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Gharial J, Guilcher G, Truong T, Shah R, Desai S, Rojas-Vasquez M, Kangarloo B, Lewis V. Busulfan with 400 centigray of total body irradiation and higher dose fludarabine: An alternative regimen for hematopoietic stem cell transplantation in pediatric acute lymphoblastic leukemia. Pediatr Blood Cancer 2024; 71:e30844. [PMID: 38217082 DOI: 10.1002/pbc.30844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 12/01/2023] [Accepted: 12/21/2023] [Indexed: 01/14/2024]
Abstract
BACKGROUND Hematopoietic stem cell transplantation can be curative for children with difficult-to-treat leukemia. The conditioning regimen utilized is known to influence outcomes. We report outcomes of the conditioning regimen used at the Alberta Children's Hospital, consisting of busulfan (with pharmacokinetic target of 3750 μmol*min/L/day ±10%) for 4 days, higher dose (250 mg/m2 ) fludarabine and 400 centigray (cGy) of total body irradiation. PROCEDURE This retrospective study involved children receiving transplant for acute lymphoblastic leukemia (ALL). It compared children who fell within the target range for busulfan with those who were either not measured or were measured and fell outside this range. All other treatment factors were identical. RESULTS Twenty-nine children (17 within target) were evaluated. All subjects engrafted neutrophils with a median [interquartile range] time of 14 days [8-30 days]. The cumulative incidence of acute graft-versus-host disease was 44.8% [95% confidence interval, CI: 35.6%-54.0%], while chronic graft-versus-host disease was noted in 16.0% [95% CI: 8.7%-23.3%]. At 2 years, the overall survival was 78.1% [95% CI: 70.8%-86.4%] and event-free survival was 74.7% [95% CI: 66.4%-83.0%]. Cumulative incidence of relapse was 11.3% [95% CI: 5.1%-17.5%]. There were no statistically significant differences in between the group that received targeted busulfan compared with the untargeted group. CONCLUSION Our conditioning regiment for children with ALL resulted in outcomes comparable to standard treatment with acceptable toxicities and significant reduction in radiation dose. Targeting busulfan dose in this cohort did not result in improved outcomes.
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Affiliation(s)
- Jaspreet Gharial
- Section of Pediatric Hematology Oncology and Bone Marrow Transplantation, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Gregory Guilcher
- Section of Pediatric Hematology Oncology and Bone Marrow Transplantation, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Tony Truong
- Section of Pediatric Hematology Oncology and Bone Marrow Transplantation, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Ravi Shah
- Section of Pediatric Hematology Oncology and Bone Marrow Transplantation, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Sunil Desai
- Division of Pediatric Hematology/Oncology & Palliative Care, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Marta Rojas-Vasquez
- Division of Pediatric Hematology/Oncology & Palliative Care, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Bill Kangarloo
- Pharmacokinetic Scientist, Alberta Blood and Marrow Transplant Program, Foothills Hospital, and Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Victor Lewis
- Section of Pediatric Hematology Oncology and Bone Marrow Transplantation, Alberta Children's Hospital, Calgary, Alberta, Canada
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2
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Klyuchnikov E, Langebrake C, Badbaran A, Dadkhah A, Massoud R, Freiberger P, Ayuk F, Janson D, Wolschke C, Bacher U, Kröger N. Individualized busulfan dosing improves outcomes compared to fixed-dose administration in pre-transplant minimal residual disease-positive acute myeloid leukemia patients with intermediate-risk undergoing allogeneic stem cell transplantation in CR. Eur J Haematol Suppl 2023; 110:188-197. [PMID: 36335432 DOI: 10.1111/ejh.13893] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 10/30/2022] [Accepted: 11/02/2022] [Indexed: 11/07/2022]
Abstract
Pre-transplant minimal residual disease (MRD) impacts negatively on post-transplant relapse risk in acute myeloid leukemia (AML). Therapeutic drug monitoring by calculating area under the curve (AUC) was developed to optimize busulfan (Bu) exposure. Here, we compared post-transplant outcomes after individualized versus fixed busulfan dosage in intermediate-risk AML who achieved CR prior to allograft focusing on pre-transplant flow-MRD. Eighty-seven patients (median, 56 years) with intermediate-risk AML and pre-transplant flow-MRD ("different from normal") were included. Thirty-two patients received individualized busulfan; 54 fixed dosages. Individualized dosage was adjusted in 25/32 patients: increased, n = 18/25 (72%); decreased: n = 7/25 (28%). After median follow-up of 27 months, we observed lower 3-year relapses (6%, 2%-19% vs. 35%, 23%-49% p = 0.02), improved 3-year leukemia-free survival (LFS) (78%, 54%-91% vs. 55%, 40%-70% p = 0.009) and - overall survival (OS) (82%, 60%-93% vs. 69%, 54%-81% p = 0.05) after individualized compared to fixed Bu. Non-relapsed mortality (NRM) and acute graft versus host disease (GvHD) were not different. In multivariate analysis, fixed Bu showed unfavorable impact on OS (hazard ratio [HR] 4.6, p = 0.044), LFS (HR 3.6, p = 0.018) and relapses (HR 3.6, p = 0.033). Fixed Bu also had unfavorable impact on LFS (3.6, 1.1-12.6, p = 0.041) in pre-transplant MRD-positive patients. Individualized, AUC-based, busulfan is associated with lower relapses in intermediate-risk AML patients allografted in CR and may overcome pre-transplant MRD-positivity.
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Affiliation(s)
- Evgeny Klyuchnikov
- Department of Stem Cell Transplantation, University Medical Center Eppendorf, University of Hamburg, Hamburg, Germany
| | - Claudia Langebrake
- Department of Stem Cell Transplantation, University Medical Center Eppendorf, University of Hamburg, Hamburg, Germany.,Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anita Badbaran
- Department of Stem Cell Transplantation, University Medical Center Eppendorf, University of Hamburg, Hamburg, Germany
| | - Adrin Dadkhah
- Department of Stem Cell Transplantation, University Medical Center Eppendorf, University of Hamburg, Hamburg, Germany.,Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Radwan Massoud
- Department of Stem Cell Transplantation, University Medical Center Eppendorf, University of Hamburg, Hamburg, Germany
| | - Petra Freiberger
- Department of Stem Cell Transplantation, University Medical Center Eppendorf, University of Hamburg, Hamburg, Germany
| | - Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Center Eppendorf, University of Hamburg, Hamburg, Germany
| | - Dietlinde Janson
- Department of Stem Cell Transplantation, University Medical Center Eppendorf, University of Hamburg, Hamburg, Germany
| | - Christine Wolschke
- Department of Stem Cell Transplantation, University Medical Center Eppendorf, University of Hamburg, Hamburg, Germany
| | - Ulrike Bacher
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Eppendorf, University of Hamburg, Hamburg, Germany
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Alatrash G, Saberian C, Bassett R, Thall PF, Ledesma C, Lu Y, Daher M, Valdez BC, Kawedia J, Popat U, Mehta R, Oran B, Nieto Y, Olson A, Anderlini P, Marin D, Hosing C, Alousi AM, Shpall EJ, Rondon G, Chen J, Qazilbash M, Champlin RE, Andersson BS, Kebriaei P. Vorinostat combined with Busulfan, Fludarabine, and Clofarabine Conditioning Regimen for Allogeneic Hematopoietic Stem Cell Transplantation in Patients with Acute Leukemia: Long-term Study Outcomes. Transplant Cell Ther 2022; 28:501.e1-501.e7. [DOI: 10.1016/j.jtct.2022.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 04/15/2022] [Accepted: 05/14/2022] [Indexed: 11/30/2022]
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4
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Rossoff J, Jacobsohn D, Kwon S, Kletzel M, Duerst RE, Tse WT, Schneiderman J, Chaudhury S. Reduced-toxicity conditioning regimen with busulfan, fludarabine, rATG, and 400 cGy TBI in pediatric patients undergoing hematopoietic stem cell transplant for high-risk hematologic malignancies. Pediatr Blood Cancer 2021; 68:e29087. [PMID: 34022093 DOI: 10.1002/pbc.29087] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 03/30/2021] [Accepted: 04/09/2021] [Indexed: 11/07/2022]
Abstract
Myeloablative conditioning regimens decrease the risk of relapse in pediatric patients undergoing allogeneic hematopoietic stem cell transplant (HCT) for hematologic malignancies, but cause significant toxicities PROCEDURE: This prospective study evaluated the use of a reduced-toxicity, myeloablative regimen with dose-adjusted busulfan, fludarabine, antithymocyte globulin and 400 cGy of total body irradiation in 40 patients < 21 years of age undergoing HCT for high-risk leukemias. Busulfan pharmacokinetics were measured to target 4000 μmol*min/day in the first 30 patients; this was increased to 5000 μmol*min/day in the subsequent 10 in efforts to further decrease relapse risk RESULTS: Overall survival at two- and five-years post-HCT was 67% and 51%, respectively. Relapse occurred in 11 patients (28%) at a median of seven months and was the leading cause of death. Transplant-related mortality was 8% and 13% at 100 days and one-year post-HCT, respectively. Trends toward improved survival were seen in patients transplanted for myeloid disease using bone marrow as stem cell source who achieved a busulfan AUC > 4000 μmol*min/day with two-year relapse-free survival approaching 80% CONCLUSIONS: This conditioning regimen is safe and effective in patients with high-risk leukemias, particularly myeloid disease. Larger studies are needed to compare its safety and efficacy to other myeloablative regimens in this population.
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Affiliation(s)
- Jenna Rossoff
- Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - David Jacobsohn
- Children's National Medical Center, Washington, District of Columbia
| | - Soyang Kwon
- Stanley Manne Children's Research Institute, Chicago, Illinois
| | - Morris Kletzel
- Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Reggie E Duerst
- Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Jennifer Schneiderman
- Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Sonali Chaudhury
- Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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D'Angelo CR, Hall A, Woo KM, Kim K, Longo W, Hematti P, Callander N, Kenkre VP, Mattison R, Juckett M. Decitabine induction with myeloablative conditioning and allogeneic hematopoietic stem cell transplantation in high-risk patients with myeloid malignancies is associated with a high rate of infectious complications. Leuk Res 2020; 96:106419. [PMID: 32683127 DOI: 10.1016/j.leukres.2020.106419] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/17/2020] [Accepted: 07/07/2020] [Indexed: 12/21/2022]
Abstract
Patients with high-risk myelodysplastic syndrome or acute myeloid leukemia have an increased risk of death following allogeneic hematopoietic stem cell transplantation (allo-HSCT). Decitabine has minimal non-hematologic toxicity and proven efficacy in myeloid diseases, and post-transplant cyclophosphamide (PTCy) has reduced rates of graft-versus-host-disease (GVHD). We hypothesized that decitabine induction with allo-HSCT and PTCy would improve outcomes in a high-risk myeloid disease population. We performed a phase-II trial of decitabine at 20 mg/m2 for 10 days followed by allo-HSCT using a myeloablative regimen of fludarabine, IV busulfan and 4 Gy total body irradiation with PTCy for GVHD prophylaxis. Twenty patients underwent decitabine induction and 17 patients proceeded to transplant per protocol. Median overall survival from decitabine induction was 210 days (95 % CI 122-not reached). All patients developed grade 4 neutropenia after decitabine, eleven patients (55 %) developed grade 3-4 infections, and 5 cases were fatal. There were 5/20 (25 %) long-term survivors with a median follow-up of 3.6 years. Decitabine induction followed by myeloablative allo-HSCT in a high-risk population was associated with a high risk of infection and mortality related to enhanced immunosuppression. Further exploration of decitabine conditioning on reduced intensity platforms and improved infectious prophylaxis and screening may better mitigate toxicity (ClinicalTrials.gov (NCT01707004)).
