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Ansari F, Behfar M, Naji P, Darvish Z, Rostami T, Mohseni R, Alimoghaddam K, Salajegheh P, Ahadi B, Mardani M, Hamidieh AA. Fanconi anemia phenotypic and transplant outcomes' associations in Iranian patients. Health Sci Rep 2023; 6:e1180. [PMID: 37033392 PMCID: PMC10075997 DOI: 10.1002/hsr2.1180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 03/10/2023] [Accepted: 03/13/2023] [Indexed: 04/08/2023] Open
Abstract
Objectives Fanconi anemia (FA) is a rare, heterogeneous, inherited disorder. Allogeneic hematopoietic stem cell transplantation (HSCT) represents the only therapeutic option to restore normal hematopoiesis. This study reports the outcomes of FA‐HSCT patients and identifies factors, including clinical phenotype. Our team examined more than 95% of Iranian FA patients during the last decade. Study Design One hundred and six FA patients (age range: 2–41) who underwent HSCT from March 2007 to February 2018 were enrolled. Clinical characteristics of genetic disease, pre‐HSCT findings, HSCT indication, and long‐term follow‐up evaluated and recorded. Data were analyzed using SPSS 19.0. Results The mean follow‐up period for survivors was 36 months (range, 1–101). The 3‐year overall survival (OS) and disease‐free survival were 72.2% and 71.2%, respectively. The 3‐year OS rate for patients with limited and extensive malformations was 78.8% and 56.6%, respectively (p = 0.025). Acute graft versus host disease incidence was 60.52% for patients with limited malformations versus 70% for patients with extensive ones (p = 0.49). Chronic graft versus host disease incidence for these two groups was 9.21% and 10%, respectively (p = 0.91). Conclusions OS was not associated with each of the malformations singly; however, it was lower in the extensive group. The younger age of patients at the HSCT time leads to a higher OS. The differences in FA patients' outcomes and the various genotypes were probably related. These data provide a powerful tool for further studies on genotype–phenotype association with HSCT results. The younger age of FA patients at the HSCT time leads to a higher OS. OS was lower in the congenital malformations extensive group. The malformations’ scope affects aGvHD incidence significantly, while not cGvHD. Various HSCT outcomes in different centers can be due to distinct genotypes.
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Affiliation(s)
- Faezeh Ansari
- Pediatric Cell and Gene Therapy Research Centre, Gene, Cell & Tissue Research InstituteTehran University of Medical SciencesTehranIran
| | - Maryam Behfar
- Pediatric Cell and Gene Therapy Research Centre, Gene, Cell & Tissue Research InstituteTehran University of Medical SciencesTehranIran
- Pediatric Hematopoietic Stem Cell Transplant Department, Children's Medical CenterTehran University of Medical SciencesTehranIran
| | - Parisa Naji
- Pediatric Cell and Gene Therapy Research Centre, Gene, Cell & Tissue Research InstituteTehran University of Medical SciencesTehranIran
| | - Zahra Darvish
- Institute for Oncology, Hematology and Cell Therapy, Shariati HospitalTehran University of Medical SciencesTehranIran
| | - Tahereh Rostami
- Institute for Oncology, Hematology and Cell Therapy, Shariati HospitalTehran University of Medical SciencesTehranIran
| | - Rashin Mohseni
- Pediatric Cell and Gene Therapy Research Centre, Gene, Cell & Tissue Research InstituteTehran University of Medical SciencesTehranIran
| | - Kamran Alimoghaddam
- Hematology‐Oncology and Stem Cell Transplantation Research CenterTehran University of Medical SciencesTehranIran
| | - Pouria Salajegheh
- Department of Pediatric, Faculty of MedicineKerman University of Medical SciencesKermanIran
| | - Batool Ahadi
- Pediatric Cell and Gene Therapy Research Centre, Gene, Cell & Tissue Research InstituteTehran University of Medical SciencesTehranIran
| | - Mahta Mardani
- Pediatric Cell and Gene Therapy Research Centre, Gene, Cell & Tissue Research InstituteTehran University of Medical SciencesTehranIran
| | - Amir Ali Hamidieh
- Pediatric Cell and Gene Therapy Research Centre, Gene, Cell & Tissue Research InstituteTehran University of Medical SciencesTehranIran
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2
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Fink O, Even-Or E, Avni B, Grisariu S, Zaidman I, Schejter YD, NaserEddin A, Najajreh M, Stepensky P. Two decades of stem cell transplantation in patients with Fanconi anemia: Analysis of factors affecting transplant outcomes. Clin Transplant 2023; 37:e14835. [PMID: 36259220 PMCID: PMC10078339 DOI: 10.1111/ctr.14835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 10/10/2022] [Accepted: 10/11/2022] [Indexed: 01/18/2023]
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) is currently the only curative treatment for the hematological complications of patients with Fanconi anemia (FA). Over the last two decades, HSCT outcomes have improved dramatically following the development of regimens tailored for FA patients. In this study, we analyzed genetic, clinical, and transplant data of 41 patients with FA who underwent HSCT at Hadassah Medical Center between November 1996 and September 2020. Overall survival (OS) was 82.9% with a median follow-up time of 2.11-years (95% CI, .48-16.56). Thirteen patients (31.7%) developed acute graft-versus-host disease (GVHD), three of them with grades 3-4. Nine patients developed chronic GVHD, five had extensive disease. Twelve patients (29.3%) developed stable mixed-chimerism with complete resolution of bone marrow failure (BMF); none of them had acute nor chronic GVHD. Significantly higher GVHD rates were observed in transplants from peripheral blood stem cell grafts as compared to other stem cell sources (p = .002 for acute and p = .004 for chronic GVHD). Outcome parameters were comparable between HSCT from matched-sibling (n = 20) to other donors (n = 21), including survival rates (p = .1), time to engraftment (p = .69 and p = .14 for neutrophil and platelet engraftment time, respectively), chimerism status (p = .36 and p = .83 for full-donor and mixed chimerism, respectively), and GVHD prevalence (p = 1). Our results demonstrate the vast improvements in HSCT outcomes of patients with FA, narrowing the gap between matched-sibling versus alternative donor transplantations. Our data identifies factors that may significantly affect transplant outcomes such as graft source and chimerism status.
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Affiliation(s)
- Orly Fink
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ehud Even-Or
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Bone Marrow Transplantation and Cancer Immunotherapy, Hadassah Medical Center, Jerusalem, Israel
| | - Batia Avni
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Bone Marrow Transplantation and Cancer Immunotherapy, Hadassah Medical Center, Jerusalem, Israel
| | - Sigal Grisariu
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Bone Marrow Transplantation and Cancer Immunotherapy, Hadassah Medical Center, Jerusalem, Israel
| | - Irina Zaidman
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Bone Marrow Transplantation and Cancer Immunotherapy, Hadassah Medical Center, Jerusalem, Israel
| | - Yael Dinur Schejter
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Bone Marrow Transplantation and Cancer Immunotherapy, Hadassah Medical Center, Jerusalem, Israel
| | - Adeeb NaserEddin
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Bone Marrow Transplantation and Cancer Immunotherapy, Hadassah Medical Center, Jerusalem, Israel
| | - Mohammad Najajreh
- The Huda Al Masri Pediatric Cancer Department, Beit Jala Hospital, Beit Jala, Palestine
| | - Polina Stepensky
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Bone Marrow Transplantation and Cancer Immunotherapy, Hadassah Medical Center, Jerusalem, Israel
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3
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Medina-Valencia D, Aristizabal AM, Beltran E, Franco AA. Fanconi anemia and haploidentical stem cell transplantation. Pediatr Transplant 2022; 26:e14348. [PMID: 35781747 DOI: 10.1111/petr.14348] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 05/24/2022] [Accepted: 06/07/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Fanconi anemia is a congenital disorder belonging to bone marrow syndromes, with a risk of developing malignancy. Hematopoietic stem cell transplantation is the only curative treatment in these cases. Here, we aimed to report our clinical experience in pediatric patients with Fanconi anemia treated with haploidentical stem cell transplantation and post-transplant cyclophosphamide, an alternative strategy. METHODS We performed a case report based on clinical records of two patients who signed the informed consent form and were treated at Fundación Valle del Lili. RESULT Two pediatric patients, both with reduced-intensity conditioning, prophylaxis for acute graft-versus-host disease with post-transplant cyclophosphamide. They achieved primary neutrophil/platelets engraftment, and 100% chimerism. Had grade I or II graft-versus-host disease resolved? Currently are alive and in complete remission. CONCLUSIONS The use of mismatched related donors for haploidentical stem cell transplantation and post-transplant cyclophosphamide might be a promising option, and well-tolerated in pediatric patients. Serial chimerism can be useful during follow-up.
