Duarte, California
| | - Xueli Liu
- Division of Biostatistics, City of Hope, Duarte, California
| | - Sandra H Thomas
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | | | - Jeffrey Weitzel
- Division of Clinical Cancer Genetics, City of Hope, Duarte, California
| | - Stephen J Forman
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Ryotaro Nakamura
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
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24
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Blank G, Welker C, Sipos B, Sonntag K, Müller F, Eckert F, Seitz C, Nadalin S, LaCorcia G, Königsrainer A, Snell D, Handgretinger R, Schilbach K. Preemptive administration of human αβ T cell receptor-targeting monoclonal antibody GZ-αβTCR potently abrogates aggressive graft-versus-host disease in vivo. Ann Hematol 2015; 94:1907-19. [PMID: 26264693 DOI: 10.1007/s00277-015-2471-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 08/03/2015] [Indexed: 10/23/2022]
Abstract
GVHD, both acute and chronic, remains the major cause of morbidity and mortality after allogeneic hematopoietic stem cell transplantation. Thus, there is still a great need for therapeutic tools for the prevention and treatment of GVHD. Several biologics have shown promising results in salvage therapies but are attendant on an increased risk for opportunistic infections, lymphoproliferative disorders, and relapse. This is partly due to efficient T cell elimination that neither dissects alloreactive from non-alloreactive T cells nor considers functional and structural distinctiveness of pathogen- and malignancy-reactive γδ and iNKT T cells. A novel, humanized monoclonal antibody, GZ-αβTCR, specific for the human αβ T cell receptor, was evaluated in a xenogeneic GVHD model for its potential to prevent or ameliorate GVHD and prolong survival. We could show that GZ-αβTCR significantly attenuated clinical signs of GVHD and prolonged survival by preferential depletion of CD4 cells and the naïve T cell compartment, the trigger and driver of GVHD. In a regimen that included a preemptive dose, GZ-αβTCR treatment sufficiently abrogated GVHD. Importantly, GZ-αβTCR's specificity spared host cell-mediated immune competence of cell types other than αβT cells: namely γδT cells. GZ-αβTCR's outstanding capacity to prevent GVHD and ameliorate an ongoing GVHD while sparing immune cells other than αβT cells strongly recommends GZ-αβTCR for the prevention and treatment of acute GVHD in clinical settings.
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Affiliation(s)
- Gregor Blank
- Department of General, Visceral and Transplantation Surgery, University Hospital Tübingen, Tübingen, Germany.,Department of Pediatric Hematology and Oncology, University Children's Hospital Tübingen, Hoppe-Seyler Street 1, 72076, Tübingen, Germany
| | - Christian Welker
- Department of Pediatric Hematology and Oncology, University Children's Hospital Tübingen, Hoppe-Seyler Street 1, 72076, Tübingen, Germany
| | - Bence Sipos
- Department of Pathology, University Hospital Tübingen, Tübingen, Germany
| | - Katja Sonntag
- Department of Pediatric Hematology and Oncology, University Children's Hospital Tübingen, Hoppe-Seyler Street 1, 72076, Tübingen, Germany
| | - Friederike Müller
- Department of Pediatric Hematology and Oncology, University Children's Hospital Tübingen, Hoppe-Seyler Street 1, 72076, Tübingen, Germany
| | - Franziska Eckert
- Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany
| | - Christian Seitz
- Department of Pediatric Hematology and Oncology, University Children's Hospital Tübingen, Hoppe-Seyler Street 1, 72076, Tübingen, Germany
| | - Silvio Nadalin
- Department of General, Visceral and Transplantation Surgery, University Hospital Tübingen, Tübingen, Germany
| | | | - Alfred Königsrainer
- Department of General, Visceral and Transplantation Surgery, University Hospital Tübingen, Tübingen, Germany
| | | | - Rupert Handgretinger
- Department of Pediatric Hematology and Oncology, University Children's Hospital Tübingen, Hoppe-Seyler Street 1, 72076, Tübingen, Germany
| | - Karin Schilbach
- Department of Pediatric Hematology and Oncology, University Children's Hospital Tübingen, Hoppe-Seyler Street 1, 72076, Tübingen, Germany.
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25
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Gatza E, Choi SW. Approaches for the prevention of graft-versus-host disease following hematopoietic cell transplantation. Int J Hematol Oncol 2015; 4:113-126. [PMID: 27182433 DOI: 10.2217/ijh.15.13] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Allogeneic hematopoietic cell transplantation (HCT) is an important therapeutic option for malignant and non-malignant diseases, but the more widespread application of the therapy remains limited by the occurrence of graft versus host disease (GVHD). GVHD results from immune-mediated injury by donor immune cells against tissues in the HCT recipient, and can be characterized as acute or chronic depending on the time of onset and site of organ involvement. The majority of efforts have focused on GVHD prevention. Calcineurin inhibitors are the most widely used agents and are included in almost all regimens. Despite current prophylaxis strategies, 40-70% of patients remain at risk for developing GVHD. Herein, we review standard and emerging therapies used in GVHD management.
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Affiliation(s)
- Erin Gatza
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, MI, United States; Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, United States
| | - Sung Won Choi
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, MI, United States; Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, United States
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26
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García-Martín P, Alarcón-Payer C, López-Fernández E, Moratalla L, Romero A, Sainz J, Ríos R, Jurado M. Transplantation-Associated Thrombotic Microangiopathy in Patients Treated With Sirolimus and Cyclosporine as Salvage Therapy for Graft-Versus-Host Disease. Ann Pharmacother 2015; 49:986-94. [DOI: 10.1177/1060028015593369] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background: Transplantation-associated thrombotic microangiopathy (TA-TMA) is a rare complication of hematopoietic stem cell transplantation. Because sirolimus (SIR) and calcineurin inhibitor—either cyclosporine (CsA) or tacrolimus—have become more common as graft-versus-host disease (GVHD) prophylaxis, we are witnessing a higher frequency of this complication. Objective: To analyze the incidence, timing, and management of TA-TMA in patients who received the combination of CsA and SIR as therapy for uncontrolled GVHD in one single center. Methods: This was a retrospective analysis from February 2002 to June 2014 of the combination of SIR and CsA as salvage therapy in 61 patients with treatment-refractory or relapsed acute GVHD (n = 24) or chronic GVHD (n = 37) in a tertiary hospital. Results: A total of 61 patients received CsA and SIR as salvage therapy for acute (n = 16), late acute (n = 8), overlap syndrome (n = 22), or classic chronic (n = 15) GVHD. We identified 13 patients with TA-TMA (21.3%), and the status of GVHD was active in 11 of 13 patients. Only 1 patient showed high CsA levels, and 6 of 13 patients had very high concentrations of SIR in blood. We used an enzyme inducer in 6 patients, which proved effective in 3. Overall survival for TA-TMA patients was inferior compared to that for non TA-TMA patients at 12 months (42.9% vs 51.9%) and 24 months (34.3% vs 49.1%), although this difference was not significant. Conclusion: Prompt identification and good management of TA-TMA, with better control of GVHD, may contribute to a decrease in patient mortality that would result from this complication.