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Affiliation(s)
- Christopher R D'Angelo
- Section of Hematology/Oncology and Bone Marrow Transplantation, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Aric Hall
- Section of Hematology/Oncology and Bone Marrow Transplantation, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Kaitlin M Woo
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - KyungMann Kim
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Walter Longo
- Section of Hematology/Oncology and Bone Marrow Transplantation, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Peiman Hematti
- Section of Hematology/Oncology and Bone Marrow Transplantation, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Natalie Callander
- Section of Hematology/Oncology and Bone Marrow Transplantation, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Vaishalee P Kenkre
- Section of Hematology/Oncology and Bone Marrow Transplantation, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Ryan Mattison
- Section of Hematology/Oncology and Bone Marrow Transplantation, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Mark Juckett
- Section of Hematology/Oncology and Bone Marrow Transplantation, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
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6
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Medina D, Estacio M, Rosales M, Manzi E. Haploidentical stem cell transplant with post-transplantation cyclophosphamide and mini-dose methotrexate in children. Hematol Oncol Stem Cell Ther 2020; 13:208-213. [PMID: 32224144 DOI: 10.1016/j.hemonc.2020.01.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 01/15/2019] [Accepted: 01/14/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Haploidentical stem cell transplantation (haplo-SCT) is an option for patients without human leukocyte antigen-matched related or unrelated donor. Post-transplantation cyclophosphamide (PTCy) is an effective method of graft versus host disease (GVHD) prophylaxis and permits the use of T-cell replete grafts in settings were ex vivo manipulation is not feasible. METHODS A retrospective study among patients younger than 18 years, with a history of hematologic malignancies who underwent haplo-SCT between 2012 and 2016. All patients received a preparative regimen of fludarabine, busulfan, and 400 cGy total body irradiation or melphalan. Post-transplant GvHD prophylaxis consisted either of PTCy (50 mg/kg on Days + 3 and + 4) and cyclosporine (CSA) plus mycophenolate (MMF) (15 mg/kg/dose, thrice daily, per os), or mini-dose methotrexate (MTX; 5 mg/m2 dose) on Days + 5, +7, +10, and + 15. RESULTS A total of 52 children were included, whose median age was 9 years (interquartile range, 4.9-14; range, 1.2-17 years), and 63% were males. The most common complications were cytomegalovirus reactivation (57%) and hemorrhagic cystitis (36%). The acute GVHD prophylaxis was PTCy, CSA, and mini-dose MTX in 42 (81%) patients, and 10 (19%) patients received PTCy, CSA, and MMF. The cumulative incidence of acute GvHD II-IV, acute GvHD III-IV, and chronic GvHD were 42%, 8.5%, and 19%, respectively. Grades I-IV acute GvHD occurred in 100% of the patients who received prophylaxis with CSA and MMF, and 62% who received CSA and mini-dose MTX (p = .055). The transplant-related mortality at 100 days was 18%. The 5-year overall and event-free survival were 59% and 57%, respectively. CONCLUSIONS Haplo-SCT with PT/Cy can be an available, safe, and feasible option for children with hematologic malignancies; meanwhile, the use of mini-dose of MTX was associated with lower rates of acute GVHD. However, our results require further support from prospective randomized studies to improve the efficacy of this prophylactic strategy.
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Affiliation(s)
- Diego Medina
- Stem Cell Transplant, Fundación Valle del Lili, Cali, Colombia.
| | - Mayra Estacio
- Stem Cell Transplant, Fundación Valle del Lili, Cali, Colombia.
| | - Maria Rosales
- Stem Cell Transplant, Fundación Valle del Lili, Cali, Colombia
| | - Eliana Manzi
- Stem Cell Transplant, Fundación Valle del Lili, Cali, Colombia
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7
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Kawaguchi H, Soejima T, Ishibashi N, Akiba T, Hasegawa M, Isobe K, Ito H, Imai M, Ejima Y, Hata M, Sasai K, Shimoda E, Oguchi M, Akimoto T. National survey on total-body irradiation prior to reduced-intensity stem cell transplantation in Japan: The Japanese Radiation Oncology Study Group. JOURNAL OF RADIATION RESEARCH 2019; 60:579-585. [PMID: 31125077 PMCID: PMC6805977 DOI: 10.1093/jrr/rrz028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 03/21/2019] [Indexed: 06/09/2023]
Abstract
Reduced-intensity stem cell transplantation (RIST) minimizes the adverse effects of traditional hematopoietic stem cell transplantation, and low-dose total-body irradiation (TBI) is administered over a short period prior to RIST (TBI-RIST). Different institutes adopt different approaches for the administration of TBI-RIST, and since no study had previously investigated this issue, a survey of the TBI schedules in Japan was conducted. In October 2015, the Japanese Radiation Oncology Study Group initiated a national survey of TBI-RIST procedures conducted between 2010 and 2014. Of 186 institutions performing TBI, 90 (48%) responded to the survey, 78 of which performed TBI-RIST. Of 2488 patients who underwent TBI for malignant disease at these institutions, 1412 (56.8%) patients were treated for leukemia, 477 (19.2%) for malignant lymphoma, 453 (18.2) for myelodysplastic syndrome, 44 (1.8%) for multiple myeloma, and 102 (4.1%) for other malignant diseases. Further, 206 (52.0%) of 396 patients (a high proportion of patients) who underwent TBI for benign disease had aplastic anemia. The TBI-RIST equipment and treatment methods were similar to those used for myeloablative regimens. Routinely shielded organs included the lungs (43.6%), eyes (50.0%) and kidneys (10.2%). The ovaries (14.1%), thyroid (6.4%) and testicles (16.7%) were also frequently shielded, possibly reflecting an emphasis on shielding reproductive organs in children. TBI-RIST was performed more frequently than myeloablative conditioning in patients with benign disease. Genital and thyroid shielding were applied more frequently in patients treated with TBI-RIST than in patients treated with myeloablative conditioning. In conclusion, this study indicates the status of TBI-RIST in Japan and can assist future efforts to standardize TBI-RIST treatment methods and to design a future multicenter collaborative research study.
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Affiliation(s)
- Hiroki Kawaguchi
- Division of Radiation Oncology, Kobe University Hospital, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe City, Hyogo, Japan
| | | | - Naoya Ishibashi
- Department of Radiology, Nihon University School of Medicine, Tokyo, Japan
| | - Takeshi Akiba
- Department of Radiation Oncology, Tokai University, Isehara, Japan
| | - Masatoshi Hasegawa
- Department of Radiation Oncology, Nara Medical University, Kashihara, Japan
| | - Kouichi Isobe
- Department of Radiology, Toho University Sakura Medical Center, Chiba, Japan
| | - Hitoshi Ito
- Department of Radiation Oncology, Kyoto Katsura Hospital, Kyoto, Japan
| | - Michiko Imai
- Department of Radiology, Iwata City General Hospital, Iwata, Japan
| | - Yasuo Ejima
- Department of Radiology, Dokkyo Medical University, Tochigi, Japan
| | - Masaharu Hata
- Division of Radiation Oncology, Department of Oncology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Keisuke Sasai
- Department of Radiation Oncology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Emiko Shimoda
- Department of Radiation Oncology, Nara Medical University, Kashihara, Japan
| | - Masahiko Oguchi
- Department of Radiation Oncology, The Cancer Institution Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Tetsuo Akimoto
- Division of Radiation Oncology and Particle Therapy, National Cancer Center Hospital East, Kashiwa, Japan
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Reduced intensity vs. myeloablative conditioning with fludarabine and PK-guided busulfan in allogeneic stem cell transplantation for patients with AML/MDS. Bone Marrow Transplant 2018; 54:1245-1253. [PMID: 30532055 DOI: 10.1038/s41409-018-0405-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 11/02/2018] [Accepted: 11/05/2018] [Indexed: 12/16/2022]
Abstract
Conditioning regimens contribute significantly to outcomes following allogeneic stem cell transplantation (allo-SCT). Reduced-intensity conditioning (RIC) regimens provide lower toxicity at the cost of reduced efficacy compared with myeloablative conditioning (MAC) regimens. However, because pre-transplant prognostic variables often determine the conditioning regimen, studies of RIC vs. MAC have been inconclusive. We present a retrospective analysis of 242 acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS) patients, 112 of whom were in 56 pairs matched using propensity scores, to account for variation that may confound clinical outcomes. The uniform conditioning regimens consisted of fludarabine with pharmacokinetic (PK)-guided intravenous busulfan (Bu). The RIC and MAC regimens were dosed at the average daily area under the concentration-vs-time curve (AUC) of 4000 µMol min and 5000-6000 µMol min, or total course AUC of 16,000 µMol min and 20,000-24,000 µMol min, respectively; PK-guided dosing removes overlap in systemic Bu exposure. When patients' data were propensity-matched, there was a trend toward significantly increased full donor chimerism and decreased chronic graft vs. host disease in RIC, and no significant differences in progression free survival and overall survival between RIC and MAC. Our results also elucidate the efficacy of PK-guided-dosing in the setting of allo-SCT for AML and MDS.
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Maximal concentration of intravenous busulfan as a determinant of veno-occlusive disease: a pharmacokinetic-pharmacodynamic analysis in 293 hematopoietic stem cell transplanted children. Bone Marrow Transplant 2018; 54:448-457. [PMID: 30108322 DOI: 10.1038/s41409-018-0281-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 06/27/2018] [Accepted: 06/29/2018] [Indexed: 12/28/2022]
Abstract
Veno-occlusive disease (VOD) is a severe adverse reaction to busulfan-containing regimens used in the preparation of children for hematopoietic stem cell transplantation (HSCT). We conducted a retrospective analysis of data to examine determinants of VOD in children who received IV busulfan for HSCT conditioning. Busulfan PK parameters as well as various indices (maximal concentration-Cmax, area under the concentration-time curve-AUC) were estimated using a validated Bayesian approach. The influence of available PK, demographic, and clinical variables on the incidence of VOD was evaluated by using logistic regression and classification and regression tree (CART) analyses. Among the 293 patients included, the mean age was 6.5 years and the mean actual body weight was 26.3 kg. The incidence of VOD was 25.6%. Busulfan Cmax as well as weight <9 kg or age <3 years were identified as independent predictors of VOD in logistic regression analysis. CART analysis identified busulfan Cmax over the entire regimen as the strongest predictor of VOD. This study suggests that busulfan-associated VOD is in part a concentration-dependent reaction. In addition, the youngest children showed the highest risk of VOD. These findings may have important implications for busulfan dosing and therapeutic drug monitoring practice in HSCT children.
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10
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Fludarabine and busulfan plus low-dose TBI as reduced intensity conditioning in older patients undergoing allogeneic hematopoietic cell transplant for myeloid malignancies. Ann Hematol 2018; 97:1975-1985. [DOI: 10.1007/s00277-018-3391-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 06/02/2018] [Indexed: 12/18/2022]
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11
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Kebriaei P, Anasetti C, Zhang MJ, Wang HL, Aldoss I, de Lima M, Khoury HJ, Sandmaier BM, Horowitz MM, Artz A, Bejanyan N, Ciurea S, Lazarus HM, Gale RP, Litzow M, Bredeson C, Seftel MD, Pulsipher MA, Boelens JJ, Alvarnas J, Champlin R, Forman S, Pullarkat V, Weisdorf D, Marks DI. Intravenous Busulfan Compared with Total Body Irradiation Pretransplant Conditioning for Adults with Acute Lymphoblastic Leukemia. Biol Blood Marrow Transplant 2017; 24:726-733. [PMID: 29197676 DOI: 10.1016/j.bbmt.2017.11.025] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 11/22/2017] [Indexed: 01/22/2023]
Abstract
Total body irradiation (TBI) has been included in standard conditioning for acute lymphoblastic leukemia (ALL) before hematopoietic cell transplantation (HCT). Non-TBI regimens have incorporated busulfan (Bu) to decrease toxicity. This retrospective study analyzed TBI and Bu on outcomes of ALL patients 18-60 years old, in first or second complete remission (CR), undergoing HLA-compatible sibling, related, or unrelated donor HCT, who reported to the Center for International Blood and Marrow Transplant Research from 2005 to 2014. TBI plus etoposide (25%) or cyclophosphamide (75%) was used in 819 patients, and intravenous Bu plus fludarabine (41%), clofarabine (30%), cyclophosphamide (15%), or melphalan (13%) was used in 299 patients. Bu-containing regimens were analyzed together, since no significant differences for patient outcomes were noted between them. Bu patients were older, with better performance status; took longer to achieve first CR and receive HCT; were treated more recently; and were more likely to receive peripheral blood grafts, antithymocyte globulin, or tyrosine kinase inhibitors. With median follow-up of 3.6 years for Bu and 5.3 years for TBI, adjusted 3-year outcomes showed treatment-related mortality Bu 19% versus TBI 25% (P = .04); relapse Bu 37% versus TBI 28% (P = .007); disease-free survival (DFS) Bu 45% versus TBI 48% (P = .35); and overall survival (OS) Bu 57% versus TBI 53% (P = .35). In multivariate analysis, Bu patients had higher risk of relapse (relative risk, 1.46; 95% confidence interval, 1.15 to 1.85; P = .002) compared with TBI patients. Despite the higher relapse, Bu-containing conditioning led to similar OS and DFS following HCT for ALL.