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Affiliation(s)
- Diego Medina-Valencia
- Departamento Materno infantil, servicio de hemato-onlogía pediátrica, unidad de trasplante de médula ósea, Fundación Valle del Lili, Cali, Colombia.,Facultad de medicina, Universidad Icesi, Cali, Colombia
| | - Ana Maria Aristizabal
- Facultad de medicina, Universidad Icesi, Cali, Colombia.,Departamento Materno infantil, servicio de pediatría, Fundación Valle del Lili, Cali, Colombia
| | - Estefania Beltran
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cali, Colombia
| | - Alexis A Franco
- Departamento Materno infantil, servicio de hemato-onlogía pediátrica, unidad de trasplante de médula ósea, Fundación Valle del Lili, Cali, Colombia.,Facultad de medicina, Universidad Icesi, Cali, Colombia
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4
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Xu L, Lu Y, Hu S, Li C, Tang Y, Wang H, Yan J, Chen J, Liu S, Sun Y, Wu X, Lin F, Lu P, Huang X. Unmanipulated haploidentical haematopoietic cell transplantation with radiation-free conditioning in Fanconi anaemia: A retrospective analysis from the Chinese Blood and Marrow Transplantation Registry Group. Br J Haematol 2022; 199:401-410. [PMID: 35989315 DOI: 10.1111/bjh.18408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 07/16/2022] [Accepted: 08/03/2022] [Indexed: 11/29/2022]
Abstract
Haematopoietic cell transplantation (HCT) is the only curative treatment for haematological complications in patients with Fanconi anaemia (FA). Haploidentical (haplo-) HCT is a promising alternative for FA. We aimed to analyse the outcomes of unmanipulated haplo-HCT in patients with FA with radiation-free conditioning. A total of 56 patients from 11 centres between 2013 and 2021 in China were retrospectively analysed. The mean (SD) cumulative incidence was 96.4% (0.08%) for 30-day neutrophil engraftment and 85.5% (0.24%) for 100-day platelet engraftment. With a median (range) follow-up of 2.4 (0.2-5.8) years, favourable mean (SD) overall survival of 80.9% (5.5%) and event-free survival of 79.3% (5.6%) were achieved. The mean (SD) incidences of acute graft-versus-host disease (aGvHD) Grade II-IV and Grade III-IV were 55.4% (0.45%) and 42.9 (0.45%) respectively. The mean (SD) cumulative incidence of 3-year chronic graft-versus-host disease (cGvHD) was 34.7% (0.86%) and that of moderate-to-severe cGvHD was 9.0% (0.19%). Our data demonstrate that in unmanipulated haplo-HCT for patients with FA, radiation-free regimens based on fludarabine and low-dose cyclophosphamide ± busulfan achieved favourable engraftment and survival with relatively high incidences of aGvHD and cGvHD. These results prompt the use of low-intensity conditioning without radiation and intensive GvHD prophylaxis when considering unmanipulated haplo-HCT in patients with FA.
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Affiliation(s)
- Lanping Xu
- Peking University People's Hospital, Peking University Institute of Haematology, National Clinical Research Center for Haematologic Disease, Collaborative Innovation Center of Haematology, Beijing Key Laboratory of Haematopoietic Stem Cell Transplant, Beijing, P.R. China
| | - Yue Lu
- Hebei Yanda Lu Daopei Hospital and Beijing Lu Daopei Hospital, Beijing, Hebei, China
| | - Shaoyan Hu
- Children's Hospital of Soochow University, Soochow, China
| | - Chunfu Li
- Nanfang-Chunfu Children's Institute of Hematology and Oncology, Dongguan, China
| | - Yongmin Tang
- The Children's Hospital of Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Hongmei Wang
- The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Jinsong Yan
- The Second Hospital of Dalian Medical University, Dalian, China
| | - Jing Chen
- Shanghai Children's Medical Center, Shanghai, China
| | - Sixi Liu
- Shenzhen Children's Hospital, Shenzhen, China
| | - Yuan Sun
- Beijing Jingdu Children's Hospital, Beijing, China
| | - Xuedong Wu
- Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Fan Lin
- Peking University People's Hospital, Peking University Institute of Haematology, National Clinical Research Center for Haematologic Disease, Collaborative Innovation Center of Haematology, Beijing Key Laboratory of Haematopoietic Stem Cell Transplant, Beijing, P.R. China
| | - Peihua Lu
- Hebei Yanda Lu Daopei Hospital and Beijing Lu Daopei Hospital, Beijing, Hebei, China
| | - Xiaojun Huang
- Peking University People's Hospital, Peking University Institute of Haematology, National Clinical Research Center for Haematologic Disease, Collaborative Innovation Center of Haematology, Beijing Key Laboratory of Haematopoietic Stem Cell Transplant, Beijing, P.R. China.,Peking-Tsinghua Centre for Life Sciences, Beijing, China
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5
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Bayram N, Yaman Y, Elli M, Ozdilli K, Nepesov S, Dogan MS, Ayaz A, Anak S. HLA - matched related donor hematopoietic stem cell transplantation in a patient with polynucleotide kinase 3-phosphatase mutation developed acute myeloid leukemia. Pediatr Transplant 2022; 26:e14255. [PMID: 35187769 DOI: 10.1111/petr.14255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 01/27/2022] [Accepted: 02/07/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND PNPK gene mutations result in DNA repair disorders and have a spectrum of neurodevelopmental manifestations. To date, cancer predisposition has not been described in patients with PNKP mutations. OBSERVATION Here, we report a patient with PNKP mutation, who developed AML at age of five and underwent reduced-intensity HSCT. CONCLUSION Although many DNA repair disorders are known to have increased risk of malignancy, association between PNKP mutations and malignancy is not well-described. This report is the first description of a PNPK mutation patient developing a malignancy and undergoing curative HSCT.
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Affiliation(s)
- Nihan Bayram
- Pediatric Hematology and Oncology Department, Istanbul Medipol University, Istanbul, Turkey
| | - Yontem Yaman
- Pediatric Hematology and Oncology Department, Istanbul Medipol University, Istanbul, Turkey
| | - Murat Elli
- Pediatric Hematology and Oncology Department, Istanbul Medipol University, Istanbul, Turkey
| | - Kursat Ozdilli
- Medical Biology Department, Istanbul Medipol University, Istanbul, Turkey
| | - Serdar Nepesov
- Immunology Department, Istanbul Medipol University, Istanbul, Turkey
| | - Mehmet Sait Dogan
- Pediatric Radiology Department, Istanbul Medipol University, Istanbul, Turkey
| | - Akif Ayaz
- Genetics Department, Istanbul Medipol University, Istanbul, Turkey
| | - Sema Anak
- Pediatric Hematology and Oncology Department, Istanbul Medipol University, Istanbul, Turkey
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6
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Bonfim C, Nichele S, Loth G, Funke VAM, Nabhan SK, Pillonetto DV, Lima ACM, Pasquini R. Transplantation for Fanconi anaemia: lessons learned from Brazil. THE LANCET HAEMATOLOGY 2022; 9:e228-e236. [DOI: 10.1016/s2352-3026(22)00032-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 01/10/2022] [Accepted: 01/13/2022] [Indexed: 12/11/2022]
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7
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Kidney complications in 107 Fanconi anemia patients submitted to hematopoietic cell transplantation. Eur J Pediatr 2022; 181:715-723. [PMID: 34553252 DOI: 10.1007/s00431-021-04263-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 08/14/2021] [Accepted: 09/08/2021] [Indexed: 02/06/2023]
Abstract
Fanconi anemia (FA) is a rare disease characterized by progressive bone marrow failure, cancer predisposition, and multiple systemic malformations, including congenital abnormalities of the kidney and urinary tract (CAKUT). Hematopoietic cell transplantation (HCT), the only potentially curative treatment for the hematological complications of FA, may precipitate acute kidney injury (AKI) and hypertension. We retrospectively investigated 107 FA patients who underwent HCT between 2009 and 2017. We investigated the incidence and risk factors of AKI within 100 days after HCT in a cohort of FA patients, and kidney function and hypertension over 2-year follow-up.The incidence of AKI (mainly stage I) was 18.7%. Patients aged ≥ 11 years at transplantation showed a higher risk of AKI (OR 3.53). The eGFR was 60-90 mL/min/1.73 m2 in 53 (49.5%), 55 (51.4%), 50 (50.5%), 50 (51%), and 46 (59.7%) patients before HCT, at 100 days, 6 months, 1 year, and 2 years. Within the first 100 days after HCT, hypertension was observed in 72% of the patients and was associated with cyclosporine therapy. Most (62.3%) patients had stage 2 hypertension. CAKUT was observed in 33.7% of the patients and was associated with both hypertension (86%) and diminished kidney function but not with AKI.Conlusion: Although AKI, a commonly known HCT complication, was mild in this study, the prevalence of chronic kidney disease (CKD), as well as the high incidence of hypertension, specially associated with CAKUT point out the importance of kidney care in short and long-term follow up of FA patients. What is Known: • Fanconi anemia (FA) is the most frequent inherited bone marrow failure in children, and 30% of cases have congenital anomalies of kidney (CAKUT). • Acute kidney injury and hypertension after hematopoietic cell transplantation (HCT) may impact the outcomes.. What is New: • Despite the presence of CAKUT and stage 2 CKD in 33.7% and 50% of the patients, respectively, AKI was mild and transitory after HCT in FA patients. • CAKUT in FA patients was associated with lower kidney function and hypertension after HCT.
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8
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Kiumarsi A, Mousavi SA, Kasaeian A, Rostami T, Rad S, Ghavamzadeh A, Mousavi SA. Radiation-free Reduced-intensity Hematopoietic Stem Cell Transplantation with In-Vivo T-cell Depletion from Matched Related and Unrelated Donors for Fanconi Anemia: Prognostic Factor Analysis. Exp Hematol 2022; 109:27-34. [DOI: 10.1016/j.exphem.2022.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 02/11/2022] [Accepted: 02/14/2022] [Indexed: 11/25/2022]
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9
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Pierri F, Faraci M, Giardino S, Dufour C. Hematopoietic stem cell transplantation for classical inherited bone marrow failure syndromes: an update. Expert Rev Hematol 2021; 14:911-925. [PMID: 34488529 DOI: 10.1080/17474086.2021.1977119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Inherited bone marrow failure syndromes (IBMFS) feature complex molecular pathophysiology resulting in ineffective hematopoiesis and increased risk of progression to myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML). Allogenic hematopoietic stem cell transplantation (HSCT) is the only well-established cure for the hematological manifestations of these diseases. AREAS COVERED In recent years, analysis of large series from international databases (mainly from the European Bone Marrow Transplantation [EBMT] database) has improved knowledge about HSCT in IBMFS. This review, following a thorough Medline search of the pertinent published studies, reports the most recent data on HSCT in IBMFS. EXPERT OPINION Despite the common features, IBMFS are very different in their manifestations and in the occurrence and management of HSCT complications. Thus, a 'disease-specific' HSCT using an optimized conditioning regimen based on the characteristics of the disease is essential for achieving long-term survival. The phenotypical heterogeneity associated with extramedullary abnormalities has to be carefully evaluated before HSCT because transplantation may only correct impaired hematopoiesis. HSCT may be associated with the risk of treatment-related mortality and with significant early and late morbidity. For these reasons, the benefits should be carefully weighed against the risks.