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Affiliation(s)
- Paloma García-Martín
- Department of Hematology, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | | | - Elisa López-Fernández
- Department of Hematology, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Lucía Moratalla
- Department of Hematology, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Antonio Romero
- Department of Hematology, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Juan Sainz
- Department of Hematology, Hospital Universitario Virgen de las Nieves, Granada, Spain
- Genyo, Pfizer-University of Granada-Junta de Andalucía, Granada, Spain
| | - Rafael Ríos
- Department of Hematology, Hospital Universitario Virgen de las Nieves, Granada, Spain
- Genyo, Pfizer-University of Granada-Junta de Andalucía, Granada, Spain
| | - Manuel Jurado
- Department of Hematology, Hospital Universitario Virgen de las Nieves, Granada, Spain
- Genyo, Pfizer-University of Granada-Junta de Andalucía, Granada, Spain
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27
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Wang L, Gu Z, Zhai R, Li D, Zhao S, Luo L, Zhao X, Wei H, Pang Z, Wang L, Liu D, Wang Q, Gao C. The efficacy and safety of sirolimus-based graft-versus-host disease prophylaxis in patients undergoing allogeneic hematopoietic stem cell transplantation: a meta-analysis of randomized controlled trials. Transfusion 2015; 55:2134-41. [PMID: 25857725 DOI: 10.1111/trf.13110] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Revised: 01/16/2015] [Accepted: 03/03/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND The efficacy and safety of sirolimus (SIR)-based graft-versus-host disease (GVHD) prophylaxis in patients who were subjected to allogeneic hematopoietic stem cell transplantation (allo-HSCT) remain to be clarified; this meta-analysis was conducted to evaluate these factors. STUDY DESIGN AND METHODS Data from original research were obtained from PubMed, Embase, and Cochrane central register of controlled trials databases. Randomized controlled trials (RCTs) evaluating the efficacy of SIR-based prophylaxis in allo-HSCT were included. The risk ratio (RR), with a 95% confidence interval (CI), was used to pool data. The random effects model was used, irrespective of the presence or absence of heterogeneity. RESULTS Five RCTs were included in the meta-analysis. SIR was observed to significantly decrease the incidence of Grade II to IV acute GVHD (aGVHD; RR, 0.65; 95% CI, 0.47-0.89). However, the incidence of Grade III to IV aGVHD and chronic GVHD was not decreased (RR, 0.91; 95% CI, 0.59-1.40; RR, 1.04; 95% CI, 0.88-1.23, respectively). An analysis of the toxic effects of SIR revealed that SIR effected a significant increase in the incidence of sinusoidal obstructive syndrome (RR, 2.24; 95% CI, 1.26-4.01), while that of thrombotic microangiopathy was not significantly increased (RR, 2.48; 95% CI, 0.87-7.06). Moreover, SIR did not improve event-free survival and overall survival (RR, 0.97; 95% CI, 0.85-1.10; and RR, 0.92; 95% CI, 0.82-1.02, respectively). CONCLUSION This meta-analysis indicated that the SIR-based regimen is an effective and safe alternative prophylaxis strategy for GVHD.
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Affiliation(s)
- Li Wang
- Department of Hematology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Zhenyang Gu
- Department of Hematology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Ruiren Zhai
- Department of Hematology and Oncology, Laoshan Branch of No. 401 Hospital of Chinese PLA, Qingdao, China
| | - Dandan Li
- Department of Hematology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Shasha Zhao
- Department of Hematology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Lan Luo
- Department of Hematology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Xiaoli Zhao
- Department of Hematology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Huaping Wei
- Department of Hematology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Zhaoxia Pang
- Department of Hematology and Oncology, Laoshan Branch of No. 401 Hospital of Chinese PLA, Qingdao, China
| | - Lili Wang
- Department of Hematology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Daihong Liu
- Department of Hematology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Quanshun Wang
- Department of Hematology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Chunji Gao
- Department of Hematology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
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28
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Remberger M, Törlén J, Ringdén O, Engström M, Watz E, Uhlin M, Mattsson J. Effect of Total Nucleated and CD34(+) Cell Dose on Outcome after Allogeneic Hematopoietic Stem Cell Transplantation. Biol Blood Marrow Transplant 2015; 21:889-93. [PMID: 25662230 DOI: 10.1016/j.bbmt.2015.01.025] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 01/26/2015] [Indexed: 12/16/2022]
Abstract
During more recent years only few studies have analyzed the effect of total nucleated cell (TNC) and CD34(+) cell dose in allogeneic hematopoietic stem cell transplantation (HSCT). A single-center analysis included 544 patients, 227 with a sibling donor and 317 with an unrelated donor. Most patients (n = 292) were treated with myeloablative conditioning, whereas the remaining patients (n = 252) received reduced-intensity conditioning. Bone marrow (BM) (n = 121) and peripheral blood stem cell (PBSC) grafts (n = 423) were analyzed separately. Median TNC and CD34(+) cell dose was 3.2 × 10(8)/kg versus 11.6 × 10(8)/kg in BM and 3.9 × 10(6)/kg versus 8.1 × 10(6)/kg in PBSC. In the BM group we found a higher TNC and CD34(+) cell dose was associated with a faster neutrophil engraftment (P < .001 and P = .02). In the PBSC group we found patients given a very high (≥11 × 10(6)/kg) CD34(+) cell dose had decreased rates of survival (P = .001) and increased relapse (P = .02). A high CD34(+) cell dose correlated with faster platelet engraftment (P < .01). In HSCT using PBSCs, the CD34(+) cell doses should be kept below 11 × 10(6)/kg but over 2.5 × 10(6)/kg.
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Affiliation(s)
- Mats Remberger
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden; Center for Allogeneic Stem Cell Transplantation, Karolinska University Hospital Huddinge, Stockholm, Sweden.