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Affiliation(s)
- Partow Kebriaei
- Department of Stem Cell Transplantation, Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas.
| | - Claudio Anasetti
- Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center Research Institute, Tampa, Florida
| | - Mei-Jie Zhang
- Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, Wisconsin; CIBMTR (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Hai-Lin Wang
- CIBMTR (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ibrahim Aldoss
- Department of Hematology & Hematopoietic Cell Transplantation, City of Hope Medical Center, Duarte, California
| | - Marcos de Lima
- Department of Medicine, Seidman Cancer Center, University Hospitals Case Medical Center, Cleveland, Ohio
| | - H Jean Khoury
- Division of Hematology and Oncology, Emory University Hospital, Atlanta, Georgia
| | - Brenda M Sandmaier
- Division of Medical Oncology, University of Washington and Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Mary M Horowitz
- CIBMTR (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Andrew Artz
- Section of Hematology/Oncology, University of Chicago School of Medicine, Chicago, Illinois
| | - Nelli Bejanyan
- Division of Hematology, Oncology and Transplantation, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Stefan Ciurea
- Department of Stem Cell Transplantation, Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Hillard M Lazarus
- Department of Medicine, Seidman Cancer Center, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Robert Peter Gale
- Hematology Research Centre, Division of Experimental Medicine, Department of Medicine, Imperial College London, London, United Kingdom
| | - Mark Litzow
- Division of Hematology, Department of Internal Medicine, Mayo Clinic Rochester, Rochester, Minnesota
| | - Christopher Bredeson
- Ottawa Hospital Blood and Marrow Transplant Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Matthew D Seftel
- Department of Medical Oncology and Hematology, CancerCare Manitoba, Winnipeg, Manitoba, Canada
| | - Michael A Pulsipher
- Division of Hematology, Oncology, and Blood and Marrow Transplantation, Children's Hospital Los Angeles, USC Keck School of Medicine, Los Angeles, California
| | | | - Joseph Alvarnas
- Department of Hematology & Hematopoietic Cell Transplantation, City of Hope Medical Center, Duarte, California
| | - Richard Champlin
- Department of Stem Cell Transplantation, Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Stephen Forman
- Department of Hematology & Hematopoietic Cell Transplantation, City of Hope Medical Center, Duarte, California
| | - Vinod Pullarkat
- Department of Hematology & Hematopoietic Cell Transplantation, City of Hope Medical Center, Duarte, California
| | - Daniel Weisdorf
- Division of Hematology, Oncology and Transplantation, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - David I Marks
- Adult Bone Marrow Transplant, University Hospitals Bristol NHS Trust, Bristol, United Kingdom
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12
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Kassim AA, Savani BN. Hematopoietic stem cell transplantation for acute myeloid leukemia: A review. Hematol Oncol Stem Cell Ther 2017; 10:245-251. [DOI: 10.1016/j.hemonc.2017.05.021] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 03/26/2017] [Indexed: 10/19/2022] Open
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13
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Kalra A, Roessner C, Jupp J, Williamson T, Tellier R, Chaudhry A, Khan F, Taparia M, Jimenez-Zepeda VH, Stewart DA, Daly A, Storek J. Risk factors for post-transplant lymphoproliferative disorder after Thymoglobulin-conditioned hematopoietic cell transplantation. Clin Transplant 2017; 32. [DOI: 10.1111/ctr.13150] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2017] [Indexed: 01/04/2023]
Affiliation(s)
- Amit Kalra
- University of Calgary; Calgary AB Canada
| | | | - Jennifer Jupp
- Pharmacy Services; Alberta Health Services; Calgary AB Canada
| | | | | | | | | | | | | | - Douglas A. Stewart
- University of Calgary; Calgary AB Canada
- University of Alberta Edmonton; AB Canada
| | | | - Jan Storek
- University of Calgary; Calgary AB Canada
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14
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Rubio MT, D'Aveni-Piney M, Labopin M, Hamladji RM, Sanz MA, Blaise D, Ozdogu H, Daguindeau E, Richard C, Santarone S, Irrera G, Yakoub-Agha I, Yeshurun M, Diez-Martin JL, Mohty M, Savani BN, Nagler A. Impact of in vivo T cell depletion in HLA-identical allogeneic stem cell transplantation for acute myeloid leukemia in first complete remission conditioned with a fludarabine iv-busulfan myeloablative regimen: a report from the EBMT Acute Leukemia Working Party. J Hematol Oncol 2017; 10:31. [PMID: 28118857 PMCID: PMC5259921 DOI: 10.1186/s13045-016-0389-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 12/31/2016] [Indexed: 01/15/2023] Open
Abstract
Background The impact of the use of anti-thymocyte globulin (ATG) in allogeneic stem cell transplantation performed with HLA-identical sibling donors following fludarabine and 4 days intravenous busulfan myeloablative conditioning regimen has been poorly explored. Methods We retrospectively analyzed 566 patients who underwent a first HLA-identical allogeneic stem cell transplantation with this conditioning regimen for acute myeloid leukemia in first complete remission between 2006 and 2013 and compared the outcomes of 145 (25.6%) patients who received ATG (ATG group) to 421 (74.4%) who did not (no-ATG group). The Kaplan-Meier estimator, the cumulative incidence function, and Cox proportional hazards regression models were used where appropriate. Results Patients in the ATG group were older, received more frequently peripheral blood stem cell grafts from older donors, and were transplanted more recently. With a median follow-up of 19 months, patients in the ATG group had reduced 2-year cumulative incidence of chronic graft-versus-host disease (GVHD) (31 vs. 52%, p = 0.0002) and of its extensive form (8 vs. 26%, p < 0.0001) but similar relapse incidence (22 vs. 27%, p = 0.23) leading to improved GVHD and relapse-free survival (GRFS) (60 vs. 40%, p = 0.0001). In multivariate analyses, the addition of ATG was independently associated with lower chronic GVHD (HR = 0.46, p = 0.0001), improved leukemia-free survival (HR = 0.67, p = 0.027), overall survival (HR = 0.65, p = 0.027), and GRFS (HR = 0.51, p = 4 × 10−5). Recipient age above 50 years was the only other factor associated with worse survivals. Conclusions These results suggest that the use of ATG with fludarabine and 4 days intravenous busulfan followed by HLA-identical sibling donor allogeneic stem cell transplantation for acute myeloid leukemia improves overall transplant outcomes due to reduced incidence of chronic GVHD without increased relapse risk. Electronic supplementary material The online version of this article (doi:10.1186/s13045-016-0389-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marie Thérèse Rubio
- Service d'Hématologie et de Médecine interne, Hôpital Brabois, CHRU Nancy, Nancy, France. .,IMoPA, CNRS UMR 7365, Nancy, France. .,Université de Lorraine, Nancy, France.
| | - Maud D'Aveni-Piney
- Service d'Hématologie et de Médecine interne, Hôpital Brabois, CHRU Nancy, Nancy, France. .,IMoPA, CNRS UMR 7365, Nancy, France. .,Université de Lorraine, Nancy, France.
| | - Myriam Labopin
- ALWP Office, Hôpital Saint Antoine, Paris, France.,Service d'Hématologie et de Thérapie Cellulaire, Hôpital Saint Antoine, Paris, France.,INSERM UMR 938, Paris, France.,Université Pierre et Marie Curie, Paris, France
| | - Rose-Marie Hamladji
- Service Hématologie Greffe de Moëlle, Centre Pierre et Marie Curie, Alger, Algeria
| | - Miguel A Sanz
- Servicio de Hematologia, Hospital Universitario La Fe, Valencia, Spain
| | - Didier Blaise
- Programme de Transplantation and Therapie Cellulaire, Centre de Recherche en Cancérologie de Marseille, Institut Paoli Calmettes, Marseille, France
| | - Hakan Ozdogu
- Hematology Division, BMT Unit, Hematology Reserach Laboratory, Training and Medical, Baskent University Hospital, Adana, Turkey
| | | | - Carlos Richard
- Servicio de Hematología-Hemoterapia, Hospital U. Marqués de Valdecilla, Santander, Spain
| | - Stella Santarone
- Dipartimento di Ematologia, Medicina Trasfusionale e Biotecnologie, Ospedale Civile, Pescara, Italy
| | - Giuseppe Irrera
- Azienda Ospedaliera, Centro Unico Regionale Trapianti, Reggio, Calabria, Italy
| | | | - Moshe Yeshurun
- Hematology and BMT Department, Beilinson Hospital, Petach-Tikva, Israel
| | - Jose L Diez-Martin
- Sección de Transplante de Medula Osea, Hospital Gregorio Marañón, Madrid, Spain
| | - Mohamad Mohty
- ALWP Office, Hôpital Saint Antoine, Paris, France.,Service d'Hématologie et de Thérapie Cellulaire, Hôpital Saint Antoine, Paris, France.,INSERM UMR 938, Paris, France.,Université Pierre et Marie Curie, Paris, France
| | - Bipin N Savani
- ALWP Office, Hôpital Saint Antoine, Paris, France.,Vanderbilt University Medical Center, Nashville, TN, USA
| | - Arnon Nagler
- ALWP Office, Hôpital Saint Antoine, Paris, France.,Université Pierre et Marie Curie, Paris, France.,Division of Hematology, Chaim Sheba Medical Center, Tel Hashomer, Israel
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15
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Andersson BS, Thall PF, Valdez BC, Milton DR, Al-Atrash G, Chen J, Gulbis A, Chu D, Martinez C, Parmar S, Popat U, Nieto Y, Kebriaei P, Alousi A, de Lima M, Rondon G, Meng QH, Myers A, Kawedia J, Worth LL, Fernandez-Vina M, Madden T, Shpall EJ, Jones RB, Champlin RE. Fludarabine with pharmacokinetically guided IV busulfan is superior to fixed-dose delivery in pretransplant conditioning of AML/MDS patients. Bone Marrow Transplant 2016; 52:580-587. [PMID: 27991894 PMCID: PMC5382042 DOI: 10.1038/bmt.2016.322] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 09/28/2016] [Accepted: 09/30/2016] [Indexed: 11/25/2022]
Abstract
We hypothesized that IV Busulfan (Bu) dosing could be safely intensified through pharmacokinetic (PK-) dose guidance to minimize the inter-patient variability in systemic exposure (SE) associated with body-sized dosing, and this should improve outcome of AML/MDS patients undergoing allogeneic stem cell transplantation (allo-HSCT). To test this hypothesis, we treated 218 patients (median age 50.7 years, male/female 50/50%) with fludarabine (Flu) 40 mg/m2 once daily ×4, each dose followed by IV Bu, randomized to 130 mg/m2 (N=107) or PK-guided to average daily SE, AUC of 6,000 µM-min (N=111), stratified for remission-status, and allo-grafting from HLA-matched donors. Toxicity and graft vs. host disease (GvHD) rates in the groups were similar; the risk of relapse or treatment-related mortality remained higher in the fixed-dose group throughout the 80-month observation period. Further, PK-guidance yielded safer disease-control, leading to improved overall and progression-free survival, most prominently in MDS-patients and in AML-patients not in remission at allo-HSCT. We conclude that AML/MDS patients receiving pretransplant conditioning treatment with our 4-day regimen may benefit significantly from PK-guided Bu-dosing. This could be considered an alternative to fixed dose delivery since it provides the benefit of precise dose delivery to a predetermined SE without increasing risk(s) of serious toxicity and/or GvHD.