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Affiliation(s)
| | - Maura Faraci
- Hematopoietic Stem Cell Transplantation Unit, Italy
| | | | - Carlo Dufour
- Hematology Unit, Department of Hematology-Oncology, IRCSS-Istituto G. Gaslini, Genova, Italy
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10
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Bonfim C. Special pre- and posttransplant considerations in inherited bone marrow failure and hematopoietic malignancy predisposition syndromes. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2020; 2020:107-114. [PMID: 33275667 PMCID: PMC7727534 DOI: 10.1182/hematology.2020000095] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Advances in the diagnosis and treatment of inherited bone marrow failure syndromes (IBMFS) have provided insight into the complexity of these diseases. The diseases are heterogeneous and characterized by developmental abnormalities, progressive marrow failure, and predisposition to cancer. A correct diagnosis allows for appropriate treatment, genetic counseling, and cancer surveillance. The common IBMFSs are Fanconi anemia, dyskeratosis congenita, and Diamond-Blackfan anemia. Hematopoietic cell transplantation (HCT) offers curative treatment of the hematologic complications of IBMFS. Because of the systemic nature of these diseases, transplant strategies are modified to decrease immediate and late toxicities. HCT from HLA-matched related or unrelated donors offers excellent survival for young patients in aplasia. Challenges include the treatment of adults with marrow aplasia, presentation with myeloid malignancy regardless of age, and early detection or treatment of cancer. In this article, I will describe our approach and evaluation of patients transplanted with IBMFS and review most frequent complications before and after transplant.
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Affiliation(s)
- Carmem Bonfim
- Division of Bone Marrow Transplantation, General Hospital of the Federal University of Parana, Curitiba, Brazil
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11
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Bone Marrow Failure in Fanconi Anemia: Clinical and Genetic Spectrum in a Cohort of 20 Pediatric Patients. J Pediatr Hematol Oncol 2019; 41:612-617. [PMID: 31259830 DOI: 10.1097/mph.0000000000001549] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Prognostic refinement in Fanconi anemia (FA) is needed, especially when considering allogeneic hematopoietic stem cell transplantation (HCT). We studied 20 children with FA and bone marrow failure from a single center. According to Hôpital Saint-Louis risk classification for FA, patients were classified in stage A (no or mild cytopenia/dysplasia), B (single non-high-risk cytogenetic abnormality), C (severe cytopenia and/or significant dysplasia and/or high-risk cytogenetic abnormality), and D (myelodysplastic syndrome with excess of blasts/acute myeloid leukemia) in 4, 2, 13, and 0 cases, respectively. Nine patients received androgens +/- steroids, with a response rate of 30%, and 11 patients underwent HCT. Ten-year cumulative incidence (CI) of myelodysplastic syndrome/acute myeloid leukemia and overall survival (OS) were 21.9% and 45.3%, respectively, in the entire cohort, whereas cumulative incidence of transplantation-related mortality and OS were 27% and 63%, respectively, in patients who underwent HCT. Patients with significant dysplasia at diagnosis (stages C and D) had significantly shorter OS post-HCT as compared with patients without dysplasia. All patients in stages C and D at diagnosis or during evolution died from their disease. HCT in recent years was associated with more favorable outcomes. Larger cohorts could validate homogenous reporting of risk and help decision-making, particularly for HCT.
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12
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Abstract
Fanconi anemia (FA) is a rare inherited disease that is associated with bone marrow failure and a predisposition to cancer. Previous clinical trials emphasized the difficulties that accompany the use of gene therapy to treat bone marrow failure in patients with FA. Nevertheless, the discovery of new drugs that can efficiently mobilize hematopoietic stem cells (HSCs) and the development of optimized procedures for transducing HSCs, using safe, integrative vectors, markedly improved the efficiency by which the phenotype of hematopoietic repopulating cells from patients with FA can be corrected. In addition, these achievements allowed the demonstration of the in vivo proliferation advantage of gene-corrected FA repopulating cells in immunodeficient mice. Significantly, new gene therapy trials are currently ongoing to investigate the progressive restoration of hematopoiesis in patients with FA by gene-corrected autologous HSCs. Further experimental studies are focused on the ex vivo transduction of unpurified FA HSCs, using new pseudotyped vectors that have HSC tropism. Because of the resistance of some of these vectors to serum complement, new strategies for in vivo gene therapy for FA HSCs are in development. Finally, because of the rapid advancements in gene-editing techniques, correction of CD34+ cells isolated from patients with FA is now feasible, using gene-targeting strategies. Taken together, these advances indicate that gene therapy can soon be used as an efficient and safe alternative for the hematopoietic treatment of patients with FA.
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Affiliation(s)
- Paula Río
- 1 Hematopoietic Innovative Therapies Division, Centro de Investigaciones Energéticas, Medioambientales y Tecnológicas (CIEMAT), Madrid, Spain; Madrid, Spain .,2 Centro de Investigación Biomédica en Red de Enfermedades Raras, Madrid, Spain; and Madrid, Spain .,3 Instituto de Investigaciones Sanitarias Fundación Jiménez Díaz (IIS-FJD) , Madrid, Spain
| | - Susana Navarro
- 1 Hematopoietic Innovative Therapies Division, Centro de Investigaciones Energéticas, Medioambientales y Tecnológicas (CIEMAT), Madrid, Spain; Madrid, Spain .,2 Centro de Investigación Biomédica en Red de Enfermedades Raras, Madrid, Spain; and Madrid, Spain .,3 Instituto de Investigaciones Sanitarias Fundación Jiménez Díaz (IIS-FJD) , Madrid, Spain
| | - Juan A Bueren
- 1 Hematopoietic Innovative Therapies Division, Centro de Investigaciones Energéticas, Medioambientales y Tecnológicas (CIEMAT), Madrid, Spain; Madrid, Spain .,2 Centro de Investigación Biomédica en Red de Enfermedades Raras, Madrid, Spain; and Madrid, Spain .,3 Instituto de Investigaciones Sanitarias Fundación Jiménez Díaz (IIS-FJD) , Madrid, Spain
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13
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Successful Outcome in Patients with Fanconi Anemia Undergoing T Cell-Replete Mismatched Related Donor Hematopoietic Cell Transplantation Using Reduced-Dose Cyclophosphamide Post-Transplantation. Biol Blood Marrow Transplant 2019; 25:2217-2221. [PMID: 31306778 DOI: 10.1016/j.bbmt.2019.07.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 06/21/2019] [Accepted: 07/09/2019] [Indexed: 11/20/2022]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) has been shown to restore normal hematopoiesis in patients with Fanconi anemia (FA), with excellent results in matched related donor HCT. Outcomes of alternative donor HCT are less favorable, however. In patients without FA, several reports have documented stable engraftment and/or a low risk of graft-versus-host disease (GVHD) using unmanipulated HLA-mismatched related donors and post-HCT cyclophosphamide (PT-CY) for GVHD prophylaxis. Data on the use of this approach in patients with FA are scarce, and thus we launched a study of HLA-mismatched related donor HCT in these patient. Here we report our findings in 19 patients. The conditioning was fludarabine 30 mg/m2/day for 5 days, antithymocyte globulin 5 mg/kg/day for 4 days, and total body irradiation (total dose, 200 cGy). GVHD prophylaxis was cyclosporine and mycophenolate and reduced doses of PT-CY, 25 mg/kg, on days +3 and +5. All patients exhibited absolute neutrophil count recovery. Grade III-IV acute GVHD occurred in 3 patients, and chronic GVHD occurred in 1 patient. At a mean follow-up of 38.3 ± 5.8 months, the 5-year probability of overall survival for our patients was 89.2% ± 7.2%. The regimen was well tolerated; hemorrhagic cystitis occurred in 7 patients, and severe mucositis occurred in 5 patients. There were 2 deaths; the primary cause of death was severe GVHD in 1 patient and leukemia recurrence in the other. We conclude that in patients with FA lacking a matched related donor, the use of mismatched related HCT with low-dose PT-CY is a viable option; it is well tolerated, with a high rate of engraftment and an acceptable incidence of GVHD.
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Ayas MF, Al-Seraihi A, Al-Agil A, Al-Ahmari A, Ghemlas I, Ayas M. Successful hematopoietic cell transplantation in Fanconi anemia patients with renal impairment using ultra-reduced doses of cyclophosphamide and fludarabine. Pediatr Blood Cancer 2018; 65:e27371. [PMID: 30070008 DOI: 10.1002/pbc.27371] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 06/27/2018] [Accepted: 06/30/2018] [Indexed: 11/11/2022]
Abstract
Hematopoietic cell transplantation (HCT) remains until now the only curative modality for hematological manifestations in patients with Fanconi anemia (FA). The doses of alkylating agents used in the conditioning of this patient population before HCT are usually significantly decreased due to the genomic instability of the FA cells. FA patients with renal impairment represent a dilemma because of the need to further modify the conditioning regimen according to the degree of renal impairment to avoid additional toxicity. At our institution, we successfully transplanted three FA patients using an ultra-modified regimen.