| | - Johan Törlén
- Center for Allogeneic Stem Cell Transplantation, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Olle Ringdén
- Center for Allogeneic Stem Cell Transplantation, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Mats Engström
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden; Center for Allogeneic Stem Cell Transplantation, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Emma Watz
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden; Department of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Michael Uhlin
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden; Center for Allogeneic Stem Cell Transplantation, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Jonas Mattsson
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden; Center for Allogeneic Stem Cell Transplantation, Karolinska University Hospital Huddinge, Stockholm, Sweden
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29
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Galera P, Martin HC, Welch L, Sulmasy P, Cerny J, Greene M, Vauthrin M, Bailey JA, Weinstein R. Automated red blood cell exchange for acute drug removal in a patient with sirolimus toxicity. J Clin Apher 2015; 30:367-70. [DOI: 10.1002/jca.21381] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Accepted: 12/17/2014] [Indexed: 11/09/2022]
Affiliation(s)
- Pallavi Galera
- Transfusion Medicine and Apheresis Service; UMass Memorial Medical Center; Worcester Massachusetts
- Department of Pathology; University of Massachusetts Medical School; Worcester Massachusetts
| | - Hannah C. Martin
- Transfusion Medicine and Apheresis Service; UMass Memorial Medical Center; Worcester Massachusetts
- University of Massachusetts Medical School; Worcester Massachusetts
| | - Linda Welch
- Transfusion Medicine and Apheresis Service; UMass Memorial Medical Center; Worcester Massachusetts
| | - Paula Sulmasy
- Transfusion Medicine and Apheresis Service; UMass Memorial Medical Center; Worcester Massachusetts
| | - Jan Cerny
- University of Massachusetts Medical School; Worcester Massachusetts
- Division of Hematology/Oncology; UMass Memorial Medical Center; Worcester Massachusetts
- Department of Medicine; University of Massachusetts Medical School; Worcester Massachusetts
| | - Mindy Greene
- Transfusion Medicine and Apheresis Service; UMass Memorial Medical Center; Worcester Massachusetts
| | - Michelle Vauthrin
- Transfusion Medicine and Apheresis Service; UMass Memorial Medical Center; Worcester Massachusetts
| | - Jeffrey A. Bailey
- Transfusion Medicine and Apheresis Service; UMass Memorial Medical Center; Worcester Massachusetts
- Department of Pathology; University of Massachusetts Medical School; Worcester Massachusetts
- University of Massachusetts Medical School; Worcester Massachusetts
- Department of Medicine; University of Massachusetts Medical School; Worcester Massachusetts
- Division of Transfusion Medicine; UMass Memorial Medical Center; Worcester Massachusetts
| | - Robert Weinstein
- Transfusion Medicine and Apheresis Service; UMass Memorial Medical Center; Worcester Massachusetts
- Department of Pathology; University of Massachusetts Medical School; Worcester Massachusetts
- University of Massachusetts Medical School; Worcester Massachusetts
- Department of Medicine; University of Massachusetts Medical School; Worcester Massachusetts
- Division of Transfusion Medicine; UMass Memorial Medical Center; Worcester Massachusetts
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30
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Abstract
Allogeneic hematopoietic cell transplantation (allo-HCT) is used for the treatment of a variety of disorders, primarily hematologic malignancies. Graft-versus-host disease (GVHD) is a significant complication following allo-HCT and a major cause of morbidity and mortality. The oral cavity is frequently involved in GVHD, leading to pain, functional impairment, and reduced quality of life. Early diagnosis, management, and long-term follow-up of oral GVHD are important components of overall patient care.
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Affiliation(s)
- Michal Kuten-Shorrer
- Department of Oral Medicine, Infection, and Immunity, Harvard School of Dental Medicine, 188 Longwood Avenue, Boston, MA 02115, USA
| | - Sook-Bin Woo
- Division of Oral Medicine and Dentistry, Brigham and Women's Hospital, 1620 Tremont Street, 3rd Floor, Boston, MA 02115, USA
| | - Nathaniel S Treister
- Division of Oral Medicine and Dentistry, Brigham and Women's Hospital, 1620 Tremont Street, 3rd Floor, Boston, MA 02115, USA.
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31
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Mycophenolate mofetil-based salvage as acute GVHD prophylaxis after early discontinuation of tacrolimus and/or sirolimus. Bone Marrow Transplant 2014; 50:307-9. [PMID: 25365064 DOI: 10.1038/bmt.2014.245] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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32
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Parody R, Lopez-Corral L, Godino OL, Cadenas IG, Martinez AP, Vazquez L, Martino R, Martinez C, Solano C, Barba P, Valcarcel D, Caballero-Velazquez T, Marquez-Malaver FJ, Sierra J, Caballero D, Perez-Simón JA. GVHD prophylaxis with sirolimus-tacrolimus may overcome the deleterious effect on survival of HLA mismatch after reduced-intensity conditioning allo-SCT. Bone Marrow Transplant 2014; 50:121-6. [PMID: 25310306 DOI: 10.1038/bmt.2014.220] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Revised: 08/11/2014] [Accepted: 08/15/2014] [Indexed: 02/05/2023]
Abstract
Large studies, mostly based on series of patients receiving CSA/tacrolimus (TKR) plus MTX as immunoprophylaxis, have demonstrated a deleterious effect on survival of the presence of a single mismatch out of eight loci after allogeneic hematopoietic SCT (alloHSCT). We retrospectively analyzed a series of 159 adult patients who received sirolimus(SRL)/TKR prophylaxis after alloHSCT. We compared overall outcomes according to HLA compatibility in A, B, C and DRB1 loci at the allele level: 7/8 (n=20) vs 8/8 (n=139). Donor type was unrelated in 95% vs 70% among 7/8 vs 8/8 pairs, respectively (P=0.01). No significant differences were observed in 3-year OS (68 vs 62%), 3-year EFS (53 vs 49%) and 1-year non-relapse mortality (9 vs 13%). Cumulative incidence of grades II-IV acute GVHD (aGVHD) was significantly higher in 7/8 alloHSCT (68% vs 42%, P<0.001) but no significant differences were found for III-IV aGVHD (4.5% vs 11%), overall (35% vs 53%) and extensive (20% vs 35%) chronic GHVD in 7/8 vs 8/8 subgroups, respectively. In summary, the present study indicates favorable outcomes after alloHSCT using the combination of SRL/TKR combination as GVHD prophylaxis with OS in the range of 55-70%, and non-significant differences in overall outcomes, irrespective of the presence of any mismatches at obligatory loci.
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Affiliation(s)
- R Parody
- Servicio de Hematología, Hospital Universitario / Instituto de Biomedicina (IBIS)/CSIC, Seville, Spain
| | | | - O L Godino
- Hospital Clínico de Salamanca, Salamanca, Spain
| | - I G Cadenas
- Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | | | - L Vazquez
- Hospital Clínico de Salamanca, Salamanca, Spain
| | - R Martino
- Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - C Martinez
- Hospital Clinic de Barcelona, Barcelona, Spain
| | - C Solano
- Hospital Clínico de Valencia, Valencia, Spain
| | - P Barba
- Hospital Vall d'Hebron, Barcelona, Spain
| | | | - T Caballero-Velazquez
- Servicio de Hematología, Hospital Universitario / Instituto de Biomedicina (IBIS)/CSIC, Seville, Spain
| | - F J Marquez-Malaver
- Servicio de Hematología, Hospital Universitario / Instituto de Biomedicina (IBIS)/CSIC, Seville, Spain
| | - J Sierra
- Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - D Caballero
- Hospital Clínico de Salamanca, Salamanca, Spain
| | - J A Perez-Simón
- Servicio de Hematología, Hospital Universitario / Instituto de Biomedicina (IBIS)/CSIC, Seville, Spain
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Ratanatharathorn V, Deol A, Ayash L, Cronin S, Bhutani D, Lum LG, Abidi M, Ventimiglia M, Mellert K, Uberti JP. Low-dose antithymocyte globulin enhanced the efficacy of tacrolimus and mycophenolate for GVHD prophylaxis in recipients of unrelated SCT. Bone Marrow Transplant 2014; 50:106-12. [PMID: 25285804 DOI: 10.1038/bmt.2014.203] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Revised: 07/03/2014] [Accepted: 07/29/2014] [Indexed: 11/12/2022]
Abstract
We performed a retrospective analysis of the outcome of 197 consecutive unrelated donor transplant recipients who received GVHD prophylaxis either TM regimen (tacrolimus and mycophenolate) (121 patients) or TM/ATG-G regimen (TM with low-dose antithymocyte globulin (ATG) of 4.5 mg/kg, ATG-G, Genzyme) (76 patients). Cumulative incidences of grade II-IV acute GVHD for the TM and TM/ATG-G cohorts were 49% and 61% (P=0.11) and grade III-IV acute GVHD for the TM and TM/ATG-G cohorts were 27% and 14% (P=0.02), respectively. There was no difference in the incidence of relapse or disease progression between TM and TM/ATG-G-16% and 23% (P=0.64). TM/ATG-G cohort had lower incidence of non-relapse mortality (NRM; 37% vs 20%, P=0.01), chronic GVHD (56% vs 43%, P<0.001) and more favorable global chronic GVHD severity (P<0.001). Univariate analyses showed improved OS and PFS of patients who received TM/ATG-G. Multivariate analysis confirmed TM/ATG-G had a favorable influence on OS (P=0.05) but not on PFS (P=0.07). We concluded that low-dose ATG of 4.5 mg/kg given in conjunction with TM improved GVHD prophylaxis without increased risk of relapse. Lower NRM, lower incidence and severity of chronic GVHD could potentially improve survival.