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Affiliation(s)
- B S Andersson
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - P F Thall
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - B C Valdez
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - D R Milton
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - G Al-Atrash
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - J Chen
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - A Gulbis
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - D Chu
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - C Martinez
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - S Parmar
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - U Popat
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Y Nieto
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - P Kebriaei
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - A Alousi
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - M de Lima
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - G Rondon
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Q H Meng
- Division of Laboratory Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - A Myers
- Division of Pharmacy Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - J Kawedia
- Division of Pharmacy Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - L L Worth
- Division of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - T Madden
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - E J Shpall
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - R B Jones
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - R E Champlin
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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16
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Kebriaei P, Bassett R, Lyons G, Valdez B, Ledesma C, Rondon G, Oran B, Ciurea S, Alousi A, Popat U, Patel K, Ahmed S, Olson A, Bashir Q, Shah N, Jones R, Marin D, Rezvani K, Nieto Y, Khouri I, Qazilbash M, Hosing C, Shpall E, Champlin RE, Andersson BS. Clofarabine Plus Busulfan is an Effective Conditioning Regimen for Allogeneic Hematopoietic Stem Cell Transplantation in Patients with Acute Lymphoblastic Leukemia: Long-Term Study Results. Biol Blood Marrow Transplant 2016; 23:285-292. [PMID: 27816651 DOI: 10.1016/j.bbmt.2016.11.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 11/01/2016] [Indexed: 11/25/2022]
Abstract
We investigated the long-term safety and disease control data obtained with i.v. busulfan (Bu) combined with clofarabine (Clo) in patients with acute lymphoblastic leukemia (ALL) undergoing allogeneic hematopoietic stem cell transplantation (HSCT). A total of 107 patients, median age 38 years (range, 19 to 64 years) received a matched sibling donor (n = 52) or matched unrelated donor (n = 55) transplant for ALL in first complete remission (n = 62), second complete remission (n = 28), or more advanced disease (n = 17). Nearly one-half of the patients had a high-risk cytogenetic profile as defined by the presence of t(9;22) (n = 34), t(4;11) (n = 4), or complex cytogenetics (n = 7). Clo 40 mg/m2 was given once daily, with each dose followed by pharmacokinetically dosed Bu infused over 3 hours daily for 4 days, followed by hematopoietic cell infusion after 2 days of rest. The Bu dose was based on the drug clearance as determined by a test Bu dose of 32 mg/m2. The target daily area under the curve was 5500 µmol/min for patients aged <60 years and 4000 µmol/min for patients aged >59 years. With a median follow-up of 3.3 years among surviving patients (range, 1 to 5.8 years), the 2-year progression-free survival (PFS) for patients undergoing HSCT in first complete remission (CR1), second complete remission (CR2), or more advanced disease was 62%, 34%, and 35%, respectively. The regimen was well tolerated, with nonrelapse mortality (NRM) of 10% at 100 days and 31% at 2 years post-HSCT. The incidence of grade II-IV and III-IV acute graft-versus-host disease (GVHD) was 35% and 10%, respectively; 18% patients developed extensive chronic GVHD. The 2-year overall survival (OS) for patients undergoing HSCT in CR1, CR2, or more advanced disease was 70%, 57%, and 35%, respectively. Among 11 patients aged >59 years treated with reduced-dose Bu in CR1 (n = 7) or CR2 (n = 4), 4 remain alive and disease-free, with a median follow-up of 2.6 years (range, 2 to 4.7 years). Only the presence of minimal residual disease at the time of transplantation was associated with significantly worse PFS and OS in multivariate analysis. Our data indicate that the Clo-Bu combination provides effective disease control while maintaining a favorable safety profile. OS and NRM rates compare favorably with those for traditional myeloablative total body irradiation-based conditioning regimens.
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Affiliation(s)
- Partow Kebriaei
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas.
| | - Roland Bassett
- Department of Biostatistics, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Genevieve Lyons
- Department of Biostatistics, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Ben Valdez
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Celina Ledesma
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Gabriela Rondon
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Betul Oran
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Stefan Ciurea
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Amin Alousi
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Uday Popat
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Krina Patel
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Sairah Ahmed
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Amanda Olson
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Qaiser Bashir
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Nina Shah
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Roy Jones
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - David Marin
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Katayoun Rezvani
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Yago Nieto
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Issa Khouri
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Muzaffar Qazilbash
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Chitra Hosing
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Elizabeth Shpall
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Richard E Champlin
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Borje S Andersson
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, Texas
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17
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Alatrash G, Thall PF, Valdez BC, Fox PS, Ning J, Garber HR, Janbey S, Worth LL, Popat U, Hosing C, Alousi AM, Kebriaei P, Shpall EJ, Jones RB, de Lima M, Rondon G, Chen J, Champlin RE, Andersson BS. Long-Term Outcomes after Treatment with Clofarabine ± Fludarabine with Once-Daily Intravenous Busulfan as Pretransplant Conditioning Therapy for Advanced Myeloid Leukemia and Myelodysplastic Syndrome. Biol Blood Marrow Transplant 2016; 22:1792-1800. [PMID: 27377901 DOI: 10.1016/j.bbmt.2016.06.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 06/22/2016] [Indexed: 12/12/2022]
Abstract
Pretransplant conditioning regimens critically determine outcomes in the setting of allogeneic stem cell transplantation (allo-SCT). The use of nucleoside analogs such as fludarabine (Flu) in combination with i.v. busulfan (Bu) has been shown to be highly effective as a pretransplant conditioning regimen in acute myeloid leukemia (AML), chronic myeloid leukemia (CML), and myelodysplastic syndrome (MDS). Because leukemia relapse remains the leading cause of death after allo-SCT, we studied whether clofarabine (Clo), a nucleoside analog with potent antileukemia activity, can be used to complement Flu. In a preliminary report, we previously showed the safety and efficacy of Clo ± Flu with i.v. Bu in 51 patients with high-risk AML, CML, and MDS. The study has now been completed, and we present long-term follow-up data on the entire 70-patient population, which included 49 (70%), 8 (11%), and 13 (19%) patients with AML, MDS, and CML, respectively. Thirteen patients (19%) were in complete remission, and 41 patients (59%) received matched unrelated donor grafts. Engraftment was achieved in all patients. Sixty-three patients (90%) achieved complete remission. There were no deaths reported at day +30, and the 100-day nonrelapse mortality rate was 4% (n = 3). Thirty-one percent of patients (n = 22) developed grades II to IV acute graft-versus-host disease, and the median overall survival and progression-free survival times were 2.4 years and .9 years, respectively. Our results confirm the safety and overall and progression-free survival advantage of the arms with higher Clo doses and lower Flu doses, which was most prominent in the AML/MDS group.
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Affiliation(s)
- Gheath Alatrash
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Peter F Thall
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Benigno C Valdez
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Patricia S Fox
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jing Ning
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Haven R Garber
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Selma Janbey
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Laura L Worth
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Uday Popat
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Chitra Hosing
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Amin M Alousi
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Partow Kebriaei
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Elizabeth J Shpall
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Roy B Jones
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Marcos de Lima
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Hematologic Malignancies and Stem Cell Transplant, Case Western Reserve University, Cleveland, Ohio
| | - Gabriela Rondon
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Julianne Chen
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Richard E Champlin
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Borje S Andersson
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas.
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18
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Kalra A, Williamson T, Daly A, Savoie ML, Stewart DA, Khan F, Storek J. Impact of Donor and Recipient Cytomegalovirus Serostatus on Outcomes of Antithymocyte Globulin-Conditioned Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2016; 22:1654-1663. [PMID: 27246372 DOI: 10.1016/j.bbmt.2016.05.020] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 05/19/2016] [Indexed: 12/24/2022]
Abstract
Although previous studies involving allogeneic hematopoietic cell transplantation (HCT) without in vivo T cell depletion by rabbit antithymocyte globulin (ATG) have reported a substantial survival difference between D-R- and D+R- patients, but little to no survival difference between D-R+ and D+R+ patients (D, donor; R, recipient; +, cytomegalovirus [CMV] seropositive; -, CMV seronegative), whether this applies to HCT using ATG is unknown. We studied 928 patients who underwent myeloablative HCT for hematologic malignancies in Alberta between 1999 and 2014 who received graft-versus-host disease (GVHD) prophylaxis using ATG (Thymoglobulin, 4.5 mg/kg) in addition to methotrexate and cyclosporine. D-R- and D+R- patients had similar survival (no significant difference). D-R+ patients had a substantially lower survival than D+R+ patients (41% versus 59% at 5 years; P = .001). This difference was attributed to higher nonrelapse mortality, apparently due to higher GVHD-associated mortality. Survival rates were also lower for D-R+ HLA-matched sibling transplant recipients compared with D+R+ HLA-matched unrelated donor transplant recipients (44% versus 66% at 5 years; P = .009). In conclusion, when using ATG, choosing a seronegative donor for a seronegative patient is relatively unimportant, whereas choosing a seropositive donor for a seropositive patient is important, even if this requires the use of a seropositive matched unrelated donor graft.
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Affiliation(s)
- Amit Kalra
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
| | - Tyler Williamson
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Andrew Daly
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Alberta Bone Marrow and Blood Cell Transplant Program, Alberta Health Services, Edmonton, Alberta, Canada
| | - M Lynn Savoie
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Alberta Bone Marrow and Blood Cell Transplant Program, Alberta Health Services, Edmonton, Alberta, Canada
| | - Douglas A Stewart
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Alberta Bone Marrow and Blood Cell Transplant Program, Alberta Health Services, Edmonton, Alberta, Canada
| | - Faisal Khan
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Alberta Bone Marrow and Blood Cell Transplant Program, Alberta Health Services, Edmonton, Alberta, Canada
| | - Jan Storek
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Alberta Bone Marrow and Blood Cell Transplant Program, Alberta Health Services, Edmonton, Alberta, Canada
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19
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Podgorny PJ, Pratt LM, Liu Y, Dharmani-Khan P, Luider J, Auer-Grzesiak I, Mansoor A, Williamson TS, Ugarte-Torres A, Hoegh-Petersen M, Khan FM, Larratt L, Jimenez-Zepeda VH, Stewart DA, Russell JA, Daly A, Storek J. Low Counts of B Cells, Natural Killer Cells, Monocytes, Dendritic Cells, Basophils, and Eosinophils are Associated with Postengraftment Infections after Allogeneic Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2015; 22:37-46. [PMID: 26363444 DOI: 10.1016/j.bbmt.2015.09.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 09/02/2015] [Indexed: 01/06/2023]
Abstract
Hematopoietic cell transplant (HCT) recipients are immunocompromised and thus predisposed to infections. We set out to determine the deficiency of which immune cell subset(s) may predispose to postengraftment infections. We determined day 28, 56, 84, and 180 blood counts of multiple immune cell subsets in 219 allogeneic transplant recipients conditioned with busulfan, fludarabine, and Thymoglobulin. Deficiency of a subset was considered to be associated with infections if the low subset count was significantly associated with subsequent high infection rate per multivariate analysis in both discovery and validation cohorts. Low counts of monocytes (total and inflammatory) and basophils, and low IgA levels were associated with viral infections. Low plasmacytoid dendritic cell (PDC) counts were associated with bacterial infections. Low inflammatory monocyte counts were associated with fungal infections. Low counts of total and naive B cells, total and CD56(high) natural killer (NK) cells, total and inflammatory monocytes, myeloid dendritic cells (MDCs), PDCs, basophils and eosinophils, and low levels of IgA were associated with any infections (due to any pathogen or presumed). In conclusion, deficiencies of B cells, NK cells, monocytes, MDCs, PDCs, basophils, eosinophils, and/or IgA plasma cells appear to predispose to postengraftment infections.