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Affiliation(s)
| | - Amal Al-Seraihi
- Department of Pediatric Hematology Oncology, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Amal Al-Agil
- Department of Pharmaceutical Care, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Ali Al-Ahmari
- Department of Pediatric Hematology Oncology, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Ibrahim Ghemlas
- Department of Pediatric Hematology Oncology, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Mouhab Ayas
- Department of Pediatric Hematology Oncology, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
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15
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Haworth KG, Ironside C, Ramirez MA, Weitz S, Beard BC, Schwartz JD, Adair JE, Kiem HP. Minimal conditioning in Fanconi anemia promotes multi-lineage marrow engraftment at 10-fold lower cell doses. J Gene Med 2018; 20:e3050. [PMID: 30129972 DOI: 10.1002/jgm.3050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 08/10/2018] [Accepted: 08/11/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Gene therapy approaches for the treatment of Fanconi anemia (FA) hold promise for patients without a suitably matched donor for an allogeneic bone marrow transplant. However, significant limitations include the collection of sufficient stem cell numbers from patients, the fragility of these cells during ex vivo manipulation, and clinically meaningful engraftment following transplantation. With these challenges in mind, we were interested in determining (i) whether gene-corrected cells at progressively lower numbers can successfully engraft in FA; (ii) whether low-dose conditioning facilitates this engraftment; and (iii) whether these cells can be selected for post-transplant. METHODS Utilizing a well characterized mouse model of FA, we infused donor bone marrow from healthy heterozygote littermates that are unaffected carriers of the FANCA mutation to mimic a gene-corrected product, after administering low-dose conditioning. Once baseline engraftment was observed, we administered a second, very-low selective dose to determine whether gene-corrected cells could be selected for in vivo. RESULTS We demonstrate that upfront low-dose conditioning greatly increases successful engraftment of hematopoietic corrected cells in a pre-clinical animal model of FA. Additionally, without conditioning, cells can still engraft and demonstrate a selective advantage in vivo over time following transplantation, and these corrected cells can be directly selected for in vivo after engraftment. CONCLUSIONS Minimal conditioning prior to bone marrow transplant in Fanconi anemia promotes the multi-lineage engraftment of 10-fold fewer cells compared to nonconditioned controls. These data provide important insights into the potential of minimally toxic conditioning protocols for FA gene therapy applications.
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Affiliation(s)
- Kevin G Haworth
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Christina Ironside
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Megan A Ramirez
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Sarah Weitz
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | | | | | - Jennifer E Adair
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA
| | - Hans-Peter Kiem
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA.,Department of Pathology, University of Washington, Seattle, WA, USA
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16
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Ayas M. Hematopoietic cell transplantation in Fanconi anemia and dyskeratosis congenita: A minireview. Hematol Oncol Stem Cell Ther 2017. [DOI: 10.1016/j.hemonc.2017.05.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
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17
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Long-Term Outcomes of Cord Blood Transplantation from an HLA-Identical Sibling for Patients with Bone Marrow Failure Syndromes: A Report From Eurocord, Cord Blood Committee and Severe Aplastic Anemia Working Party of the European Society for Blood and Marrow Transplantation. Biol Blood Marrow Transplant 2017; 23:1939-1948. [DOI: 10.1016/j.bbmt.2017.08.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Accepted: 08/03/2017] [Indexed: 12/13/2022]
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18
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Foglesong JS, Bannon SA, DiNardo CD. Inherited Bone Failure Syndromes, Focus on the Haematological Manifestations: A Review. EUROPEAN MEDICAL JOURNAL 2017. [DOI: 10.33590/emj/10310433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
The purpose of this review is to provide the haematologist with a working knowledge of the common inherited bone marrow failure syndromes (iBMFS) diagnosed in early childhood to young adulthood. Although these disorders are heterogeneous, this article discusses their common features, pathophysiology, and management. Each of these syndromes has a spectrum of clinical variation and can cause both haematological and non-haematological manifestations. Most pathogenic mutations responsible are in genes important to a progenitor cell’s ability to maintain genomic integrity, which accounts for the clinical phenotypes often affecting multiple tissues. Furthermore, all of these syndromes predispose not only to aplastic anaemia but also to myelodysplastic syndrome/acute myeloid leukaemia. Since iBMFS only account for a small percentage of childhood leukaemia cases, it is important that the clinician maintains a high clinical suspicion as appropriate diagnosis impacts treatment, health screening, and family members. Identification of iBMFS is critically important for appropriate donor selection and transplant regimens, as haematopoietic stem cell transplantation is curative for the haematological manifestations of these diseases, but treatment-related mortality can be excessive if modifications are not made to conditioning.
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Affiliation(s)
- Jessica S. Foglesong
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sarah A. Bannon
- Department of Clinical Cancer Genetics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Courtney D. DiNardo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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19
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Abstract
Fanconi Anaemia is a rare, genetic heterogeneous multisystem disease that is the most common congenital syndrome of marrow failure. Twenty genes have been reported to cause the disease. Remarkable progress has been made over the last 20 years in the understanding of the genetic and pathophysiological mechanisms. Unfortunately, these advances have not been completely paralleled by advances in medical treatment, where the most important component remains stem cell transplantation. This therapy, although contributing to long-term negative effects, such as increased occurrence of late malignancies, is the only current option capable of prolonging the survival of patients. In spite of relevant recent progress in matched unrelated donor transplants, the largest studies with longer follow-up still show a superiority of matched sibling donor transplants with a success rate, in selected cohorts, of over 90%. This article reviews different aspects of the disease, including genetics, diagnosis and treatment options, with special focus on stem cell transplantation, comprehensive post-diagnosis management, decision-making processes and long-term follow-up.
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Affiliation(s)
- Carlo Dufour
- Haematology Unit, G. Gaslini Children's Research Hospital, Genova, Italy.,Chairman Severe Aplastic Anemia Working Party, EBMT
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20
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Savage SA, Dufour C. Classical inherited bone marrow failure syndromes with high risk for myelodysplastic syndrome and acute myelogenous leukemia. Semin Hematol 2017. [PMID: 28637614 DOI: 10.1053/j.seminhematol.2017.04.004] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The inherited marrow failure syndromes (IBMFS) are a heterogeneous group of diseases characterized by failure in the production of one or more blood lineage. The clinical manifestations of the IBMFS vary according to the type and number of blood cell lines involved, including different combinations of anemia, leukopenia, and thrombocytopenia. In some IBMFS, systemic non-hematologic manifestations, including congenital malformations, mucocutaneous abnormalities, developmental delay, and other medical complications, may be present. Fanconi anemia (FA), caused by germline pathogenic variants in the DNA repair genes comprising the FA/BRCA pathway is associated with congenital anomalies, bone marrow failure, and increased risk of myelodysplastic syndrome (MDS), acute myelogenous leukemia (AML), and solid tumors. Dyskeratosis congenita (DC) is a telomere biology disorder (TBD) caused by aberrations in key telomere biology genes. In addition to mucocutaneous manifestations, patients with DC are at increased risk of marrow failure, MDS, AML, pulmonary fibrosis, and other complications. Ribosomal biology defects are the primary causes of Diamond Blackfan anemia (DBA) and Shwachman Diamond syndrome (SDS). In addition to pure red blood cell aplasia, DBA is associated with elevated risk of solid tumors, AML, and MDS. Patients with SDS have pancreatic insufficiency, neutropenia, as well as MDS and AML risks. Patients with severe congenital neutropenia (SCN), caused by pathogenic variants in genes essential in myeloid development, have profound neutropenia and high risk of MDS and AML. Herein we review the genetic causes, clinical features, diagnostic modalities, predisposition to malignancies with focus on leukemogenic markers whenever available, and approaches to treatments of the classical IBMFS: FA, DC, SDS, DBA, and SCN.
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Affiliation(s)
- Sharon A Savage
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA.
| | - Carlo Dufour
- Haematology Unit, Istituto Giannina Gaslini, Genoa, Italy
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21
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Radiation-free, alternative-donor HCT for Fanconi anemia patients: results from a prospective multi-institutional study. Blood 2017; 129:2308-2315. [PMID: 28179273 DOI: 10.1182/blood-2016-09-743112] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 01/25/2017] [Indexed: 12/22/2022] Open
Abstract
Fanconi anemia (FA) is an inherited bone marrow failure syndrome characterized by chromosomal fragility, progressive marrow failure, and cancer predisposition. Hematopoietic cell transplantation (HCT) is curative for FA-related marrow failure or leukemia, but both radiation exposure during transplant and graft-versus-host disease (GVHD) may increase risk of later malignancies of the head and neck and anogenital area. In this study, we tested a radiation-free conditioning regimen with a T-cell-depleted graft to eliminate radiation exposure and minimize early and late toxicities of transplant. Forty-five patients (median age, 8.2 years; range 4.3-44) with FA underwent HCT between June 2009 and May 2014. The preparative regimen included busulfan, cyclophosphamide, fludarabine, and rabbit anti-thymocyte globulin. Busulfan levels were monitored to avoid excess toxicity. All grafts were CD34-selected/T-cell-depleted using the CliniMacs CD34 columns (Miltenyi). Thirty-four patients (75.6%) with marrow failure and 11 (24.4%) with myelodysplastic syndrome underwent HCT using matched unrelated (n = 25, 55.5%), mismatched unrelated (n = 14, 31.1%), or mismatched related donors (n = 6, 13.4%). One year probabilities of overall and disease-free survival for the entire cohort, including patients with myeloid malignancy and those receiving mismatched related/haploidentical grafts, were 80% (±6%) and 77.7% (±6.2%), respectively (median follow-up 41 months). All young children (<10 years of age) undergoing HCT for marrow failure using low-dose busulfan-containing regimen survived. No patients developed acute grade 3-4 GVHD. Sequential reduction of busulfan dose was successfully achieved per study design. Our results show excellent outcomes in patients with FA undergoing alternative donor HCT without radiation exposure. The study is registered to www.clinicaltrials.gov as #NCT01082133.
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22
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Bonfim C, Ribeiro L, Nichele S, Loth G, Bitencourt M, Koliski A, Kuwahara C, Fabro AL, Pereira NF, Pilonetto D, Thakar M, Kiem HP, Page K, Fuchs EJ, Eapen M, Pasquini R. Haploidentical Bone Marrow Transplantation with Post-Transplant Cyclophosphamide for Children and Adolescents with Fanconi Anemia. Biol Blood Marrow Transplant 2017; 23:310-317. [DOI: 10.1016/j.bbmt.2016.11.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 11/03/2016] [Indexed: 11/28/2022]
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23
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Dose-adapted post-transplant cyclophosphamide for HLA-haploidentical transplantation in Fanconi anemia. Bone Marrow Transplant 2017; 52:570-573. [PMID: 28067886 PMCID: PMC5382060 DOI: 10.1038/bmt.2016.301] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 08/22/2016] [Accepted: 08/23/2016] [Indexed: 01/09/2023]
Abstract
We developed a haploidentical transplantation protocol with post-transplant cyclophosphamide (CY) for in vivo T-cell depletion using a novel adapted-dosing schedule (25 mg/kg on days +3 and +4) for Fanconi Anemia. With median follow-up of 3 years (range, 37 days to 6.2 years), all six patients engrafted. Two patients with multiple co-morbidities and late referrals to transplant died from sepsis (n=2) and chronic graft-versus-host disease (GVHD) (n=1). Four patients without pre-existing co-morbidities and early transplant referrals are alive with 100% donor chimerism and excellent performance status. We conclude that modulated-dosing post-transplant CY is effective in vivo T-cell depletion to promote full donor engraftment in patients with Fanconi anemia.