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Affiliation(s)
- V Ratanatharathorn
- Blood and Marrow Stem Cell Transplantation Program, Department of Oncology, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI, USA
| | - A Deol
- Blood and Marrow Stem Cell Transplantation Program, Department of Oncology, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI, USA
| | - L Ayash
- Blood and Marrow Stem Cell Transplantation Program, Department of Oncology, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI, USA
| | - S Cronin
- Blood and Marrow Stem Cell Transplantation Program, Department of Oncology, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI, USA
| | - D Bhutani
- Blood and Marrow Stem Cell Transplantation Program, Department of Oncology, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI, USA
| | - L G Lum
- Blood and Marrow Stem Cell Transplantation Program, Department of Oncology, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI, USA
| | - M Abidi
- Blood and Marrow Stem Cell Transplantation Program, Department of Oncology, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI, USA
| | - M Ventimiglia
- Blood and Marrow Stem Cell Transplantation Program, Department of Oncology, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI, USA
| | - K Mellert
- Blood and Marrow Stem Cell Transplantation Program, Department of Oncology, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI, USA
| | - J P Uberti
- Blood and Marrow Stem Cell Transplantation Program, Department of Oncology, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI, USA
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Kornblit B, Maloney DG, Storer BE, Maris MB, Vindeløv L, Hari P, Langston AA, Pulsipher MA, Bethge WA, Chauncey TR, Lange T, Petersen FB, Hübel K, Woolfrey AE, Flowers MED, Storb R, Sandmaier BM. A randomized phase II trial of tacrolimus, mycophenolate mofetil and sirolimus after non-myeloablative unrelated donor transplantation. Haematologica 2014; 99:1624-31. [PMID: 25085357 DOI: 10.3324/haematol.2014.108340] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The study is a randomized phase II trial investigating graft-versus-host disease prophylaxis after non-myeloablative (90 mg/m(2) fludarabine and 2 Gy total body irradiation) human leukocyte antigen matched unrelated donor transplantation. Patients were randomized as follows: arm 1 - tacrolimus 180 days and mycophenolate mofetil 95 days (n=69); arm 2 - tacrolimus 150 days and mycophenolate mofetil 180 days (n=71); arm 3 - tacrolimus 150 days, mycophenolate mofetil 180 days and sirolimus 80 days (n=68). All patients had sustained engraftment. Grade II-IV acute graft-versus-host disease rates in the 3 arms were 64%, 48% and 47% at Day 150, respectively (arm 3 vs. arm 1 (hazard ratio 0.62; P=0.04). Owing to the decreased incidence of acute graft-versus-host disease, systemic steroid use was lower at Day 150 in arm 3 (32% vs. 55% in arm 1 and 49% in arm 2; overall P=0.009 by hazard ratio analysis). The Day 150 incidence of cytomegalovirus reactivation was lower in arm 3 (arm 1, 54%; arm 2, 47%; arm 3, 22%; overall P=0.002 by hazard ratio analysis). Non-relapse mortality was comparable in the three arms at two years (arm 1, 26%; arm 2, 23%; arm 3, 18%). Toxicity rates and other outcome measures were similar between the three arms. The addition of sirolimus to tacrolimus and mycophenolate mofetil is safe and associated with lower incidence of acute graft-versus-host disease and cytomegalovirus reactivation. (clinicaltrials.gov identifier: 00105001).
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Affiliation(s)
- Brian Kornblit
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - David G Maloney
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA Division of Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Barry E Storer
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA Department of Biostatistics, University of Washington, Seattle, WA, USA
| | | | | | | | | | - Michael A Pulsipher
- Division of Hematology and Hematologic Malignancies, Huntsman Cancer Institute, University of Utah School of Medicine, Salt Lake City, UT, USA
| | | | | | | | | | | | - Ann E Woolfrey
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA Division of Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Mary E D Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA Division of Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Rainer Storb
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA Division of Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Brenda M Sandmaier
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA Division of Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
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Abstract
Pharmacologic inhibition of the mechanistic target of rapamycin (mTOR) represents a stress test for tumor cells and T cells. Mechanisms exist that allow cells to survive this stress, including suboptimal target block, alternative signaling pathways, and autophagy. Rapamycin-resistant effector T (T-Rapa) cells have an altered phenotype that associates with increased function. Ex vivo rapamycin, when used in combination with polarizing cytokines and antigen-presenting-cell free costimulation, is a flexible therapeutic approach as polarization to T-helper 1 (Th1)- or Th2-type effectors is possible. Murine T-Rapa cells skewed toward a Th2-type prevented graft rejection and graft-versus-host disease (GVHD) more potently than control Th2 cells and effectively balanced GVHD and graft-versus-tumor (GVT) effects. A phase II clinical trial using low-intensity allogeneic hematopoietic cell transplantation demonstrated that interleukin-4 polarized human T-Rapa cells had a mixed Th2/Th1 phenotype; T-Rapa cell recipients had a balanced Th2/Th1 cytokine profile, conversion of mixed chimerism toward full donor chimerism, and a potentially favorable balance between GVHD and GVT effects. In addition, a phase I clinical trial evaluating autologous T-Rapa cells skewed toward a Th1- and Tc1-type is underway. Use of ex vivo rapamycin to modulate effector T-cell function represents a promising new approach to transplantation therapy.