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Affiliation(s)
- Peter J Podgorny
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.
| | - Laura M Pratt
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Yiping Liu
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Joanne Luider
- Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Iwona Auer-Grzesiak
- Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Adnan Mansoor
- Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | | | | | - Faisal M Khan
- Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Loree Larratt
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Douglas A Stewart
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - James A Russell
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Andrew Daly
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jan Storek
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
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20
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Valdez BC, Li Y, Murray D, Ji J, Liu Y, Popat U, Champlin RE, Andersson BS. Comparison of the cytotoxicity of cladribine and clofarabine when combined with fludarabine and busulfan in AML cells: Enhancement of cytotoxicity with epigenetic modulators. Exp Hematol 2015; 43:448-61.e2. [PMID: 25704054 DOI: 10.1016/j.exphem.2015.02.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 01/20/2015] [Accepted: 02/12/2015] [Indexed: 11/17/2022]
Abstract
Clofarabine (Clo), fludarabine (Flu), and busulfan (Bu) combinations are efficacious in hematopoietic stem cell transplantation for myeloid leukemia. We sought to determine whether the more affordable drug cladribine (Clad) can provide a viable alternative to Clo, with or without panobinostat (Pano) and 5-aza-2'-deoxycytidine (DAC). Both Clad+Flu+Bu and Clo+Flu+Bu combinations showed synergistic cytotoxicity in KBM3/Bu250(6), HL60, and OCI-AML3 cell lines. Cell exposure to these drug combinations resulted in 60%-80% inhibition of proliferation; activation of the ATM pathway; increase in histone modifications; decrease in HDAC3, HDAC4, HDAC5 and SirT7 proteins; decrease in mitochondrial membrane potential; activation of apoptosis and stress signaling pathways; and downregulation of the AKT pathway. These drug combinations activated DNA-damage response and apoptosis in primary cell samples from AML patients. At lower concentrations of Clad/Clo, Flu, and Bu, inclusion of Pano and DAC enhanced cell killing, increased histone modifications and DNA demethylation, and increased the levels of P16/INK4a, P15/INK4b and P21/Waf1/Cip1 proteins. The observed DNA demethylating activity of Clad and Clo may complement DAC activity; increase demethylation of the gene promoters for SFRP1, DKK3, and WIF1; and cause degradation of β-catenin in cells exposed to Clad/Clo+Flu+Bu+DAC+Pano. The overlapping activities of Clad/Clo+Flu+Bu, Pano, and DAC in DNA-damage formation and repair, histone modifications, DNA demethylation, and apoptosis may underlie their synergism. Our results provide a basis for supplanting Clo with Clad and for including epigenetic modifiers in the pre-hematopoietic stem cell transplantation conditioning regimen for myeloid leukemia patients.
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Affiliation(s)
- Benigno C Valdez
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Yang Li
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David Murray
- Department of Experimental Oncology, Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Jie Ji
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yan Liu
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Uday Popat
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Richard E Champlin
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Borje S Andersson
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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21
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Myeloablative BU, fludarabine, antithymocyte globulin and low-dose TBI in the treatment of juvenile myelomonocytic leukaemia with allogeneic haematopoietic cell transplantation. Bone Marrow Transplant 2014; 50:455-6. [PMID: 25486583 DOI: 10.1038/bmt.2014.272] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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22
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Patel P, Aydogan B, Koshy M, Mahmud D, Oh A, Saraf SL, Quigley JG, Khan I, Sweiss K, Mahmud N, Peace DJ, DeMasi V, Awan AM, Weichselbaum RR, Rondelli D. Combination of Linear Accelerator–Based Intensity-Modulated Total Marrow Irradiation and Myeloablative Fludarabine/Busulfan: A Phase I Study. Biol Blood Marrow Transplant 2014; 20:2034-41. [DOI: 10.1016/j.bbmt.2014.09.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Accepted: 09/09/2014] [Indexed: 12/31/2022]
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23
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Tewari P, Franklin AR, Tarek N, Askins MA, Mofield S, Kebriaei P. Hematopoietic stem cell transplantation in adolescents and young adults. Acta Haematol 2014; 132:313-25. [PMID: 25228557 DOI: 10.1159/000360211] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Adolescents and young adults (AYAs) are a very unique subset of our population journeying through a dynamic stage of their lives. This age group often remains understudied as a separate entity because they are commonly lumped into either pediatric or adult subgroups. METHODS Here we review acute and chronic issues surrounding hematopoietic stem cell transplantation (HSCT) with a focus on the AYA age group. RESULTS HSCT is a commonly used treatment modality for patients with certain types of cancers. AYA patients undergoing HSCT present a very unique perspective, circumstances, medical, psychological and social issues requiring a diligent workup, care and follow-up. CONCLUSION The medical care of these patients should be approached in a multidisciplinary method involving the patient, caregivers, physicians, psychologists and social workers.
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Chawla S, Dharmani-Khan P, Liu Y, Prokopishyn N, Amlish Munir M, Griffiths C, Khan FM, Stewart DA, Russell JA, Daly A, Storek J. High Serum Level of Antithymocyte Globulin Immediately before Graft Infusion Is Associated with a Low Likelihood of Chronic, But Not Acute, Graft-versus-Host Disease. Biol Blood Marrow Transplant 2014; 20:1156-62. [DOI: 10.1016/j.bbmt.2014.04.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Accepted: 04/07/2014] [Indexed: 11/28/2022]
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25
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Allogeneic hematopoietic cell transplantation for myelofibrosis using fludarabine-, intravenous busulfan- and low-dose TBI-based conditioning. Bone Marrow Transplant 2014; 49:1162-9. [PMID: 24978138 DOI: 10.1038/bmt.2014.131] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 05/08/2014] [Accepted: 05/12/2014] [Indexed: 12/31/2022]
Abstract
Graft failure is one of the major barriers to the success of allogeneic hematopoietic cell transplantation (HCT) in myelofibrosis (MF). We report our institutional experience with 27 MF patients who underwent HCT using fludarabine-, intravenous BU- and low-dose total body irradiation (FBT)-based reduced-intensity (n=20) or full-intensity (n=7) conditioning regimens. Eight patients had prior exposure to JAK1/2 inhibitor therapy; six patients received JAK1/2 inhibitors leading on to HCT and two patients received transplant at the failure of JAK1/2 inhibitor therapy. No adverse impact of JAK1/2 inhibitor therapy was observed on early post-transplant outcomes. All evaluable patients had neutrophil recovery, and no primary graft failure was observed. Cumulative incidence of grades II-IV acute GVHD at day 100 was 48% (95% confidence interval (CI), 29-67%) and chronic GVHD at 2 years was 66% (95% CI, 49-84%). Cumulative incidences of nonrelapse mortality (NRM), relapse and probability of OS at 2 years were: 43% (95% CI, 12-74%), 10% (95% CI, 0-39%) and 56% (95% CI, 28-77%), respectively. FBT-based conditioning regimen has a favorable impact on engraftment; however, further efforts are required to reduce NRM.
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26
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Song G, Valdez BC, Li Y, Dominguez JR, Corn P, Champlin RE, Andersson BS. The histone deacetylase inhibitor SAHA sensitizes acute myeloid leukemia cells to a combination of nucleoside analogs and the DNA-alkylating agent busulfan. Leuk Lymphoma 2014; 55:1625-34. [PMID: 24144307 DOI: 10.3109/10428194.2013.856007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Fludarabine (Flu), clofarabine (Clo) and busulfan (Bu) are used in allogeneic hematopoietic stem cell transplant (allo-HSCT). We reported that combining [Flu + Clo + Bu] had a synergistic cytotoxicity in AML cells. We hypothesized that combining [Flu + Clo + Bu] with the histone deacetylase inhibitor SAHA will further enhance cytotoxicity. We exposed the acute myeloid leukemia (AML) cell lines KBM3/Bu250(6) and OCI-AML3 to Flu, Clo, Bu and SAHA alone and in various combinations. [Flu + Clo + Bu + SAHA] resulted in synergistic cytotoxicity, which can be attributed to (1) activated DNA-damage response and cell cycle checkpoint activation through the ATM-CHK2-P53 (or P73) pathway or ATM-CHK2-cdc25-cdc2 pathway, (2) histone modifications and (3) activated apoptosis pathway. The [Flu + Clo + Bu + SAHA] combination causes mitochondrial outer membrane permeabilization, leakage of cytochrome c and Smac/Diablo into the cytosol with caspase activation, and release of apoptosis-inducing factor (AIF) into the nucleus resulting in nuclear fragmentation and cell death. These results provide a mechanistic basis for using SAHA in future clinical trials with double nucleoside analog-busulfan combinations in pretransplant conditioning therapy.
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Affiliation(s)
- Guiyun Song
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M. D. Anderson Cancer Center , Houston, TX , USA
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27
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Podgorny PJ, Liu Y, Dharmani-Khan P, Pratt LM, Jamani K, Luider J, Auer-Grzesiak I, Mansoor A, Williamson TS, Ugarte-Torres A, Hoegh-Petersen M, Stewart DA, Daly A, Khan FM, Russell JA, Storek J. Immune cell subset counts associated with graft-versus-host disease. Biol Blood Marrow Transplant 2014; 20:450-62. [PMID: 24406506 DOI: 10.1016/j.bbmt.2014.01.002] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Accepted: 01/02/2014] [Indexed: 02/02/2023]
Abstract
Graft-versus-host disease (GVHD) is a major transplantation complication. The purpose of this study was to measure immune cell subsets by flow cytometry early after transplantation (before median day of GVHD onset) to identify subsets that may play a role in GVHD pathogenesis. We also measured the subsets later after transplantation to determine which subsets may be influenced by GVHD or its treatment. We studied 219 patients. We found that acute GVHD (aGVHD) was preceded by high counts of CD4 T cells and CD8 T cells. It was followed by low counts of total and naive B cells, total and cytolytic NK cells, and myeloid and plasmacytoid dendritic cells. Chronic GVHD (cGVHD) was preceded by low counts of memory B cells. In conclusion, both CD4 and CD8 T cells appear to play a role in the pathogenesis of aGVHD. Generation of B cells, NK cells, and dendritic cells may be hampered by aGVHD and/or its treatment. Memory B cells may inhibit the development of cGVHD.
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Affiliation(s)
- Peter J Podgorny
- Department of Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada.
| | - Yiping Liu
- Department of Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Poonam Dharmani-Khan
- Department of Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Laura M Pratt
- Department of Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kareem Jamani
- Department of Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Joanne Luider
- Department of Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Iwona Auer-Grzesiak
- Department of Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Adnan Mansoor
- Department of Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Tyler S Williamson
- Department of Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Alejandra Ugarte-Torres
- Department of Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Mette Hoegh-Petersen
- Department of Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Douglas A Stewart
- Department of Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Andrew Daly
- Department of Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Faisal M Khan
- Department of Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - James A Russell
- Department of Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jan Storek
- Department of Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
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28
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Bartelink IH, van Reij EML, Gerhardt CE, van Maarseveen EM, de Wildt A, Versluys B, Lindemans CA, Bierings MB, Boelens JJ. Fludarabine and exposure-targeted busulfan compares favorably with busulfan/cyclophosphamide-based regimens in pediatric hematopoietic cell transplantation: maintaining efficacy with less toxicity. Biol Blood Marrow Transplant 2013; 20:345-53. [PMID: 24315842 DOI: 10.1016/j.bbmt.2013.11.027] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Accepted: 11/29/2013] [Indexed: 02/05/2023]
Abstract
Busulfan (Bu) is used as a myeloablative agent in conditioning regimens before allogeneic hematopoietic cell transplantation (allo-HCT). In line with strategies explored in adults, patient outcomes may be optimized by replacing cyclophosphamide (Cy) with or without melphalan (Mel) with fludarabine (Flu). We compared outcomes in 2 consecutive cohorts of HCT recipients with a nonmalignant HCT indication, a myeloid malignancy, or a lymphoid malignancy with a contraindication for total body irradiation (TBI). Between 2009 and 2012, 64 children received Flu + Bu at a target dose of 80-95 mg·h/L, and between 2005 and 2008, 50 children received Bu targeted to 74-80 mg·h/L + Cy. In the latter group, Mel was added for patients with myeloid malignancy (n = 12). Possible confounding effects of calendar time were studied in 69 patients receiving a myeloablative dose of TBI between 2005 and 2012. Estimated 2-year survival and event-free survival were 82% and 78%, respectively, in the FluBu arm and 78% and 72%, respectively, in the BuCy (Mel) arm (P = not significant). Compared with the BuCy (Mel) arm, less toxicity was noted in the FluBu arm, with lower rates of acute (noninfectious) lung injury (16% versus 36%; P = .007), veno-occlusive disease (3% versus 28%; P = .003), chronic graft-versus-host disease (9% versus 26%; P = .047), adenovirus infection (3% versus 32%; P = .001), and human herpesvirus 6 infection reactivation (21% versus 44%; P = .005). Furthermore, the median duration of neutropenia was shorter in the FluBu arm (11 days versus 22 days; P < .001), and the patients in this arm required fewer transfusions. Our data indicate that Flu (160 mg/m(2)) with targeted myeloablative Bu (90 mg·h/L) is less toxic than and equally effective as BuCy (Mel) in patients with similar indications for allo-HCT.