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24
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Ebens CL, MacMillan ML, Wagner JE. Hematopoietic cell transplantation in Fanconi anemia: current evidence, challenges and recommendations. Expert Rev Hematol 2017; 10:81-97. [PMID: 27929686 PMCID: PMC6089510 DOI: 10.1080/17474086.2016.1268048] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Hematopoietic cell transplantation for Fanconi Anemia (FA) has improved dramatically over the past 40 years. With an enhanced understanding of the intrinsic DNA-repair defect and pathophysiology of hematopoietic failure and leukemogenesis, sequential changes to conditioning and graft engineering have significantly improved the expectation of survival after allogeneic hematopoietic cell transplantation (alloHCT) with incidence of graft failure decreased from 35% to <10% and acute graft-versus-host disease (GVHD) from >40% to <10%. Today, five-year overall survival exceeds 90% in younger FA patients with bone marrow failure but remains about 50% in those with hematologic malignancy. Areas covered: We review the evolution of alloHCT contributing to decreased rates of transplant related complications; highlight current challenges including poorer outcomes in cases of clonal hematologic disorders, alloHCT impact on endocrine function and intrinsic FA risk of epithelial malignancies; and describe investigational therapies for prevention and treatment of the hematologic manifestations of FA. Expert commentary: Current methods allow for excellent survival following alloHCT for FA associated BMF irrespective of donor hematopoietic cell source. Alternative curative approaches, such as gene therapy, are being explored to eliminate the risks of GVHD and minimize therapy-related adverse effects.
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Affiliation(s)
- Christen L Ebens
- a Division of Pediatric Blood and Marrow Transplantation, Department of Pediatrics , University of Minnesota Medical School , Minneapolis , MN , USA
| | - Margaret L MacMillan
- a Division of Pediatric Blood and Marrow Transplantation, Department of Pediatrics , University of Minnesota Medical School , Minneapolis , MN , USA
| | - John E Wagner
- a Division of Pediatric Blood and Marrow Transplantation, Department of Pediatrics , University of Minnesota Medical School , Minneapolis , MN , USA
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25
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Peffault de Latour R. Transplantation for bone marrow failure: current issues. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:90-98. [PMID: 27913467 PMCID: PMC6142500 DOI: 10.1182/asheducation-2016.1.90] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The preferred treatment of idiopathic aplastic anemia (AA) is allogeneic hematopoietic stem cell transplantation (HSCT) from a human leukocyte antigen (HLA)-identical sibling donor. Transplantation from a well-matched unrelated donor (MUD) may be considered for patients without a sibling donor after failure of immunosuppressive therapy, as may alternative transplantation (mismatched, cord blood or haplo-identical HSCT) for patients without a MUD. HSCT may also be contemplated for congenital disorders in cases of pancytopenia or severe isolated cytopenia. Currently, HSCT aims are not only to cure patients but also to avoid long-term complications, notably chronic graft-versus-host disease (GVHD), essential for a good quality of life long term. This paper summarizes recent advances in HSCT for idiopathic and inherited AA disorders. The effect of age on current transplantation outcomes, the role of transplantation in paroxysmal nocturnal hemoglobinuria, and the prevention of GVHD are also discussed. Emerging strategies regarding the role of up-front unrelated donor and alternative donor HSCT in idiopathic AA, along with advances in the treatment of clonal evolution in Fanconi anemia, are also examined.
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Affiliation(s)
- Régis Peffault de Latour
- Service d'Hématologie-Greffe, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France; Université Paris Diderot, Institut Universitaire d'Hématologie, Sorbonne Paris Cité, Paris, France; Centre de Référence Aplasie Médullaire, APHP, Paris, France; and Severe Aplastic Anemia Working Party of the European Group for Blood and Marrow Transplantation, Leiden, The Netherlands
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26
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Alhuraiji A, Alzahrani H, Al Mohareb F, Chaudhri N, Alsharif F, Mohamed S, Rasheed W, Aldawsari G, Ahmed SO, Aljurf M. Hematopoietic Stem Cell Transplant in Adolescent and Young Adults With Fanconi Anemia Is Feasible With Acceptable Toxicity, With Those Surviving 100 Days Posttransplant Having Excellent Outcomes. EXP CLIN TRANSPLANT 2016; 14:660-664. [PMID: 27447289 DOI: 10.6002/ect.2015.0364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Fanconi anemia is a congenital bone marrow failure syndrome that is associated with congenital anomalies and increased risk of cancer. Hematopoietic stem cell transplant is a potentially curative modality for bone marrow failure in Fanconi anemia patients. Here, we report our center's experience regarding adolescent and young adult patients with Fanconi anemia and hematopoietic stem cell transplant. MATERIALS AND METHODS We conducted a retrospective patient record analyses of patients who presented at our center from 1988 to 2014. We included patients greater than 14 years old with confirmed Fanconi anemia based on positive chromosome breakage study and who underwent hematopoietic stem cell transplant at our institution. RESULTS Our study group comprised 12 patients with Fanconi anemia who underwent hematopoietic stem cell transplant at our institution. The median age was 20 years (range, 14-31 y) with a female predominance of 83%. Low-dose cyclophosphamide (20-80 mg/kg)-based conditioning regimens were used with different combinations that included fludarabine, antithymocyte globulin, or total body irradiation. All patients had HLA-matched sibling grafts. In all patients, stem cell source was the bone marrow. All patients showed engraftment. Four patients (33%) developed acute graft-versus-host disease. Three patients (25%) died early before day 100 after hematopoietic stem cell transplant due to infectious complications, with 1 patient having steroid refractory acute graft-versus-host disease. Overall survival was 75% at a median follow-up of 43 months. All patients who survived are well and remained transfusion independent without evidence of secondary malignancy. CONCLUSIONS Our findings support the feasibility of reduced intensity conditioning allogeneic hematopoietic stem cell transplant in older and more heavily pretreated patients with Fanconi anemia, especially for those who are engrafted.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Mahmoud Aljurf
- From the Hematology/HSCT Section, Oncology Department, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
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27
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Kuşkonmaz B, Ünal Ş, Bayhan T, Aytaç Eyüboğlu S, Tavil B, Çetin M, Gümrük F, Uçkan Çetinkaya D. Successful Outcome With Fludarabine-Based Conditioning Regimen for Hematopoietic Stem Cell Transplantation From Related Donor in Fanconi Anemia: A Single Center Experience From Turkey. Pediatr Blood Cancer 2016; 63:695-700. [PMID: 26703084 DOI: 10.1002/pbc.25844] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Revised: 10/20/2015] [Accepted: 10/22/2015] [Indexed: 11/08/2022]
Abstract
BACKGROUND Fanconi anemia (FA) is a heterogeneous autosomal recessive (and rarely X linked) disorder, which is characterized by congenital malformations, progressive bone marrow failure, and predisposition to malignancies. Hematopoietic stem cell transplantation (HSCT) is the only definitive treatment for the hematological manifestations in FA. PROCEDURE Twenty-seven patients with FA underwent HSCT using fludarabine (Flu) based regimen at our center between April 2004 and May 2014. One patient who developed acute leukemia before HSCT was excluded from the study. The remaining 26 patients were included. The median age of the patients at the time of transplantation was 9.6 years (range 5.6-17.0 years) and male/female ratio was 19/7. Donors were Human leukocyte antigen (HLA)-identical sibling in 18 patients, HLA-identical other relatives in six patients, and HLA 1-antigen mismatched sibling in two patients. Conditioning regimen consisted of Flu, cyclophosphamide, and antithymocyte globulin. RESULTS All patients engrafted but one developed poor graft function and underwent second HSCT. Acute graft versus host disease (GVHD) (≥grade 2) occurred in two patients (7.6%) and chronic GVHD in one patient (3.9%). Three patients developed venoocclusive disease (11.5%). Survival rate was 96.2% (25/26) at a median follow-up of 54 months (10-131 months) and all patients who survived were in good clinical condition. None of the patients developed secondary malignancy during the follow-up period. CONCLUSIONS The present study from Turkey, a middle-income country, shows successful transplant outcome with low toxicity using Flu-based conditioning in patients with FA who underwent HSCT from HLA-related donors.
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Affiliation(s)
- Barış Kuşkonmaz
- Division of Bone Marrow Transplantation, Faculty of Medicine, Department of Pediatrics, Hacettepe University, Ankara, Turkey
| | - Şule Ünal
- Division of Hematology, Faculty of Medicine, Department of Pediatrics, Hacettepe University, Ankara, Turkey
| | - Turan Bayhan
- Division of Hematology, Faculty of Medicine, Department of Pediatrics, Hacettepe University, Ankara, Turkey
| | - Selin Aytaç Eyüboğlu
- Division of Hematology, Faculty of Medicine, Department of Pediatrics, Hacettepe University, Ankara, Turkey
| | - Betül Tavil
- Division of Hematology, Faculty of Medicine, Department of Pediatrics, Hacettepe University, Ankara, Turkey
| | - Mualla Çetin
- Division of Hematology, Faculty of Medicine, Department of Pediatrics, Hacettepe University, Ankara, Turkey
| | - Fatma Gümrük
- Division of Hematology, Faculty of Medicine, Department of Pediatrics, Hacettepe University, Ankara, Turkey
| | - Duygu Uçkan Çetinkaya
- Division of Bone Marrow Transplantation, Faculty of Medicine, Department of Pediatrics, Hacettepe University, Ankara, Turkey
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Abstract
Fanconi anemia (FA) is the most frequent inherited cause of bone marrow failure (BMF). Most FA patients experience hematopoietic stem cell attrition and cytopenia during childhood, which along with intrinsic chromosomal instability, favor clonal evolution and the frequent emergence in their teens or young adulthood of myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML). To early identify and further predict bone marrow (BM) clonal progression and enable timely treatment, the follow-up of FA patients includes regular BM morphological and cytogenetic examinations. Allogeneic hematopoietic stem cell transplantation (HSCT) remains the only curative treatment of FA patients with MDS or AML. Although questions remain concerning HSCT itself (including the need for pretransplant chemotherapy, the best conditioning regimen, and the optimal long-term follow-up of such patients especially regarding secondary malignancies), clonal evolution in the absence of significant BM dysplasia and blast cells can be difficult to address in FA patients, for whom the concept of preemptive HSCT is discussed. Illustrated by 3 representative clinical vignettes showing specific features of MDS and AML in FA patients, this paper summarizes our practical approach from diagnosis through treatment in this particular situation.