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Affiliation(s)
- Daniel H Fowler
- Experimental Transplantation and Immunology Branch, National Cancer Institute, Center for Cancer Research, Bethesda, MD, USA
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36
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Kharfan-Dabaja MA, Labopin M, Bazarbachi A, Hamladji RM, Blaise D, Socié G, Lioure B, Bermudez A, Lopez-Corral L, Or R, Arcese W, Fegueux N, Nagler A, Mohty M. Comparing i.v. BU dose intensity between two regimens (FB2 vs FB4) for allogeneic HCT for AML in CR1: a report from the Acute Leukemia Working Party of EBMT. Bone Marrow Transplant 2014; 49:1170-5. [PMID: 24978140 DOI: 10.1038/bmt.2014.133] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2014] [Revised: 05/07/2014] [Accepted: 05/12/2014] [Indexed: 01/20/2023]
Abstract
This retrospective analysis compared two regimens of fludarabine combined with i.v. BU 6.4 mg/kg (FB2) or BU 12.8 mg/kg (FB4) for allografting of AML in first CR. A total of 437 patients (median age: 50 years) were administered FB2 (n = 225, 51%) or FB4 (n = 212, 49%). Median follow-up time was 28 months. Use of FB2 resulted in a longer time to neutrophil engraftment (17 vs 15 days, P < 0.0001) but no difference in incidence of grade II-IV acute (P = 0.54) or chronic GVHD (P = 0.51). In patients < 50 years of age, FB2 was associated with a higher 2-year cumulative incidence of relapse (33 ± 6% vs 20 ± 4%, P = 0.04), but there was no difference in 2-year leukemia-free survival (LFS) (P = 0.45), OS (P = 0.53) or non-relapse mortality (P = 0.17). In recipients ⩾ 50 years of age, FB2 resulted in better 2-year LFS (63 ± 4% vs 42 ± 7%, P = 0.02) and OS (68 ± 4% vs 45 ± 7%, P = 0.006); a lower 2-year non-relapse mortality, albeit not statistically significant (15 ± 3% vs 29 ± 6%, P = 0.06), was observed with FB2. FB2 is an effective and well-tolerated regimen in patients ⩾ 50 years of age and does not compromise survival when used in patients <50 years undergoing allogeneic transplantation for AML in first CR.
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Affiliation(s)
- M A Kharfan-Dabaja
- 1] Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center/University of South Florida College of Medicine, Tampa, Florida, USA [2] Division of Hematology-Oncology and Bone Marrow Transplantation Program, American University of Beirut Medical Center, Beirut, Lebanon
| | - M Labopin
- Acute Leukemia Working Party of EBMT, Paris, France
| | - A Bazarbachi
- Division of Hematology-Oncology and Bone Marrow Transplantation Program, American University of Beirut Medical Center, Beirut, Lebanon
| | | | - D Blaise
- Unité de Transplantation et de Thérapie Cellulaire (U2T), Institut Paoli-Calmettes, Marseille, France
| | - G Socié
- Service d'Hématologie Greffe, Hôpital Saint Louis, Paris, France
| | - B Lioure
- CHU Hautepierre- Département d'Hématologie et Oncologie, Strasbourg, France
| | - A Bermudez
- Department of Hematology, Hospital Universitario Marqués de Valdecilla, Instituto de Formación e Investigación Marqués de Valdecilla, Santander, Spain
| | - L Lopez-Corral
- Servicio de Hematologia, Hospital Universitario de Salamanca, Salamanca, Spain
| | - R Or
- Department of Bone Marrow Transplantation and Cancer Immunotherapy, Hadassah University Hospital, Jerusalem, Israel
| | - W Arcese
- Rome Transplant Network, Department of Hematology, Stem Cell Transplant Unit, Tor Vergata University, Rome, Italy
| | - N Fegueux
- Service d'Hématologie, CHU, Montpellier, France
| | - A Nagler
- Hematology Division, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - M Mohty
- 1] Acute Leukemia Working Party of EBMT, Paris, France [2] Département d'Hématologie, Hopital Saint Antoine, Paris, France
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37
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Tacrolimus/sirolimus vs tacrolimus/methotrexate as GVHD prophylaxis after matched, related donor allogeneic HCT. Blood 2014; 124:1372-7. [PMID: 24982504 DOI: 10.1182/blood-2014-04-567164] [Citation(s) in RCA: 150] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Grades 2-4 acute graft-versus-host disease (GVHD) occurs in approximately 35% of matched, related donor (MRD) allogeneic hematopoietic cell transplantation (HCT) recipients. We sought to determine if the combination of tacrolimus and sirolimus (Tac/Sir) was more effective than tacrolimus and methotrexate (Tac/Mtx) in preventing acute GVHD and early mortality after allogeneic MRD HCT in a phase 3, multicenter trial. The primary end point of the trial was to compare 114-day grades 2-4 acute GVHD-free survival using an intention-to-treat analysis of 304 randomized subjects. There was no difference in the probability of day 114 grades 2-4 acute GVHD-free survival (67% vs 62%, P = .38). Grades 2-4 GVHD was similar in the Tac/Sir and Tac/Mtx arms (26% vs 34%, P = .48). Neutrophil and platelet engraftment were more rapid in the Tac/Sir arm (14 vs 16 days, P < .001; 16 vs 19 days, P = .03). Oropharyngeal mucositis was less severe in the Tac/Sir arm (peak Oral Mucositis Assessment Scale score 0.70 vs 0.96, P < .001), but otherwise toxicity was similar. Chronic GVHD, relapse-free survival, and overall survival at 2 years were no different between study arms (53% vs 45%, P = .06; 53% vs 54%, P = .77; and 59% vs 63%, P = .36). Based on similar long-term outcomes, more rapid engraftment, and less oropharyngeal mucositis, the combination of Tac/Sir is an acceptable alternative to Tac/Mtx after MRD HCT. This study was funded by the National Heart, Lung, and Blood Institute and the National Cancer Institute; and the trial was registered at www.clinicaltrials.gov as #NCT00406393.
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38
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Abstract
Graft-versus-host disease (GVHD) represents the most serious and challenging complication of allogeneic haematopoietic stem-cell transplantation (HSCT). New insights on the role of regulatory T-cells, T cells, and antigen-presenting cells have led to an improved understanding of the pathophysiology of GVHD. However, little progress has been made since the introduction of calcineurin-inhibitor-based regimens in the mid-1980s. Despite standard prophylaxis with these regimens, GVHD still develops in approximately 40-60% of recipients. Thus, there is a need for developing newer approaches to mitigate GVHD, which may facilitate the use of allogeneic HSCT for the treatment of a wider range of haematological cancers. We discuss the rationale, clinical evidence, and outcomes of current (and widely employed) strategies for GVHD prophylaxis, namely calcineurin-inhibitor-based regimens (such as cyclosporine or tacrolimus) combined with methotrexate or mycophenolate mofetil. We assess the clinical evidence for emerging approaches in the prevention of GVHD, including therapies targeting T cells or B cells, the use of mesenchymal stem cells, chemo-cytokine antagonists (such as maraviroc, TNF-α inhibitor, IL-2 receptor antagonist, IL-6 inhibitor), and the use of novel molecular regulators that target multiple cell types simultaneously, including atorvastatin, bortezomib, and epigenetic modulators.