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Affiliation(s)
- I H Bartelink
- Clinical Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California
| | - E M L van Reij
- Clinical Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - C E Gerhardt
- Pediatric Blood and Marrow Transplantation Program, University Medical Center Utrecht, Utrecht, The Netherlands
| | - E M van Maarseveen
- Clinical Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - A de Wildt
- Pediatric Blood and Marrow Transplantation Program, University Medical Center Utrecht, Utrecht, The Netherlands
| | - B Versluys
- Pediatric Blood and Marrow Transplantation Program, University Medical Center Utrecht, Utrecht, The Netherlands
| | - C A Lindemans
- Pediatric Blood and Marrow Transplantation Program, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M B Bierings
- Pediatric Blood and Marrow Transplantation Program, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jaap Jan Boelens
- Pediatric Blood and Marrow Transplantation Program, University Medical Center Utrecht, Utrecht, The Netherlands; U-DANCE, Section Tumorimmunology, Laboratory for Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands.
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29
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Establishing a Target Exposure for Once-Daily Intravenous Busulfan Given with Fludarabine and Thymoglobulin before Allogeneic Transplantation. Biol Blood Marrow Transplant 2013; 19:1381-6. [DOI: 10.1016/j.bbmt.2013.07.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Accepted: 07/02/2013] [Indexed: 12/14/2022]
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30
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Promising role of reduced-toxicity hematopoietic stem cell transplantation (PART-I). Stem Cell Rev Rep 2013; 8:1254-64. [PMID: 22836809 DOI: 10.1007/s12015-012-9401-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) remains a potential curative option for many patients with hematological malignancies (HM). However, the high rate of transplantation-related mortality (TRM) restricted the use of standard myeloablative HSCT to a minority of young and fit patients. Over the past few years, it has become evident that the alloreactivity of the immunocompetent donor cells mediated anti-malignancy effects independent of the action of high dose chemoradiotherapy. The use of reduced intensity conditioning (RIC) regimens has allowed a graft-versus-malignancy (GvM) effect to be exploited in patients who were previously ineligible for HSCT on the grounds of age and comorbidity. Retrospective analysis showed that RIC has been associated with lower TRM but a higher relapse rate leading to similar intermediate term overall and progression-free survivals when compared to standard myeloablative HSCT. However, the long term antitumor effect of this approach is less well established. Prospective studies are ongoing to define which patients might most benefit from reduced toxicity stem cell transplant (RT-SCT) and which transplant protocols are suitable for the different types of HM. The advent of RT-SCT permits the delivery of a potentially curative GvM effect to the majority of patients with HM whose outcome with conventional chemotherapy would be dismal. Remaining challenges include development of effective strategies to reduce relapse rates by augmenting GvM effects without increasing toxicity.
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31
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Indications and outcomes of reduced-toxicity hematopoietic stem cell transplantation in adult patients with hematological malignancies. Int J Hematol 2013; 97:581-98. [PMID: 23585244 DOI: 10.1007/s12185-013-1313-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Revised: 03/12/2013] [Accepted: 03/12/2013] [Indexed: 02/05/2023]
Abstract
Hematopoietic stem cell transplantation (HCT) utilizing non-myeloablative (NMA) and reduced-intensity conditioning (RIC) regimens (collectively referred to as reduced-toxicity HCT, RT-HCT) has become a viable therapeutic option for patients with hematological malignancies who are ineligible for standard myeloablative conditioning transplantation (MA-HCT). RT-HCT has been shown to induce stable engraftment with low toxicity, and to produce similar overall and progression-free survival (PFS) when compared to MA-HCT in acute myeloid leukemia and myelodysplastic syndrome. The best results for RT-HCT have been reported for patients with disease that is in remission, indolent and chemosensitive, and with a strong graft-versus-malignancy effect. Chronic graft-versus-host disease seems to correlate with a lower relapse rate and better PFS. RT-HCT is inferior when performed in poor risk or advanced disease, due to high relapse rates. A search for novel strategies that includes the most appropriate conditioning regimens and post-transplant immunomodulation protocols with more intensive anti-malignancy activity but limited toxicity is in progress. This review provides an update on the results of clinical studies of RT-HCT, and discusses possible indications and investigative strategies for improving the clinical outcomes of RT-HCT for the major hematological malignancies.
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32
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Kebriaei P, Ravandi F. Treating adults with acute lymphoblastic leukemia: it is time to grow up. Int J Hematol Oncol 2013. [DOI: 10.2217/ijh.12.25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Partow Kebriaei
- Department of Cellular Therapy & Stem Cell Transplantation, University of Texas – MD Anderson Cancer Center, Unit 423, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Farhad Ravandi
- Department of Leukemia, University of Texas – MD Anderson Cancer Center, Unit 428, 1515 Holcombe Boulevard, Houston, TX 77030, USA
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33
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Kebriaei P, Basset R, Ledesma C, Ciurea S, Parmar S, Shpall EJ, Hosing C, Khouri I, Qazilbash M, Popat U, Alousi A, Nieto Y, Jones RB, de Lima M, Champlin RE, Andersson BS. Clofarabine combined with busulfan provides excellent disease control in adult patients with acute lymphoblastic leukemia undergoing allogeneic hematopoietic stem cell transplantation. Biol Blood Marrow Transplant 2012; 18:1819-26. [PMID: 22750645 PMCID: PMC4319530 DOI: 10.1016/j.bbmt.2012.06.010] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2012] [Accepted: 06/13/2012] [Indexed: 11/21/2022]
Abstract
We investigated the safety and early disease control data for i.v. busulfan (Bu) in combination with clofarabine (Clo) in patients with acute lymphoblastic leukemia undergoing allogeneic hematopoietic stem cell transplantation (SCT). Fifty-one patients (median age, 36 years; range, 20-64 years) received a matched sibling (n = 24), syngeneic (n = 2), or matched unrelated donor transplant (n = 25) for acute lymphoblastic leukemia in first complete remission (n = 30), second complete remission (n = 13), or active disease (n = 8). More than one-half of the patients had a high-risk cytogenetic profile, as defined by the presence of t(9;22) (n = 17), t(4;11) (n = 3), or complex cytogenetics (n = 7). Clo 40 mg/m(2) was given once daily, with each dose followed by pharmacokinetically dosed Bu infused over 3 hours daily for 4 days, followed by hematopoietic SCT 2 days later. The Bu dose was based on drug clearance, as determined by the patient's response to a 32-mg/m(2) Bu test dose given 48 hours before the high-dose regimen. The target daily area under the receiver-operating characteristic curve was 5500 μM/min for patients age <60 years and 4000 μM/min for those age ≥60 years. The regimen was well tolerated, with a 100-day nonrelapse mortality rate of 6%. With a median follow-up of 14 months among surviving patients (range, 6-28 months), the 1-year overall survival, disease-free survival, and nonrelapse mortality rates were 67% (95% confidence interval [CI], 55%-83%), 54% (95% CI, 41%-71%), and 32% (95% CI, 16%-45%), respectively. For patients undergoing SCT in first remission, these respective rates were 74%, 64%, and 25%. Our data indicate that the combination of Clo and Bu provides effective disease control while maintaining a favorable safety profile.
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Affiliation(s)
- Partow Kebriaei
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M.D. Anderson Cancer Center, Houston, USA.
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Daly A, Savoie ML, Geddes M, Chaudhry A, Stewart D, Duggan P, Bahlis N, Storek J, Brown C, Shafey M, Turner AR, Russell J. Fludarabine, Busulfan, Antithymocyte Globulin, and Total Body Irradiation for Pretransplantation Conditioning in Acute Lymphoblastic Leukemia: Excellent Outcomes in All but Older Patients with Comorbidities. Biol Blood Marrow Transplant 2012; 18:1921-6. [DOI: 10.1016/j.bbmt.2012.07.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Accepted: 07/19/2012] [Indexed: 10/28/2022]
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35
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The role of allogeneic hematopoietic stem cell transplantation in the therapy of patients with acute lymphoblastic leukemia. Curr Hematol Malig Rep 2012; 7:144-52. [PMID: 22410763 DOI: 10.1007/s11899-012-0116-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (alloHSCT) is an effective post-remission therapy in patients with acute lymphoblastic leukemia (ALL), but is associated with significant toxicity, so the optimal timing and use of this modality remains an issue of debate. Increased advances in reduced-intensity transplant preparative regimens and alternative donors has increased the accessibility of allogeneic transplantation. A risk adapted paradigm, using minimal residual disease analysis, may help in the selection of patients at highest risk for relapse, who may benefit most from alloHSCT. In this review, we summarize the indications for allogeneic transplantation within the risk-oriented paradigm, and also explore the latest literature on reduced intensity transplant regimens, as well as alternative donor transplantation for patients with ALL.
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Abstract
BACKGROUND Allogeneic hematopoietic cell transplantation (HCT) offers a curative treatment option for management of a variety of hematologic malignancies. While sibling donors have been the gold standard for adult patients in need of an HCT, not all patients have a suitable family donor. The availability of unrelated volunteer donor registries and alternative stem cell sources has expanded the wide application of this procedure. METHODS PubMed and MEDLINE were searched for human trials and the English language from 2001 to 2011. Factors influencing transplantation outcomes involving unrelated donors over the last decade are discussed, and feasible alternative stem cell sources when a matched unrelated donor is not available are reviewed. RESULTS HCT using a matched unrelated donor offers outcomes comparable to sibling HCT due to current molecular-based HLA typing and improvements in conditioning regimens and/or supportive care. The primary factor that contributes to improved outcome is the degree of donor-to-recipient HLA matching. The selection of younger unrelated donors has also been associated with improved outcomes in HCT. Evidence supports the universal application of matched unrelated donors even in high-risk leukemia and/or older patients. In adult patients without a matched related donor, other promising options as stem cell source includes mismatched unrelated donors, umbilical cord blood units, and haploidentical donors. CONCLUSIONS With current methodologies for molecular HLA typing and supportive care tools, outcomes of transplants with matched unrelated donors are comparable to those achieved with sibling donors. Alternative stem cell donors when a matched unrelated donor is not available are feasible expanding the stem cell donor pool.
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Affiliation(s)
- Lia Elena Perez
- Blood and Marrow Transplant Program, Moffitt Cancer Center, Tampa, FL 33612, USA.