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29
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Bonfim C, Ribeiro L, Nichele S, Bitencourt M, Loth G, Koliski A, Funke VAM, Pilonetto DV, Pereira NF, Flowers MED, Velleuer E, Dietrich R, Fasth A, Torres-Pereira CC, Pedruzzi P, Eapen M, Pasquini R. Long-term Survival, Organ Function, and Malignancy after Hematopoietic Stem Cell Transplantation for Fanconi Anemia. Biol Blood Marrow Transplant 2016; 22:1257-1263. [PMID: 26976241 DOI: 10.1016/j.bbmt.2016.03.007] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2015] [Accepted: 03/03/2016] [Indexed: 11/27/2022]
Abstract
We report on long-term survival in 157 patients with Fanconi anemia (FA) who survived 2 years or longer after their first transplantation with a median follow-up of 9 years. Marrow failure (80%) was the most common indication for transplantation. There were 20 deaths beyond 2 years after transplantation, with 12 of the deaths occurring beyond 5 years after transplantation. Donor chimerism was available for 149 patients: 112 (76%) reported > 95% chimerism, 27 (18%) reported 90% to 95% chimerism, and 8 (5%) reported 20% to 89% donor chimerism. Two patients have < 20% donor chimerism. The 10- and 15-year probabilities of survival were 90% and 79%, respectively. Results of multivariate analysis showed higher mortality risks for transplantations before 2003 (hazard ratio [HR], 7.87; P = .001), chronic graft-versus-host disease (GVHD) (HR, 3.80; P = .004) and squamous cell carcinoma after transplantation (HR, 38.17; P < .0001). The predominant cause of late mortality was squamous cell carcinoma, with an incidence of 8% and 14% at 10 and 15 years after transplantation, respectively, and was more likely to occur in those with chronic GVHD. Other causes of late mortality included chronic GVHD, infection, graft failure, other cancers, and hemorrhage. Although most patients are disease free and functional long term, our data support aggressive surveillance for long periods to identify those at risk for late mortality.
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Affiliation(s)
- Carmem Bonfim
- Bone Marrow Transplantation Unit, Federal University of Paraná, Curitiba, Brazil.
| | - Lisandro Ribeiro
- Bone Marrow Transplantation Unit, Federal University of Paraná, Curitiba, Brazil
| | - Samantha Nichele
- Bone Marrow Transplantation Unit, Federal University of Paraná, Curitiba, Brazil
| | - Marco Bitencourt
- Bone Marrow Transplantation Unit, Federal University of Paraná, Curitiba, Brazil
| | - Gisele Loth
- Bone Marrow Transplantation Unit, Federal University of Paraná, Curitiba, Brazil
| | - Adriana Koliski
- Bone Marrow Transplantation Unit, Federal University of Paraná, Curitiba, Brazil
| | - Vaneuza A M Funke
- Bone Marrow Transplantation Unit, Federal University of Paraná, Curitiba, Brazil
| | | | - Noemi F Pereira
- Immunogenetics Laboratory, Federal University of Paraná, Curitiba, Brazil
| | - Mary E D Flowers
- Clinical Research Divisions, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Eunike Velleuer
- Clinic for Pediatric Oncology, Hematology and Clinical Immunology, Children's Hospital, University Hospital of Düsseldorf, Germany
| | - Ralf Dietrich
- Deutsche Fanconi-Anämie-Hilfe, Unna-Siddinghausen, Germany
| | - Anders Fasth
- Department of Pediatrics, University of Gothenburg, Gothenburg, Sweden
| | | | - Paola Pedruzzi
- Oncology Department, Hospital Erasto Gaertner, Curitiba, Brazil
| | - Mary Eapen
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ricardo Pasquini
- Bone Marrow Transplantation Unit, Federal University of Paraná, Curitiba, Brazil
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Vincent CL, Primack WA, Hipps J, Kasow KA. Sequential renal and bone marrow transplants in a child with Fanconi anemia. Pediatr Transplant 2016; 20:146-50. [PMID: 26481770 DOI: 10.1111/petr.12619] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/14/2015] [Indexed: 11/27/2022]
Abstract
FA is an autosomal recessive disorder characterized by small stature and renal abnormalities. FA can lead to progressive bone marrow failure, myelodysplastic syndrome, or acute leukemia. Using a multidisciplinary team approach, we managed a 3-yr-old boy with FA who simultaneously developed renal and hematopoietic failure. Because renal function was insufficient to support the conditioning regimen for HCT, we performed a deceased donor renal transplant in December 2012 prior to HCT with the known risk of graft-versus-graft rejection of the donor kidney. Seven months later he underwent allogeneic HCT. He obtained myeloid engraftment on day +11 and peripheral blood chimerism demonstrated all donor by day +21. He developed asymptomatic CMV reactivation and despite antirejection medications, mild skin graft-versus-host disease. He has maintained excellent renal function and remains transfusion independent with full hematopoietic recovery. He has not experienced any renal rejection episodes nor developed donor-specific antibodies toward his renal donor. Peripheral blood chimerism remains completely HCT donor. He is clinically well, now greater than two and a half yr after renal transplant and two yr after HCT. The continuing close collaboration between the Pediatric Nephrology and Bone Marrow Transplant teams is a major factor in this successful outcome.
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Affiliation(s)
- Carol L Vincent
- Department of Pediatrics, University of North Carolina, Chapel Hill, NC, USA.,Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - William A Primack
- Department of Pediatrics, University of North Carolina, Chapel Hill, NC, USA.,Department of Medicine, University of North Carolina, Chapel Hill, NC, USA.,Division of Nephrology, University of North Carolina, Chapel Hill, NC, USA
| | - John Hipps
- Department of Pediatrics, University of North Carolina, Chapel Hill, NC, USA.,Division of Pediatric Hematology/Oncology, University of North Carolina, Chapel Hill, NC, USA
| | - Kimberly A Kasow
- Department of Pediatrics, University of North Carolina, Chapel Hill, NC, USA.,Division of Pediatric Hematology/Oncology, University of North Carolina, Chapel Hill, NC, USA
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Buchbinder D, Hsieh L, Mahajerin A, Puthenveetil G, Soni A, Nugent D. Successful treatment of secondary graft failure following unrelated cord blood transplant with hematopoietic growth factors in a pediatric patient with Fanconi anemia. Pediatr Transplant 2015; 19:E181-4. [PMID: 26228438 DOI: 10.1111/petr.12564] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/16/2015] [Indexed: 01/02/2023]
Abstract
Graft failure following allogeneic HCT in Fanconi anemia is associated with significant mortality. Retransplantation may be considered; however, the limited toxicity profile of HGFs also makes them an option for the treatment of graft failure. We describe a five-yr-old female diagnosed with Fanconi anemia and marrow failure treated with HCT. The course was complicated by secondary graft failure treated successfully with HGFs including G-CSF, EPO, and romiplostim. The outcome could be related to the intervention, but could also be the natural course of recovery, including recovering from a recent CMV infection treated with ganciclovir. We found the use of HGFs to be an effective and safe alternative to the potential complications as well as morbidity and mortality associated with the use of retransplantation.
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Affiliation(s)
- David Buchbinder
- Division of Hematology, CHOC Children's Hospital, Orange, CA, USA
| | - Loan Hsieh
- Division of Hematology, CHOC Children's Hospital, Orange, CA, USA
| | - Arash Mahajerin
- Division of Hematology, CHOC Children's Hospital, Orange, CA, USA
| | | | - Amit Soni
- Division of Hematology, CHOC Children's Hospital, Orange, CA, USA
| | - Diane Nugent
- Division of Hematology, CHOC Children's Hospital, Orange, CA, USA
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Ayas M, Eapen M, Le-Rademacher J, Carreras J, Abdel-Azim H, Alter BP, Anderlini P, Battiwalla M, Bierings M, Buchbinder DK, Bonfim C, Camitta BM, Fasth AL, Gale RP, Lee MA, Lund TC, Myers KC, Olsson RF, Page KM, Prestidge TD, Radhi M, Shah AJ, Schultz KR, Wirk B, Wagner JE, Deeg HJ. Second Allogeneic Hematopoietic Cell Transplantation for Patients with Fanconi Anemia and Bone Marrow Failure. Biol Blood Marrow Transplant 2015; 21:1790-5. [PMID: 26116087 PMCID: PMC4568139 DOI: 10.1016/j.bbmt.2015.06.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 06/14/2015] [Indexed: 12/11/2022]
Abstract
A second allogeneic hematopoietic cell transplantation (HCT) is the sole salvage option for individuals who develop graft failure after their first HCT. Data on outcomes after second HCT in patients with Fanconi anemia (FA) are scarce. Here we report outcomes after second allogeneic HCT for FA (n = 81). The indication for second HCT was graft failure after the first HCT. Transplantations were performed between 1990 and 2012. The timing of the second HCT predicted subsequent graft failure and survival. Graft failure was high when the second HCT was performed less than 3 months from the first. The 3-month probability of graft failure was 69% when the interval between the first HCT and second HCT was less than 3 months, compared with 23% when the interval was longer (P < .001). Consequently, the 1-year survival rate was substantially lower when the interval between the first and second HCTs was less than 3 months compared with longer (23% vs 58%; P = .001). The corresponding 5-year probability of survival was 16% and 45%, respectively (P = .006). Taken together, these data suggest that fewer than one-half of patients with FA undergoing a second HCT for graft failure are long-term survivors. There is an urgent need to develop strategies to reduce the rate of graft failure after first HCT.