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Peksa GD, Schultz K, Fung HC. Dosing algorithm for concomitant administration of sirolimus, tacrolimus, and an azole after allogeneic hematopoietic stem cell transplantation. J Oncol Pharm Pract 2014; 21:409-15. [PMID: 24938293 DOI: 10.1177/1078155214539825] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Allogeneic hematopoietic stem cell transplant patients are at risk of invasive fungal infections and prophylaxis with azole agents is common practice. The concomitant use of these agents with sirolimus and tacrolimus for the prevention of graft-versus-host disease may result in excessive immunosuppression or toxicity. METHODS This retrospective study identified hospitalized patients who underwent allogeneic hematopoietic stem cell transplantation between August 2009 and April 2011 at Rush University Medical Center. From this group, patients who underwent concomitant tacrolimus, sirolimus, and azole therapy were included for evaluation. The immunosuppression dosing in conjunction with azole use at discharge was analyzed to develop a dosing algorithm dependent on whether fluconazole, posaconazole, or voriconazole was used. RESULTS A total of 36 patients were screened for inclusion, of which 8 were excluded due to acute renal failure and/or hemolysis. The remaining patients were stratified by the azole they were concomitantly taking with tacrolimus and sirolimus. The fluconazole arm required the lowest magnitude of dose reductions, while voriconazole required the greatest. CONCLUSION Dose reductions of 50-75% for both sirolimus and tacrolimus, in combination with standard dosing of azole antifungal agents, were necessary to achieve therapeutic drug concentrations for immunosuppressants and potentially avoid toxicities.
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Affiliation(s)
- Gary D Peksa
- Department of Pharmacy, Rush University Medical Center, Chicago, IL, USA
| | - Kathryn Schultz
- Department of Pharmacy, Rush University Medical Center, Chicago, IL, USA
| | - Henry C Fung
- Division of Hematology, Oncology and Stem Cell Transplant, Rush University Medical Center, Chicago, IL, USA
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40
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Nakamura R, Forman SJ. Reduced intensity conditioning for allogeneic hematopoietic cell transplantation: considerations for evidence-based GVHD prophylaxis. Expert Rev Hematol 2014; 7:407-21. [DOI: 10.1586/17474086.2014.898561] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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41
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Pulsipher MA, Langholz B, Wall DA, Schultz KR, Bunin N, Carroll WL, Raetz E, Gardner S, Gastier-Foster JM, Howrie D, Goyal RK, Douglas JG, Borowitz M, Barnes Y, Teachey DT, Taylor C, Grupp SA. The addition of sirolimus to tacrolimus/methotrexate GVHD prophylaxis in children with ALL: a phase 3 Children's Oncology Group/Pediatric Blood and Marrow Transplant Consortium trial. Blood 2014; 123:2017-25. [PMID: 24497539 PMCID: PMC3968388 DOI: 10.1182/blood-2013-10-534297] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Accepted: 01/08/2014] [Indexed: 11/20/2022] Open
Abstract
Sirolimus has activity against acute lymphoblastic leukemia (ALL) in xenograft models and efficacy in preventing acute graft-versus-host disease (aGVHD). We tested whether addition of sirolimus to GVHD prophylaxis of children with ALL would decrease aGVHD and relapse. Patients were randomized to tacrolimus/methotrexate (standard) or tacrolimus/methotrexate/sirolimus (experimental). The study met futility rules for survival after enrolling 146 of 259 patients. Rate of Grade 2-4 aGVHD was 31% vs 18% (standard vs experimental, P = .04), however, grade 3-4 aGVHD was not different (13% vs 10%, P = .28). Rates of veno-occlusive disease (VOD) and thrombotic microangiopathy (TMA) were lower in the nonsirolimus arm (9% vs 21% VOD, P = .05; 1% vs 10% TMA, P = .06). At 2 years, event free survival (EFS) and overall survival (OS) were 56% vs 46%, and 65% vs 55% (standard vs experimental), respectively (P = .28 and .23). Multivariate analysis showed increased relapse risk in children with ≥0.1% minimal residual disease (MRD) pretransplant, and decreased risk in patients with grades 1-3 aGVHD (P = .04). Grades 1-3 aGVHD were associated with improved EFS (P = .02), whereas grade 4 aGVHD and extramedullary disease at diagnosis led to inferior OS. Although addition of sirolimus decreased aGVHD, survival was not improved. This study is registered with ClinicalTrials.gov as #NCT00382109.
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Affiliation(s)
- Michael A Pulsipher
- Division of Hematology and Hematological Malignancies, Huntsman Cancer Institute/University of Utah School of Medicine, Primary Children's Hospital, Salt Lake City, UT
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Yum SK, Choi HY, Lee JW, Jang PS, Chung NG, Jeong DC, Cho B, Kim HK. Evaluation of risk for graft-versus-host disease in children who receive less than the full doses of mini-dose methotrexate for graft-versus-host disease prophylaxis in allogeneic hematopoietic stem cell transplantation. KOREAN JOURNAL OF PEDIATRICS 2013; 56:490-5. [PMID: 24348662 PMCID: PMC3859882 DOI: 10.3345/kjp.2013.56.11.490] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Revised: 10/04/2013] [Accepted: 10/08/2013] [Indexed: 11/27/2022]
Abstract
PURPOSE The use of cyclosporine and mini-dose methotrexate (MTX) is a common strategy for graft-versus-host disease (GVHD) prophylaxis in allogeneic transplants. We investigated whether patients who receive fewer than the planned MTX doses are at increased risk for GVHD. METHODS The study cohort included 103 patients who received allogeneic transplants at the Department of Pediatrics of The Catholic University of Korea College of Medicine, from January 2010 to December 2011. MTX was administered on days 1, 3, 6, and 11 after transplant at a dose of 5 mg/m(2) each. Within the cohort, 76 patients (74%) received all 4 doses of MTX [MTX(4) group], while 27 patients (26%) received 0-3 doses [MTX(0-3) group]. RESULTS Although there was no difference in neutrophil engraftment between the 2 groups, platelet engraftment was significantly faster in the MTX(4) group (median, 15 days), compared to the MTX(0-3) group (median, 25 days; P=0.034). The incidence of grades II-IV acute GVHD was not different between the MTX(4) and MTX(0-3) groups (P=0.417). In the multivariate study, human leukocyte antigen mismatch was the most significant factor causing grades II-IV acute GVHD (P=0.002), followed by female donor to male recipient transplant (P=0.034). No difference was found between the MTX(4) and MTX (0-3) groups regarding grades III-IV acute GVHD, chronic GVHD, and disease-free survival. CONCLUSION Our results indicate that deviations from the full dose schedule of MTX for GVHD prophylaxis do not lead to increased incidence of either acute or chronic GVHD.