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37
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Hoegh-Petersen M, Roa L, Liu Y, Zhou F, Ugarte-Torres A, Louie P, Fonseca K, Khan F, Russell JA, Storek J. Low cytomegalovirus-specific T-cell counts at reactivation are associated with progression to high-level viremia or disease in seropositive recipients of hematopoietic cell grafts from seropositive but not seronegative donors. Cytotherapy 2012; 14:194-204. [DOI: 10.3109/14653249.2011.634402] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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38
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Casper J, Holowiecki J, Trenschel R, Wandt H, Schaefer-Eckart K, Ruutu T, Volin L, Einsele H, Stuhler G, Uharek L, Blau I, Bornhaeuser M, Zander AR, Larsson K, Markiewicz M, Giebel S, Kruzel T, Mylius HA, Baumgart J, Pichlmeier U, Freund M, Beelen DW. Allogeneic hematopoietic SCT in patients with AML following treosulfan/fludarabine conditioning. Bone Marrow Transplant 2011; 47:1171-7. [PMID: 22158386 DOI: 10.1038/bmt.2011.242] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
An alternative reduced-toxicity conditioning regimen for allogeneic transplantation, based on treosulfan and fludarabine, has recently been identified. The safety and efficacy of this new conditioning regimen has been investigated prospectively in patients with AML. A total number of 75 patients with AML in CR were treated with 3 × 14 g/m(2) treosulfan and 5 × 30 mg/m(2) fludarabine, followed by matched sibling or unrelated SCT. Patients were evaluated for engraftment, adverse events, GVHD, and for non-relapse mortality, relapse incidence, overall and disease-free survival (DFS). All patients showed primary engraftment of neutrophils after a median of 20 days. Non-hematological adverse events grade III-IV in severity included mainly infections (59%) and gastrointestinal symptoms (7%). Acute GVHD grade II-IV occurred in 21% and extensive chronic GVHD occurred in 16% of the patients. After a median follow-up of 715 days, the 2-year overall and DFS estimates were 61% and 55%, respectively. The 2-year incidences of relapse and non-relapse mortality reached 34% and 11%, respectively. In summary, our data confirm promising safety and efficacy of the treosulfan-based conditioning therapy in AML patients, ClinicalTrials.gov Identifier: NCT01063660.
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Affiliation(s)
- J Casper
- Division of Hematology and Oncology, University of Rostock, Rostock, Germany.
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39
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Lee SE, Lim J, Yahng SA, Cho BS, Eom KS, Kim M, Kim YJ, Kim HJ, Min CK, Lee S, Kim DW, Lee JW, Min WS, Park CW, Cho SG. Reduced-intensity conditioning regimen combined with low-dose total body irradiation in the treatment of myelodysplastic syndrome. Acta Haematol 2011; 126:21-9. [PMID: 21411986 DOI: 10.1159/000323717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2010] [Accepted: 12/21/2010] [Indexed: 11/19/2022]
Abstract
Although reduced-intensity conditioning (RIC) has been increasingly used in patients with myelodysplastic syndrome (MDS) to reduce transplant-related mortality, a high relapse rate in RIC remains an unresolved problem. Considering the additive antileukemic effect of low-dose total body irradiation (TBI), we evaluated the feasibility of combining RIC regimens with low-dose TBI in de novo MDS. The RIC regimen combined with low-dose TBI in this study consisted of fludarabine (150 mg/m(2)), intravenous busulfan (6.4 mg/kg), and TBI (400 cGy). Antithymocyte globulin was used to overcome HLA mismatching. A total of 31 subjects were recruited with a median age of 39 years (range 19-63). The patients received transplants from siblings (n = 20) or unrelated donors (n = 11). All patients rapidly achieved full-donor chimerism. At a median follow-up for survivors of 35 months (range 6.0-54.9), the 3-year overall survival, event-free survival, transplantation-related mortality, and relapse rates were 67.6, 63.2, 20.5 and 11.4%, respectively. The 3-year cumulative incidence of acute (grades II-IV) and chronic extensive graft-versus-host disease in patients who survived at least 100 days was 39.2 and 44.6%, respectively. These results suggest that an RIC combined with low-dose TBI may be a feasible therapeutic approach for treating de novo MDS.
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Affiliation(s)
- Sung-Eun Lee
- Department of Hematology, Catholic Blood and Marrow Transplantation Center, The Catholic University of Korea, College of Medicine, Seoul, Korea
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40
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Santarone S, Pidala J, Di Nicola M, Field T, Alsina M, Ayala E, Janssen W, Kharfan-Dabaja MA, Ochoa L, Perez L, Perkins J, Raychaudhuri J, Fernandez H, Anasetti C. Fludarabine and pharmacokinetic-targeted busulfan before allografting for adults with acute lymphoid leukemia. Biol Blood Marrow Transplant 2011; 17:1505-11. [PMID: 21385623 DOI: 10.1016/j.bbmt.2011.02.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2011] [Accepted: 02/26/2011] [Indexed: 11/12/2022]
Abstract
We aimed to evaluate the safety and efficacy of fludarabine (FLU) and pharmacokinetic-targeted busulfan (BU) as conditioning regimen for hematopoietic cell transplantation (HCT) in adult patients with acute lymphoid leukemia (ALL). Forty-four patients with ALL (27 in first complete remission [CR1] and 17 in more advanced disease stage: 4 with primary induction failure [PIF], 12 in CR2, and 1 in CR3) received FLU and pharmacokinetic-targeted BU as preparative therapy for HCT. Grafts were T-replete, filgrastim-mobilized peripheral blood stem cells (PBSC). Graft-versus-host disease (GVHD) prophylaxis consisted of tacrolimus (TAC) and short-course methotrexate in 36 patients, TAC and sirolimus in 3, and TAC and mycophenolate mofetil in 5. Primary engraftment was achieved in all 44 patients. The cumulative incidence of transplant-related mortality (TRM) was 2% (95% confidence interval [CI] 0%-16%) at 100 days and 18% (95% CI 10%-34%) at 2 years. The 2-year cumulative incidence of relapse was 19% (95% CI 8%-41%) for those transplanted in CR1, and 48% (29%-80%) for those with more advanced disease. After a median follow-up of 32 months (range: 15-69 months), the 2-year overall survival (OS) was 54% (95% CI 39%-69%). Relapse-free survival (RFS) at 2 years was 63% (95% CI 45%-81%) for patients transplanted in CR1 and 34% (95% CI 11%-57%) for patients transplanted in more advanced disease. When compared to irradiation-containing regimens, FLU and PK-targeted BU appear safer and similarly effective in controlling ALL, providing a treatment option for adult patients with ALL.
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Affiliation(s)
- Stella Santarone
- Department of Biomedical Sciences, Chieti-Pescara University, Chieti, Italy
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41
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Valdez BC, Li Y, Murray D, Champlin RE, Andersson BS. The synergistic cytotoxicity of clofarabine, fludarabine and busulfan in AML cells involves ATM pathway activation and chromatin remodeling. Biochem Pharmacol 2011; 81:222-32. [PMID: 20933509 PMCID: PMC3006064 DOI: 10.1016/j.bcp.2010.09.027] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2010] [Revised: 09/27/2010] [Accepted: 09/28/2010] [Indexed: 10/19/2022]
Abstract
DNA alkylating agents alone or with ionizing radiation have been the preferred conditioning treatment in allogeneic hematopoietic stem cell transplantation (allo-HSCT). In search of less toxic alternatives, we hypothesized that combination of busulfan (Bu), fludarabine (Flu) and clofarabine (Clo) would provide superior efficacy. At low concentrations, these drugs show synergistic cytotoxicity in Bu-resistant AML KBM3/Bu250(6) cells. Similar molecular responses were observed in other AML cell lines and in primary explanted AML cells. The [Clo+Flu+Bu] combination activates an intense DNA damage response through the ATM pathway, leading to cell cycle checkpoint activation and apoptosis. Phosphorylations of SMC1 and SMC3, and methylations of histones 3 and 4, are much more pronounced in cells exposed to [Clo+Flu+Bu] than [Clo+Flu], suggesting their relevance in the efficacy of the triple-drug combination. A possible mechanism for these observed synergistic effects involves the capability of [Clo+Flu] to induce histone methylations and subsequent chromatin remodeling, which may render the genomic DNA more accessible to Bu alkylation. The Bu-mediated DNA cross-linking may provide a feedback loop which perpetuates the DNA damage response initiated by [Clo+Flu] and commits the cells to apoptosis. Our results provide a conceptual mechanistic basis for exploring this triple-drug combination in pretransplant conditioning therapy for allo-HSCT.
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Affiliation(s)
- Benigno C. Valdez
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030
| | - Yang Li
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030
| | - David Murray
- Department of Experimental Oncology, Cross Cancer Institute, 11560 University Ave., Edmonton, AB, Canada T6G 1Z2
| | - Richard E. Champlin
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030
| | - Borje S. Andersson
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030
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42
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LeMaistre JA, Bachier C, Smith B, LeMaistre CF, Shaughnessy PJ. Once daily busulfan cyclophosphamide is well tolerated and effective as a preparative regimen for allogeneic hematopoietic stem cell transplant. J Oncol Pharm Pract 2011; 18:17-22. [PMID: 21228086 DOI: 10.1177/1078155210392616] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We report a retrospective review of our institutional data using once daily intravenous (IV) busulfan (Bu) and cyclophosphamide (Cy) and total body irradiation (TBI)/Cy in patients who received allogeneic hematopoietic stem cell transplant (HCT) from January 2000 to December 2006. Bu 3.2 mg/kg IV once daily × 4 days followed by Cy 60 mg/kg IV daily × 2 days was given to 42 patients. Cy 60 mg/kg IV daily for 2 days and fractionated TBI 1200 cGy delivered over 3 days was given to 60 patients. Veno-occlusive disease developed in two patients in the once daily BuCy group and no patients in the TBI/Cy group. The once daily BuCy group had significantly less transplant-related mortality (TRM) than the TBI/Cy group at 100 days (p = 0.047) and better overall survival at 1 year (p = 0.01). This review demonstrates once daily IV BuCy and allogeneic HCT is well tolerated with no unexpected TRM or differences in clinical outcomes.
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43
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Gaber AO, Monaco AP, Russell JA, Lebranchu Y, Mohty M. Rabbit antithymocyte globulin (thymoglobulin): 25 years and new frontiers in solid organ transplantation and haematology. Drugs 2010; 70:691-732. [PMID: 20394456 DOI: 10.2165/11315940-000000000-00000] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The more than 25 years of clinical experience with rabbit antithymocyte globulin (rATG), specifically Thymoglobulin, has transformed immunosuppression in solid organ transplantation and haematology. The utility of rATG has evolved from the treatment of allograft rejection and graft-versus-host disease to the prevention of various complications that limit the success of solid organ and stem cell transplantation. Today, rATG is being successfully incorporated into novel therapeutic regimens that seek to reduce overall toxicity and improve long-term outcomes. Clinical trials have demonstrated the efficacy and safety of rATG in recipients of various types of solid organ allografts, recipients of allogeneic stem cell transplants who are conditioned with both conventional and nonconventional regimens, and patients with aplastic anaemia. Over time, clinicians have learnt how to better balance the benefits and risks associated with rATG. Advances in the understanding of the multifaceted mechanism of action will guide research into new therapeutic areas and future applications.
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Affiliation(s)
- A Osama Gaber
- Department of Surgery, The Methodist Hospital, Houston, Texas 77030, USA.
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44
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Bashir Q, Andersson BS, Fernandez-Vina M, de Padua Silva L, Giralt S, Chiattone A, Wei W, Sharma M, Anderlini P, Shpall EJ, Popat U, Rodrigues M, Champlin RE, de Lima M. Unrelated donor transplantation for acute myelogenous leukemia in first remission. Biol Blood Marrow Transplant 2010; 17:1067-71. [PMID: 21087679 DOI: 10.1016/j.bbmt.2010.11.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2010] [Accepted: 11/05/2010] [Indexed: 11/26/2022]
Abstract
We retrospectively analyzed the outcomes of all acute myelogenous leukemia (AML) patients in first remission (n = 44; median age = 48 years; high-risk cytogenetics = 59%) who received unrelated donor hematopoietic cell transplantation (HCT) with myeloablative conditioning regimen of i.v. busulfan, fludarabine, and antithymocyte globulin (ATG) between January 2002 and November 2009 at our institution. Donor-recipient pairs were matched by high-resolution HLA-A, -B, -C, -DRB1, and -DQB1 typing (10/10 matches, n = 41; 9/10 matches, n = 3). With a median follow-up of 34 months, actuarial 3-year event-free survival (EFS) and overall survival (OS) is 70% and 78%, respectively. The 3-year EFS and OS in patients with and without poor risk cytogenetics is similar (63% versus 82%, P = 0.43 and 78% versus 82%, P = .89, respectively). The 3-year EFS and OS is also similar in patients above age 55 year versus patients age 55 year or younger (80% versus 67%, P = .47 and 80% versus 78%, P = .81, respectively). The 100-day and 3-year cumulative incidence of transplant-related mortality is 5% and 15%, respectively. Six patients have relapsed, and 3 of them are alive and in remission after salvage therapy, with a median follow-up of 23 months. These results indicate that the majority of AML patients eligible for this treatment can achieve long-term disease control.