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Affiliation(s)
- Mouhab Ayas
- Department of Pediatric Hematology Oncology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.
| | - Mary Eapen
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jennifer Le-Rademacher
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jeanette Carreras
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Hisham Abdel-Azim
- Division of Hematology, Oncology and Blood and Marrow Transplantation, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Blanche P Alter
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Paolo Anderlini
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Minoo Battiwalla
- Hematology Branch, National Heart and Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Marc Bierings
- Department of Pediatric Hematology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - David K Buchbinder
- Division of Pediatrics Hematology, Children's Hospital of Orange County, Orange, California
| | - Carmem Bonfim
- Hospital de Clinicas, Federal University of Parana, Curitiba, Brazil
| | - Bruce M Camitta
- Midwest Center for Cancer and Blood Disorders, Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Anders L Fasth
- Department of Pediatrics, University of Gothenburg, Gothenburg, Sweden
| | - Robert Peter Gale
- Hematology Research Centre, Division of Experimental Medicine, Department of Medicine, Imperial College London, London, United Kingdom
| | - Michelle A Lee
- Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
| | - Troy C Lund
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Kasiani C Myers
- Division of Bone Marrow Transplant and Immune Deficiency, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Richard F Olsson
- Division of Therapeutic Immunology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden; Centre for Clinical Research Sörmland, Uppsala University, Uppsala, Sweden
| | - Kristin M Page
- Pediatric Blood and Marrow Transplant, Duke University Medical Center, Durham, North Carolina
| | - Tim D Prestidge
- Blood and Cancer Centre, Starship Children's Hospital, Auckland, New Zealand
| | - Mohamed Radhi
- Pediatric Hematology/Oncology/Stem Cell Transplantation, Children's Mercy Hospital, Kansas City, Missouri
| | - Ami J Shah
- Division of Hematology/Oncology, Department of Pediatrics, Mattel Children's Hospital at UCLA, Los Angeles, California
| | - Kirk R Schultz
- Department of Pediatric Hematology, Oncology and Bone Marrow Transplant, British Columbia's Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Baldeep Wirk
- Division of Bone Marrow Transplant, Seattle Cancer Care Alliance, Seattle, Washington
| | - John E Wagner
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - H Joachim Deeg
- Clincal Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
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Abstract
Fanconi anemia (FA) is an inherited bone marrow failure syndrome characterized by congenital abnormalities and chromosomal breakages with the occurrence of hematological and solid malignancies. FA is the most common type of inherited bone marrow failure and poses tremendous challenges. FA patients are uniquely hypersensitive to hematopoietic stem cell transplantation (HSCT) conditioning agents due to the underling chromosomal instability. HSCT has shown important progress in the last years, especially after the introduction of fludarabine and the reduction of cyclophosphamide in the preparative regimen. For patients with HLA-identical-related donors HSCT should be performed as first-line therapy, for patients with alternative donors HSCT remains a therapy with increased morbidity and mortality.
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HLA-matched related-donor HSCT in Fanconi anemia patients conditioned with cyclophosphamide and fludarabine. Blood 2015; 125:417-8. [DOI: 10.1182/blood-2014-10-605113] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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36
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Oral manifestations compatible with chronic graft-versus-host disease in patients with Fanconi anemia. Biol Blood Marrow Transplant 2014; 21:275-80. [PMID: 25316110 DOI: 10.1016/j.bbmt.2014.10.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 10/07/2014] [Indexed: 01/19/2023]
Abstract
Fanconi anemia (FA) is a genetic disease that is characterized by several congenital abnormalities and progressive bone marrow failure and is associated with an increased susceptibility to malignant disorders. Currently, the only potential cure for hematological disorders is hematopoietic stem cell transplantation (HSCT). However, 1 of the most common complications after HSCT is the development of oral chronic graft-versus-host disease (cGVHD), which is also a risk factor for the development of cancer, particularly oral squamous cell carcinoma. Therefore, the purpose of this study was to describe the prevalence and characteristics of oral manifestations compatible with cGVHD in patients diagnosed with FA according to the National Institutes of Health (NIH) consensus criteria. A total of 96 patients (51 females, 45 males; median age, 16 years) with FA, who were in medical follow-up after HSCT at the outpatient clinic of the bone marrow transplantation unit (Hospital de Clínicas from the Universidade Federal do Paraná) underwent an oral evaluation between January 2013 and December 2013. Post-HSCT periods varied from 1 to 261 months and were divided into 3 periods: immediate post-HSCT period; intermediate post-HSC period, and late post-HSCT period. Among the evaluated patients, 40 of 96 (42%) presented with oral manifestations of cGVHD, with 29 of 40 (73%) of these patients in the late post-HSCT period. NIH scale scores varied from 0 to 10, and lichenoid and hyperkeratotic lesions were the abnormalities most frequently observed (100%). Overall, a high prevalence of oral manifestations was observed for cGVHD patients with FA. These data highlight the importance of monitoring oral manifestations compatible with cGVHD to identify and treat individuals with a higher risk of developing oral cancer.
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Factors Affecting the Outcome of Related Allogeneic Hematopoietic Cell Transplantation in Patients with Fanconi Anemia. Biol Blood Marrow Transplant 2014; 20:1599-603. [DOI: 10.1016/j.bbmt.2014.06.016] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 06/11/2014] [Indexed: 12/20/2022]
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Abstract
Allogeneic hematopoietic stem cell transplantation has been shown to be curative for well-described as well as newly discovered immunodeficiencies. However, it is difficulty to define a universal transplant regimen given the rarity of these disorders and the varied pathophysiology these disorders encompass. This article discusses those primary immunodeficiencies most commonly treated by hematopoietic stem cell transplant and describes the transplant issues specific to these disorders.
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Affiliation(s)
- Elizabeth Kang
- Hematotherapeutics Unit, Laboratory of Host Defenses, National Institute of Allergy and Infectious Diseases, National Institutes of Health, 10-CRC Room 6-3752, 10 Centre Drive, Bethesda, MD 20892, USA.
| | - Andrew Gennery
- Paediatric Immunology Department, Institute of Cellular Medicine, Great North Children's Hospital, c/o Ward 3, Queen Victoria Road, Newcastle upon Tyne NE1 4LP, UK
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41
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Ayas M, Saber W, Davies SM, Harris RE, Hale GA, Socie G, LeRademacher J, Thakar M, Deeg HJJ, Al-Seraihy A, Battiwalla M, Camitta BM, Olsson R, Bajwa RS, Bonfim CM, Pasquini R, Macmillan ML, George B, Copelan EA, Wirk B, Al Jefri A, Fasth AL, Guinan EC, Horn BN, Lewis VA, Slavin S, Stepensky P, Bierings M, Gale RP. Allogeneic hematopoietic cell transplantation for fanconi anemia in patients with pretransplantation cytogenetic abnormalities, myelodysplastic syndrome, or acute leukemia. J Clin Oncol 2013; 31:1669-76. [PMID: 23547077 PMCID: PMC3635221 DOI: 10.1200/jco.2012.45.9719] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
PURPOSE Allogeneic hematopoietic cell transplantation (HCT) can cure bone marrow failure in patients with Fanconi anemia (FA). Data on outcomes in patients with pretransplantation cytogenetic abnormalities, myelodysplastic syndrome (MDS), or acute leukemia have not been separately analyzed. PATIENTS AND METHODS We analyzed data on 113 patients with FA with cytogenetic abnormalities (n = 54), MDS (n = 45), or acute leukemia (n = 14) who were reported to the Center for International Blood and Marrow Transplant Research from 1985 to 2007. RESULTS Neutrophil recovery occurred in 78% and 85% of patients at days 28 and 100, respectively. Day 100 cumulative incidences of acute graft-versus-host disease grades B to D and C to D were 26% (95% CI, 19% to 35%) and 12% (95% CI, 7% to 19%), respectively. Survival probabilities at 1, 3, and 5 years were 64% (95% CI, 55% to 73%), 58% (95% CI, 48% to 67%), and 55% (95% CI, 45% to 64%), respectively. In univariate analysis, younger age was associated with superior 5-year survival (≤ v > 14 years: 69% [95% CI, 57% to 80%] v 39% [95% CI, 26% to 53%], respectively; P = .001). In transplantations from HLA-matched related donors (n = 82), younger patients (≤ v > 14 years: 78% [95% CI, 64% to 90%] v 34% [95% CI, 20% to 50%], respectively; P < .001) and patients with cytogenetic abnormalities only versus MDS/acute leukemia (67% [95% CI, 52% to 81%] v 43% [95% CI, 27% to 59%], respectively; P = .03) had superior 5-year survival. CONCLUSION Our analysis indicates that long-term survival for patients with FA with cytogenetic abnormalities, MDS, or acute leukemia is achievable. Younger patients and recipients of HLA-matched related donor transplantations who have cytogenetic abnormalities only have the best survival.
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Affiliation(s)
- Mouhab Ayas
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.
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Matched and mismatched unrelated donor transplantation: is the outcome the same as for matched sibling donor transplantation? Hematology 2012. [DOI: 10.1182/asheducation.v2012.1.223.3798305] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
The outcome of allogeneic stem cell transplantation has improved over the past decades due to a significant reduction of nonrelapse mortality, whereas our ability to control underlying malignant diseases has remained unchanged. Reduction of nonrelapse mortality has been achieved in matched sibling donor transplantation, but perhaps more so with unrelated donor transplantation, in part due to the advances in HLA matching between donor and recipient, but also as a result of improved supportive care, better GVHD prophylaxis, and tailored conditioning regimens. Therefore, over the past decade, results of matched sibling donor and unrelated donor grafts have grown more similar, and the difference in 1-year survival for patients with leukemia has gone from 21% in 1988 in favor of MSD to 9% in 2008. However, due to the significant and combined effect of patient, transplantation, and donor variables, comparisons are made here in the context of defined subsets of patients and specific diseases and in some circumstances also looking at separate studies in children and adults.