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Affiliation(s)
- Sook Kyung Yum
- Department of Pediatrics, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Hye-Yoon Choi
- Department of Pediatrics, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Jae Wook Lee
- Department of Pediatrics, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Pil-Sang Jang
- Department of Pediatrics, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Nack-Gyun Chung
- Department of Pediatrics, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Dae-Chul Jeong
- Department of Pediatrics, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Bin Cho
- Department of Pediatrics, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Hack-Ki Kim
- Department of Pediatrics, The Catholic University of Korea College of Medicine, Seoul, Korea
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Jim HSL, Barata A, Small BJ, Jacobsen PB, Pidala J. Quality of life associated with sirolimus for prevention of graft-versus-host disease: results from a randomized trial. Haematologica 2013; 99:548-53. [PMID: 24241491 DOI: 10.3324/haematol.2013.088781] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Several studies have examined sirolimus-based immune suppression for the prevention of graft-versus-host disease after allogeneic hematopoietic cell transplantation, but little is known regarding its effects on quality of life. The current study reports on changes in quality of life to Day 360 in a randomized phase II trial of sirolimus and tacrolimus versus methotrexate and tacrolimus. Quality of life was assessed prior to transplant and on Days 30, 90, 180, 270, and 360 with the Functional Assessment of Cancer Therapy - Bone Marrow Transplant Trial Outcome Index. Random effects models examined the effects of study arm on change in Trial Outcome Index scores from Day 30 to 360, controlling for base-line Trial Outcome Index. The sirolimus/tacrolimus arm (n=37) showed less improvement in Trial Outcome Index scores over time compared to the methotrexate/tacrolimus arm (n=34) (P=0.02). Patients receiving sirolimus and tacrolimus were more likely to endorse nausea and a lack of energy over time (PS≤0.01). These data suggest that sirolimus-based immune suppression is associated with less improvement in quality of life in the first year post-transplant compared to methotrexate/tacrolimus. Quality of life differences may be due to increased fatigue and nausea in patients treated with sirolimus. These findings should be considered in the clinical management of patients treated with sirolimus. (Clinicaltrials.gov identifier:00803010).
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Uhm J, Kuruvilla J. Allogeneic stem cell transplantation for diffuse large B cell lymphoma: Defining the role of allografts. Transfus Apher Sci 2013; 49:63-71. [DOI: 10.1016/j.transci.2013.05.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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45
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Farag SS, Srivastava S, Messina-Graham S, Schwartz J, Robertson MJ, Abonour R, Cornetta K, Wood L, Secrest A, Strother RM, Jones DR, Broxmeyer HE. In vivo DPP-4 inhibition to enhance engraftment of single-unit cord blood transplants in adults with hematological malignancies. Stem Cells Dev 2013; 22:1007-15. [PMID: 23270493 DOI: 10.1089/scd.2012.0636] [Citation(s) in RCA: 104] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Delayed engraftment is a significant limitation of umbilical cord blood (UCB) transplantation due to low stem cell numbers. Inhibition of dipeptidyl peptidase (DPP)-4 enhanced engraftment in murine transplants. We evaluated the feasibility of systemic DPP-4 inhibition using sitagliptin to enhance engraftment of single-unit UCB grafts in adults with hematological malignancies. Twenty-four patients (21-58 years) received myeloablative conditioning, followed by sitagliptin 600 mg orally days -1 to +2, and single UCB grafts day 0. Seventeen receiving red cell-depleted (RCD) grafts, matched at 4 (n=10) or 5 (n=7) of 6 human leucocyte antigen (HLA) loci with median nucleated cell dose 3.6 (2.5-5.2)×10(7)/kg, engrafted at median of 21 (range, 13-50) days with cumulative incidence of 94% (95% confidence interval, 84%-100%) at 50 days. Plasma DDP-4 activity was reduced to 23%±7% within 2 h. Area under DPP-4 activity-time curve (AUCA) correlated with engraftment; 9 of 11 with AUCA <6,000 activity·h engrafted within ≤21 days, while all 6 with higher AUCA engrafted later (P=0.002). Seven patients receiving red cell replete grafts had 10-fold lower colony forming units after thawing compared with RCD grafts, with poor engraftment. Systemic DPP-4 inhibition was well tolerated and may enhance engraftment. Optimizing sitagliptin dosing to achieve more sustained DPP-4 inhibition may further improve outcome.
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Affiliation(s)
- Sherif S Farag
- Division of Hematology-Oncology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana 46202, USA.
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Ramsey H, Pilat N, Hock K, Klaus C, Unger L, Schwarz C, Baranyi U, Gattringer M, Schwaiger E, Wrba F, Wekerle T. Anti-LFA-1 or rapamycin overcome costimulation blockade-resistant rejection in sensitized bone marrow recipients. Transpl Int 2012; 26:206-18. [PMID: 23240587 DOI: 10.1111/tri.12021] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2011] [Revised: 01/15/2012] [Accepted: 10/25/2012] [Indexed: 02/04/2023]
Abstract
While costimulation blockade-based mixed chimerism protocols work well for inducing tolerance in rodents, translation to preclinical large animal/nonhuman primate models has been less successful. One recognized cause for these difficulties is the high frequency of alloreactive memory T cells (Tmem) found in the (pre)clinical setting as opposed to laboratory mice. In the present study, we therefore developed a murine bone marrow transplantation (BMT) model employing recipients harboring polyclonal donor-reactive Tmem without concomitant humoral sensitization. This model was then used to identify strategies to overcome this additional immune barrier. We found that B6 recipients that were enriched with 3 × 10(7) T cells isolated from B6 mice that had been previously grafted with Balb/c skin, rejected Balb/c BM despite costimulation blockade with anti-CD40L and CTLA4Ig (while recipients not enriched developed chimerism). Adjunctive short-term treatment of sensitized BMT recipients with rapamycin or anti-LFA-1 mAb was demonstrated to be effective in controlling Tmem in this model, leading to long-term mixed chimerism and donor-specific tolerance. Thus, rapamycin and anti-LFA-1 mAb are effective in overcoming the potent barrier that donor-reactive Tmem pose to the induction of mixed chimerism and tolerance despite costimulation blockade.
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Affiliation(s)
- Haley Ramsey
- Division of Transplantation, Department of Surgery, Medical University of Vienna, Vienna, Austria
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Abstract
Graft failure may contribute to increased morbidity and mortality after allogeneic hematopoietic SCT (allo-HSCT). Here, we present risk factors for graft failure in all first allo-HSCTs performed at our center from 1995 to mid-2010 (n=967). Graft failure was defined as >95% recipient cells any time after engraftment with no signs of relapse, or re-transplantation because of primary or secondary neutropenia (<0.5 × 10(9)/L) and/or thrombocytopenia (<30 × 10(9)/L). Fifty-four patients (5.6%) experienced graft failure. The majority were because of autologous reconstitution (n=43), and only a few patients underwent re-transplantation because of primary (n=6) or secondary (n=5) graft failures. In non-malignant disorders, graft failure had no effect on survival, whereas in malignant disease graft failure was associated with reduced 5-year survival (22 vs 53%, P<0.01). In multivariate analysis, ex vivo T-cell depletion (relative risk (RR) 8.82, P<0.001), HLA-mismatched grafts (RR 7.64, P<0.001), non-malignant disorders (RR 3.32, P<0.01) and reduced-intensity conditioning (RR 2.58, P<0.01) increased the risk for graft failure, whereas graft failures were prevented by total nucleated cell doses of ≥ 2.5 × 10(8)/kg (RR 0.36, P<0.01). In conclusion, graft failure was only associated with inferior survival in malignant disease. Non-malignant disorders, HLA match, conditioning intensity, immunosuppression regimen and cell dose all influenced graft failure risk.