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Affiliation(s)
- Qaiser Bashir
- Department of Stem Cell Transplantation and Cellular Therapy, U.T. M.D. Anderson Cancer Center, Houston, Texas 77030-4009, USA.
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45
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Hoegh-Petersen M, Goodyear D, Geddes MN, Liu S, Ugarte-Torres A, Liu Y, Walker JT, Fonseca K, Daly A, Duggan P, Stewart D, Russell JA, Storek J. High incidence of post transplant lymphoproliferative disorder after antithymocyte globulin-based conditioning and ineffective prediction by day 28 EBV-specific T lymphocyte counts. Bone Marrow Transplant 2010; 46:1104-12. [PMID: 21057556 DOI: 10.1038/bmt.2010.272] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The largest study on post-allogeneic hematopoietic cell transplant lymphoproliferative disorder (PTLD) epidemiology showed a cumulative incidence of 1.7% in patients receiving antithymocyte globulin (ATG). We had noted an apparently higher incidence in our transplant recipients whose conditioning included ATG. Therefore, we formally determined the incidence of PTLD through chart review. We also evaluated whether counts of EBV-specific T lymphocytes measured by cytokine flow cytometry could identify patients at risk of developing PTLD. Among 307 allogeneic transplant recipients, 25 (8.1%) developed PTLD. This was biopsy proven in 11 patients, and was fatal in seven patients. Patient age, EBV serostatus, donor type/match or GVHD did not influence PTLD risk significantly. Median onset of PTLD was 55 (range, 28-770) days post transplant. Day 28 EBV-specific T lymphocyte counts were not significantly different in 11 patients who developed PTLD and 31 non-PTLD patients matched for published risk factors for PTLD. In summary, when using conditioning with thymoglobulin 4.5 mg/kg, the incidence of PTLD is relatively high and cannot be predicted by day 28 cytokine flow cytometry-determined EBV-specific T lymphocyte counts. Thus, in this scenario PTLD prevention may be warranted, for example, using EBV DNAemia monitoring with preemptive therapy.
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Affiliation(s)
- M Hoegh-Petersen
- University of Calgary and Alberta Health Services, Calgary, Alberta, Canada.
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46
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Influence of comorbidities on transplant outcomes in patients aged 50 years or more after myeloablative conditioning incorporating fludarabine, BU and ATG. Bone Marrow Transplant 2010; 46:1077-83. [DOI: 10.1038/bmt.2010.257] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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47
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Andersson BS, Valdez BC, de Lima M, Wang X, Thall PF, Worth LL, Popat U, Madden T, Hosing C, Alousi A, Rondon G, Kebriaei P, Shpall EJ, Jones RB, Champlin RE. Clofarabine ± fludarabine with once daily i.v. busulfan as pretransplant conditioning therapy for advanced myeloid leukemia and MDS. Biol Blood Marrow Transplant 2010; 17:893-900. [PMID: 20946966 DOI: 10.1016/j.bbmt.2010.09.022] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2010] [Accepted: 09/30/2010] [Indexed: 11/18/2022]
Abstract
Although a combination of i.v. busulfan (Bu) and fludarabine (Flu) is a safe, reduced-toxicity conditioning program for acute myelogenous leukemia/myelodysplastic syndromes (AML/MDS), recurrent leukemia posttransplantation remains a problem. To enhance the conditioning regimen's antileukemic effect, we decided to supplant Flu with clofarabine (Clo), and assayed the interactions of these nucleoside analogs alone and in combination with Bu in Bu-resistant human cell lines in vitro. We found pronounced synergy between each nucleoside and the alkylator but even more enhanced cytotoxic synergy when the nucleoside analogs were combined prior to exposing the cells to Bu. We then designed a 4-arm clinical trial in patients with myeloid leukemia undergoing allogeneic stem cell transplantation (allo-SCT). Patients were adaptively randomized as follows: Arm I-Clo:Flu 10:30 mg/m(2), Arm II-20:20 mg/m(2), Arm III-30:10 mg/m(2), and Arm IV-single-agent Clo at 40 mg/m(2). The nucleoside analog(s) were/was infused over 1 hour once daily for 4 days, followed on each day by Bu, infused over 3 hours to a pharmacokinetically targeted daily area under the curve (AUC) of 6000 μMol-min ± 10%. Fifty-one patients have been enrolled with a minimum follow-up exceeding 100 days. There were 32 males and 19 females, with a median age of 45 years (range: 6-59). Nine patients had chronic myeloid leukemia (CML) (BC: 2, second AP: 3, and tyrosine-kinase inhibitor refractory first chronic phase [CP]: 4). Forty-two patients had AML: 14 were induction failures, 8 in first chemotherapy-refractory relapse, 7 in untreated relapse, 3 in second or subsequent relapse, 4 were in second complete remission (CR), and 3 in second CR without platelet recovery (CRp), 2 were in high-risk CR1. Finally, 1 patient was in first CRp. Graft-versus-host disease (GVHD) prophylaxis was tacrolimus and mini-methorexate (MTX), and those who had an unrelated or 1 antigen-mismatched donor received low-dose rabbit-ATG (Thymoglobulin™). All patients engrafted. Forty-one patients had active leukemia at the time of transplant, and 35 achieved CR (85%). Twenty of the 42 AML patients and 5 of 9 CML patients are alive with a projected median overall survival (OS) of 23 months. Marrow and blood (T cell) chimerism studies at day +100 revealed that both in the lower-dose Clo groups (groups 1+2) and the higher-dose Clo groups (groups 3+4), the patients had a median of 100% donor (T cell)-derived DNA. There has been no secondary graft failure. In the first 100 days, 1 patient died of pneumonia, and 1 of liver GVHD. We conclude that (1) Clo ± Flu with i.v. Bu as pretransplant conditioning is safe in high-risk myeloid leukemia patients; (2) clofarabine is sufficiently immunosuppressive to support allo-SCT in myeloid leukemia; and (3) the median OS of 23 months in this high-risk patient population is encouraging. Additional studies to evaluate the antileukemic efficacy of Clo ± Flu with i.v. Bu as pretransplant conditioning therapy are warranted.
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MESH Headings
- Adenine Nucleotides/administration & dosage
- Animals
- Antilymphocyte Serum
- Antineoplastic Agents/administration & dosage
- Arabinonucleosides/administration & dosage
- Busulfan/administration & dosage
- Cell Line, Tumor
- Clofarabine
- Drug Administration Schedule
- Drug Resistance, Neoplasm
- Drug Synergism
- Female
- Graft vs Host Disease/mortality
- Graft vs Host Disease/prevention & control
- Hematopoietic Stem Cell Transplantation
- Humans
- Immunosuppressive Agents/administration & dosage
- Injections, Intravenous
- Leukemia, Myeloid, Acute/immunology
- Leukemia, Myeloid, Acute/mortality
- Leukemia, Myeloid, Acute/pathology
- Leukemia, Myeloid, Acute/therapy
- Male
- Middle Aged
- Myeloablative Agonists/administration & dosage
- Rabbits
- Remission Induction
- Survival Analysis
- Tacrolimus
- Transplantation Conditioning
- Transplantation, Homologous
- Vidarabine/administration & dosage
- Vidarabine/analogs & derivatives
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Affiliation(s)
- Borje S Andersson
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA.
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48
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Antithymocyte globulins and chronic graft-vs-host disease after myeloablative allogeneic stem cell transplantation from HLA-matched unrelated donors: a report from the Sociéte Française de Greffe de Moelle et de Thérapie Cellulaire. Leukemia 2010; 24:1867-74. [PMID: 20882046 DOI: 10.1038/leu.2010.200] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This retrospective report assessed the impact of rabbit antithymocyte globulins (ATG), incorporated within a standard myeloablative conditioning regimen prior to allogeneic stem cell transplantation (allo-SCT) using human leukocyte antigen-matched unrelated donors (HLA-MUD), on the incidence of acute and chronic graft-vs-host disease (GVHD). In this series of leukemia patients, 120 patients (70%) did not receive ATG ('no-ATG' group), whereas 51 patients received ATG ('ATG' group). With a median follow-up of 30.3 months, the cumulative incidence of grade 3-4 acute GVHD was 36% in the no-ATG group and 20% in the ATG group (P = 0.11). The cumulative incidence of extensive chronic GVHD was significantly lower in the ATG group as compared to the no-ATG group (4 vs 32%, respectively; P = 0.0017). In multivariate analysis, the absence of use of ATG was the strongest parameter associated with an increased risk of extensive chronic GVHD (relative risk) = 7.14, 95% CI: 1.7-33.3, P = 0.008). At 2 years, the probability of nonrelapse mortality, relapse, overall and leukemia-free survivals was not significantly different between the no-ATG and ATG groups. We conclude that the addition of ATG to GVHD prophylaxis resulted in decreased incidence of extensive chronic GVHD without an increase in relapse or nonrelapse mortality, and without compromising survival after myeloablative allo-SCT from HLA-MUD.
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49
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Favorable outcomes of intravenous busulfan, fludarabine, and 400 cGy total body irradiation-based reduced-intensity conditioning allogeneic stem cell transplantation for acute myelogenous leukemia with old age and/or co-morbidities. Int J Hematol 2010; 92:342-50. [DOI: 10.1007/s12185-010-0649-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2010] [Revised: 06/10/2010] [Accepted: 07/14/2010] [Indexed: 11/25/2022]
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50
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Valcárcel D, Sierra J, Wang T, Kan F, Gupta V, Hale GA, Marks DI, McCarthy PL, Oudshoorn M, Petersdorf EW, Ringdén O, Setterholm M, Spellman SR, Waller EK, Gajewski JL, Marino SR, Senitzer D, Lee SJ. One-antigen mismatched related versus HLA-matched unrelated donor hematopoietic stem cell transplantation in adults with acute leukemia: Center for International Blood and Marrow Transplant Research results in the era of molecular HLA typing. Biol Blood Marrow Transplant 2010; 17:640-8. [PMID: 20674756 DOI: 10.1016/j.bbmt.2010.07.022] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2010] [Accepted: 07/26/2010] [Indexed: 11/16/2022]
Abstract
Approximately 13% of patients lacking an HLA-identical sibling have a one-antigen-mismatched related donor (MMRD). Historically, outcomes from the use of a one-antigen MMRD were considered equivalent to those from the use of a matched unrelated donor (UD). Recent improvements in UD stem cell transplantation (SCT) resulting from better molecular HLA matching justifies investigating whether UD should be preferred over MMRD in adult patients with acute leukemia. Here, we compared the outcomes of MMRD (n = 89) and HLA-A, -B, -C, and -DRB1 allele-matched UD (n = 700) SCT reported to the Center for International Blood and Marrow Transplant Research between 1995 and 2005. The patients underwent transplantation for acute myelogenous leukemia or acute lymphoblastic leukemia in first or second complete remission. Donor type was not associated with hematologic recovery. Univariate and multivariate comparisons of MMRD versus HLA-matched UD transplants showed no statistically significant differences in overall survival, disease-free survival, treatment-related mortality, relapse, or 100-day grade III-IV acute graft-versus-host disease (GVHD). MMRD SCT was associated with a lower rate of chronic GVHD at 1 year (35% vs 47%; P = .03), which was confirmed by multivariate analysis (relative risk, 0.58; 95% confidence interval, 0.39-0.85; P < .01). According to our data, HLA-matched UD and MMRD SCT are associated with comparable survival. Given that less chronic GVHD was observed in the MMRD transplantations, this option, when available, remains the first choice in patients with acute leukemia without an HLA-identical sibling in need of allogeneic SCT.
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Affiliation(s)
- David Valcárcel
- Hematology and Stem Cell Transplantation Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.
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