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Ehlert K, Groll AH, Rossig C, Fruehwald MC, Juergens H. Late graft failure in FA--case report and review of the literature. Pediatr Transplant 2012; 16:E360-3. [PMID: 22616887 DOI: 10.1111/j.1399-3046.2012.01719.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Hematological disorders in patients with FA can only be cured by allogeneic HSCT. Severe infections in primary and early secondary graft failures pose a particular risk. Whereas most graft failures occur within 100 days, those observed after day +100 are infrequent. Here, we present our analysis of a secondary graft failure more than five yr after a first allogeneic HSCT. In this patient, isolated thrombocytopenia over a period of 12 months resulted in a chimerism subset analysis revealing a considerable decrease in the CD34-positive donor cell fraction. After a second fludarabine-based preparative regimen, the patient received PBSC from the same donor. Chimerism returned to full donor in all subsets. This clinical course demonstrates that isolated thrombocytopenia can precede complete graft failure for several months. Our review of the literature on late graft failures in patients with FA after day +100 reveals the absence of fludarabine in the preparative regimen as a potential risk factor. Further clinical research is necessary to identify more suitable approaches for ensuring safe and stable engraftment.
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Affiliation(s)
- Karoline Ehlert
- Department of Pediatric Hematology and Oncology, University Children's Hospital Muenster, Muenster, Germany.
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44
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Thakar MS, Bonfim C, Sandmaier BM, O’Donnell P, Ribeiro L, Gooley T, Deeg HJ, Flowers ME, Pasquini R, Storb R, Woolfrey AE, Kiem HP. Cyclophosphamide-based in vivo T-cell depletion for HLA-haploidentical transplantation in Fanconi anemia. Pediatr Hematol Oncol 2012; 29:568-78. [PMID: 22839094 PMCID: PMC3622043 DOI: 10.3109/08880018.2012.708708] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) is the only known cure for patients with Fanconi anemia (FA) who develop aplasia or leukemia. However, transplant regimens typically contain high-dose alkylators, which are poorly tolerated in FA patients. Furthermore, as many patients lack human leukocyte antigen (HLA)-matched family donors, alternative donors are used, which can increase the risk of both graft rejection and graft-versus-host disease (GVHD). To improve on these three concerns, we developed a multi-institutional clinical trial using a fludarabine (FLU)-based conditioning regimen with limited alkylators/low-dose radiation, HLA-haploidentical marrow, followed by reduced-dose cyclophosphamide (CY) to treat three FA patients with aplasia. All three patients engrafted with 100% donor CD3 chimerism at 1 month. One patient died early from disseminated toxoplasmosis infection. Of the two survivors, one had significant pretransplant co-morbidities and inadequate immunosuppression, and developed severe acute GVHD. The other patient had only mild acute and no chronic GVHD. With a follow-up of 2 and 3 years, respectively, both patients are doing well, are transfusion-independent, and maintain full donor chimerism. The patient with severe GVHD has resolving oral GVHD and good quality of life. We conclude that using low-intensity conditioning, HLA-haploidentical marrow, and reduced-dose CY for in vivo T-cell depletion can correct life-threatening aplasia in FA patients.
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Affiliation(s)
- MS Thakar
- Medical College of Wisconsin, Milwaukee, WI
| | - C Bonfim
- Hospital de Clinicas, Universidade do Parana, Curitiba Brazil
| | - BM Sandmaier
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | - P O’Donnell
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | - L Ribeiro
- Hospital de Clinicas, Universidade do Parana, Curitiba Brazil
| | - T Gooley
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | - HJ Deeg
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | - ME Flowers
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | - R Pasquini
- Hospital de Clinicas, Universidade do Parana, Curitiba Brazil
| | - R Storb
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | - AE Woolfrey
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | - HP Kiem
- Fred Hutchinson Cancer Research Center, Seattle, WA
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Yabe M, Shimizu T, Morimoto T, Koike T, Takakura H, Tsukamoto H, Muroi K, Oshima K, Asami K, Takata M, Yamashita T, Kato S, Yabe H. Matched sibling donor stem cell transplantation for Fanconi anemia patients with T-cell somatic mosaicism. Pediatr Transplant 2012; 16:340-5. [PMID: 22404423 DOI: 10.1111/j.1399-3046.2012.01669.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
SCT from HLA-identical sibling donors is generally associated with an excellent survival in FA patients if performed prior to the development of MDS or leukemia. However, the optimal conditioning regimen has not been defined. We report here our experience with 15 Japanese FA patients who underwent HLA-matched sibling donor SCT. The aim of this study is to compare radiation-based conditioning to Flu-based conditioning for FA patients in a Japanese population where the T-cell somatic mosaicism is higher than in the Caucasian population. Eight patients (a-group) received a radiation-based conditioning (500-600 cGy of thoracoabdominal/TBI) with CY dose modification (20-120 mg/kg), and ATG; two patients exhibited rejection. Seven patients (b-group) received CY (40 mg/kg), 150-180 mg/m(2) of Flu, and ATG. Durable engraftment was demonstrated in all patients. In FA patients, Flu-based conditioning may allow stable engraftment in matched sibling donor transplantation without radiation, even in patients with T-cell somatic mosaicism.
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Affiliation(s)
- Miharu Yabe
- Department of Cell Transplantation, Tokai University Hospital, Kanagawa, Japan.
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Ayas M, Al-Seraihi A, El-Solh H, Al-Ahmari A, Khairy A, Aldali A, Markiz S, Siddiqui K, Al-Jefri A. The Saudi Experience in Fludarabine-Based Conditioning Regimens in Patients with Fanconi Anemia Undergoing Stem Cell Transplantation: Excellent Outcome in Recipients of Matched Related Stem Cells but Not in Recipients of Unrelated Cord Blood Stem Cells. Biol Blood Marrow Transplant 2012; 18:627-32. [DOI: 10.1016/j.bbmt.2011.08.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2011] [Accepted: 08/16/2011] [Indexed: 10/17/2022]
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Hamidieh AA, Alimoghaddam K, Jahani M, Mousavi SA, Iravani M, Bahar B, Jalili M, Jalali A, Behfar M, Ghavamzadeh A. Long-term results of non-fludarabine versus fludarabine-based stem cell transplantation without total body irradiation in Fanconi anemia patients. Hematol Oncol Stem Cell Ther 2011; 4:109-15. [DOI: 10.5144/1658-3876.2011.109] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Abstract
Fanconi Anemia (FA) is a rare autosomic recessive and X-linked disease with chromosomal instability after exposure to crosslinking agents as the hallmark. Clinical features of FA are somatic malformations, progressive bone marrow failure and cancer proneness, however there is wide clinical heterogeneity. The symptom most frequently and early associated with morbidity and mortality is progressive pancytopenia in the first decade of life although acute myelogenous leukemia (AML) or myelodysplastic syndrome (MDS) can appear before aplastic anemia. Squamous cell carcinoma (SCC) of the head-neck, intestinal or genital tract has a very high incidence in FA and can appear at young age. This paper will focus on treatment of bone marrow failure in FA.
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Affiliation(s)
- Johanna Svahn
- Department of Pediatrie Hematology Oncology and Bone Marrow Transplantation, Caslini Childrens Hospital, Gsenova, Italy
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MacMillan ML, Hughes MR, Agarwal S, Daley GQ. Cellular therapy for fanconi anemia: the past, present, and future. Biol Blood Marrow Transplant 2011; 17:S109-14. [PMID: 21195298 DOI: 10.1016/j.bbmt.2010.11.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) remains the only proven curative therapy for the hematologic manifestation of Fanconi anemia (FA). Over the past 2 decades, major advances have been made such that transplant outcomes have markedly improved. With the development of in vitro fertilization and preimplantation genetic diagnosis, HLA-matched sibling donor umbilical blood transplantation may be an option for more patients with FA. Recently, the use of pluripotent stem cells has been explored as a novel approach to model the hematopoietic developmental defects in FA, and to provide a potential source of autologous stem cells that can be genetically manipulated and used to generate corrected hematopoietic progenitors.
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Affiliation(s)
- Margaret L MacMillan
- The Division of Pediatric Hematology, Oncology, and Blood and Marrow Transplantation, University of Minnesota Blood and Marrow Transplant Program, Minneapolis, Minnesota, USA.
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Abstract
Fanconi anemia (FA) is a human disease of bone marrow failure, leukemia, squamous cell carcinoma, and developmental anomalies, including hypogonadism and infertility. Bone marrow transplants improve hematopoietic phenotypes but do not prevent other cancers. FA arises from mutation in any of the 15 FANC genes that cooperate to repair double stranded DNA breaks by homologous recombination. Zebrafish has a single ortholog of each human FANC gene and unexpectedly, mutations in at least two of them (fancl and fancd1(brca2)) lead to female-to-male sex reversal. Investigations show that, as in human, zebrafish fanc genes are required for genome stability and for suppressing apoptosis in tissue culture cells, in embryos treated with DNA damaging agents, and in meiotic germ cells. The sex reversal phenotype requires the action of Tp53 (p53), an activator of apoptosis. These results suggest that in normal sex determination, zebrafish oocytes passing through meiosis signal the gonadal soma to maintain expression of aromatase, an enzyme that converts androgen to estrogen, thereby feminizing the gonad and the individual. According to this model, normal male and female zebrafish differ in genetic factors that control the strength of the late meiotic oocyte-derived signal, probably by regulating the number of meiotic oocytes, which environmental factors can also alter. Transcripts from fancd1(brca2) localize at the animal pole of the zebrafish oocyte cytoplasm and are required for normal oocyte nuclear architecture, for normal embryonic development, and for preventing ovarian tumors. Embryonic DNA repair and sex reversal phenotypes provide assays for the screening of small molecule libraries for therapeutic substances for FA.
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