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48
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Shayani S, Palmer J, Stiller T, Liu X, Thomas SH, Khuu T, Parker PM, Khaled SK, Forman SJ, Nakamura R. Thrombotic microangiopathy associated with sirolimus level after allogeneic hematopoietic cell transplantation with tacrolimus/sirolimus-based graft-versus-host disease prophylaxis. Biol Blood Marrow Transplant 2012; 19:298-304. [PMID: 23078784 DOI: 10.1016/j.bbmt.2012.10.006] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Accepted: 10/10/2012] [Indexed: 11/12/2022]
Abstract
Posttransplantation thrombotic microangiopathy (TMA) is a multifactorial complication of allogeneic hematopoietic cell transplantation (allo-HCT) whose incidence is increased with the use of a sirolimus plus tacrolimus (SIR/TAC) regimen for acute graft-versus-host disease (aGVHD) prophylaxis. We evaluated the incidence and possible risk factors for TMA in a case series of 177 patients who received allo-HCT using SIR/TAC-based GVHD prophylaxis. The patients received either a sibling donor graft (n = 82) or a matched unrelated donor graft (n = 95). Within the first 100 days post-HCT, 30 patients (17%) were diagnosed with TMA, and an additional 9 patients (5%) were classified as probable TMA cases. The median time to onset of TMA was 4.6 weeks (range, 1.6-10.6 weeks). Thirty-four patients developed both TMA and aGVHD, with the majority (81%) developing aGVHD first. Multivariate analysis identified the following factors as associated with increased risk of TMA: day 14 serum sirolimus level ≥9.9 ng/mL (hazard ratio [HR], 2.19; 95% confidence interval [CI], 1.13-4.27; P = .02), presence of previous aGVHD grade II-IV (HR, 3.04; 95% CI, 1.38-6.71; P < .01), and fully myeloablative conditioning (HR, 3.47; 95% CI, 1.60-7.53; P < .01). These risk factors for TMA suggest that when using a SIR/TAC regimen for GVHD prophylaxis, careful monitoring and adjustment of the sirolimus dosage is critical, particularly in patients with active aGVHD.
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Affiliation(s)
- Sepideh Shayani
- Pharmacy Department, City of Hope, Duarte, California 91010, USA
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Perez-Simón JA, Martino R, Parody R, Cabrero M, Lopez-Corral L, Valcarcel D, Martinez C, Solano C, Vazquez L, Márquez-Malaver FJ, Sierra J, Caballero D. The combination of sirolimus plus tacrolimus improves outcome after reduced-intensity conditioning, unrelated donor hematopoietic stem cell transplantation compared with cyclosporine plus mycofenolate. Haematologica 2012; 98:526-32. [PMID: 23065527 DOI: 10.3324/haematol.2012.065599] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Different types of graft-versus-host disease prophylaxis have been proposed in the setting of reduced intensity and non-myeloablative allogeneic stem cell transplantation. An alternative combination with sirolimus and tacrolimus has recently been tested although comparative studies against the classical combination of a calcineurin inhibitor and mycophenolate mofetil or methotrexate are lacking. We describe the results of a prospective, multicenter trial using sirolimus + tacrolimus as immunoprophylaxis, and compare this approach with our previous experience using cyclosporine + mycophenolate in the setting of unrelated donor transplantation setting after reduced-intensity conditioning. Forty-five patients received cyclosporine + mycophenolate between 2002 and mid-2007, while the subsequent 50 patients, who were transplanted from late 2007, were given sirolimus + tacrolimus. No significant differences were observed in terms of hematopoietic recovery or acute graft-versus-host disease overall, although gastrointestinal acute graft-versus-host disease grade ≥ 2 was more common in the cyclosporine + mycophenolate group (55% versus 21%, respectively, P=0.003). The 1-year cumulative incidence of chronic graft-versus-host disease was 50% versus 90% for the patients treated with the sirolimus- versus cyclosporine-based regimen, respectively (P<0.001), while the incidence of extensive chronic disease was 27% versus 49%, respectively (P=0.043). The 2-year non-relapse mortality rate was 18% versus 38% for patients receiving the sirolimus- versus the cyclosporine-based regimen, respectively (P=0.02). The event-free survival and overall survival at 2 years were 53% versus 29% (P=0.028) and 70% versus 45% (P=0.018) among patients receiving the sirolimus- versus the cyclosporine-based regimen, respectively. In conclusion, in the setting of reduced intensity transplantation from an unrelated donor, promising results can be achieved with the combination of sirolimus + tacrolimus, due to a lower risk of chronic graft-versus-host disease and non-relapse mortality, which translates into better event-free and overall survival rates, in comparison with those achieved with cyclosporine + mycophenolate.
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Affiliation(s)
- Jose Antonio Perez-Simón
- Servicio de Hematología, Hospital Universitario/Instituto de Biomedicina (IBIS)/CSIC, Seville, Spain.
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50
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A phase II study of sirolimus, tacrolimus and rabbit anti-thymocyte globulin as GVHD prophylaxis after unrelated-donor PBSC transplant. Bone Marrow Transplant 2012; 48:278-83. [PMID: 23000644 PMCID: PMC3566319 DOI: 10.1038/bmt.2012.175] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
We report on a prospective phase II trial of 32 patients who underwent unrelated donor hematopoietic cell transplantation, with a tacrolimus, sirolimus and rabbit anti-thymoctye globulin GVHD prophylactic regimen. The primary study endpoint was incidence of grades II-IV acute GVHD, with 80% power to detect a 30% decrease compared to institutional historical controls. Median age at transplant was 60 (19-71). Twenty-three patients (72%) received reduced-intensity conditioning, while the remainder received full-intensity regimens. Median follow up for surviving patients was 35 months (range: 21 - 49). The cumulative incidence of acute GVHD was 37.3% and the 2-year cumulative incidence of cGVHD was 63%. We observed TMA in seven patients (21.8%), one of whom also developed sinusoidal obstructive syndrome (SOS). Four patients of 32 (12.5%) failed to engraft, and three of these four died. As a result, enrollment to this trial was closed before the targeted accrual of 60 patients. Two-year overall survival was 65.5% and event-free survival was 61.3%. Two-year cumulative incidence of relapse was 12.5% and non-relapse mortality (NRM) was 15.6%. NRM and aGVHD rates were lower than historical rates; however, the unexpectedly high incidence of graft failure requires caution in the design of future studies with this regimen.
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