1
|
Gorfinkel L, Raghunandan S, Watkins B, Hebert K, Neuberg DS, Bratrude B, Betz K, Yu A, Choi SW, Davis J, Duncan C, Giller R, Grimley M, Harris AC, Jacobsohn D, Lalefar N, Farhadfar N, Pulsipher MA, Shenoy S, Petrovic A, Schultz KR, Yanik GA, Blazar BR, Horan JT, Langston A, Kean LS, Qayed M. Overlap chronic GVHD is associated with adverse survival outcomes compared to classic chronic GVHD. Bone Marrow Transplant 2024; 59:680-687. [PMID: 38383714 DOI: 10.1038/s41409-024-02245-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 12/20/2023] [Accepted: 02/07/2024] [Indexed: 02/23/2024]
Abstract
Chronic graft-versus-host-disease (cGVHD) is divided into two subtypes: classic (absence of acute GVHD features) and overlap cGVHD ('ocGVHD'), in which both chronic and acute GVHD clinical features are present simultaneously. While worse outcomes with ocGVHD have been reported, there are few recent analyses. We performed a secondary analysis of data from the ABA2 trial (N = 185), in which detailed GVHD data were collected prospectively and systematically adjudicated. Analyses included cumulative incidence of classic versus ocGVHD, their specific organ manifestations, global disease severity scores, non-relapse mortality (NRM), disease-free survival (DFS) and overall survival (OS) in these two cGVHD subtypes. Of 92 patients who developed cGVHD, 35 were classified as ocGVHD. The 1-year cumulative incidence, organ involvement, and global severity of classic and ocGVHD were similar between ABA2 patients receiving CNI/MTX+placebo and CNI/MTX+abatacept; thus, cohorts were combined for ocGVHD evaluation. This analysis identified ocGVHD as having significantly higher severity at presentation and at maximum global severity compared to classic cGVHD. OS and DFS were significantly lower for ocGVHD versus classic cGVHD. OcGVHD is associated with increased cGVHD severity scores, and is associated with decreased OS and DFS compared to classic cGVHD, underscoring the high risks with this cGVHD subtype.
Collapse
Affiliation(s)
- Lev Gorfinkel
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Sharmila Raghunandan
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Emory University, Atlanta, GA, USA
| | - Benjamin Watkins
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Emory University, Atlanta, GA, USA
| | - Kyle Hebert
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Donna S Neuberg
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Brandi Bratrude
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Kayla Betz
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Alison Yu
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, MA, USA
| | | | - Jeffrey Davis
- BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Christine Duncan
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Roger Giller
- Center for Cancer and Blood Disorders, Children Hospital of Colorado, University of Colorado, Aurora, CO, USA
| | - Michael Grimley
- University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | | | - Nahal Lalefar
- University of California San Francisco, UCSF Benioff Children's Hospital Oakland, Oakland, CA, USA
| | | | | | - Shalini Shenoy
- Washington University School of Medicine, St Louis, MO, USA
| | | | - Kirk R Schultz
- BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | | | - Bruce R Blazar
- University of Minnesota, Department of Pediatrics, Division of Blood and Marrow Transplantation, Minneapolis, MN, USA
| | - John T Horan
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Amelia Langston
- Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Leslie S Kean
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, MA, USA.
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Emory University, Atlanta, GA, USA.
| |
Collapse
|
2
|
Baumrin E, Loren AW, Falk SJ, Mays JW, Cowen EW. Chronic graft-versus-host disease. Part I: Epidemiology, pathogenesis, and clinical manifestations. J Am Acad Dermatol 2024; 90:1-16. [PMID: 36572065 PMCID: PMC10287844 DOI: 10.1016/j.jaad.2022.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 12/08/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022]
Abstract
Chronic graft-versus-host disease is a major complication of allogeneic hematopoietic cell transplantation and a leading cause of long-term morbidity, nonrelapse mortality, and impaired health-related quality of life. The skin is commonly affected and presents heterogeneously, making the role of dermatologists critical in both diagnosis and treatment. In addition, new clinical classification and grading schemes inform treatment algorithms, which now include 3 U.S. Food and Drug Administration-approved therapies, and evolving transplant techniques are changing disease epidemiology. Part I reviews the epidemiology, pathogenesis, clinical manifestations, and diagnosis of chronic graft-versus-host disease. Part II discusses disease grading and therapeutic management.
Collapse
Affiliation(s)
- Emily Baumrin
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Alison W Loren
- Blood and Marrow Transplant, Cell Therapy and Transplant Program, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Hematology/Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sandy J Falk
- Adult Survivorship Program, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Jacqueline W Mays
- Oral Immunobiology Unit, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland
| | - Edward W Cowen
- Dermatology Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland
| |
Collapse
|
3
|
Fuji S, Hakoda A, Kanda J, Fukuda T, Doki N, Katayama Y, Uchida N, Ozawa Y, Kanda Y, Tanaka M, Kataoka K, Ara T, Sawa M, Onizuka M, Onishi Y, Kimura T, Ichinohe T, Atsuta Y, Shintani A, Morishima S. Impact of HLA disparity on overall mortality risk in patients with extensive chronic GVHD: The HLA Working Group of Japanese Society for Transplantation and Cellular Therapy. Bone Marrow Transplant 2023; 58:1257-1259. [PMID: 37550450 DOI: 10.1038/s41409-023-02076-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 07/11/2023] [Accepted: 07/25/2023] [Indexed: 08/09/2023]
Affiliation(s)
- Shigeo Fuji
- Department of Hematology, Osaka International Cancer Institute, Osaka, Japan.
| | - Akitoshi Hakoda
- Department of Medical Statistics, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Junya Kanda
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takahiro Fukuda
- Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Noriko Doki
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Yuta Katayama
- Department of Hematology, Hiroshima Red Cross Hospital & Atomic-bomb Survivors Hospital, Hiroshima, Japan
| | - Naoyuki Uchida
- Department of Hematology, Federation of National Public Service Personnel Mutual Aid Associations Toranomon Hospital, Tokyo, Japan
| | - Yukiyasu Ozawa
- Department of Hematology, Japanese Red Cross Aichi Medical Center Nagoya Daiichi Hospital, Aichi, Japan
| | - Yoshinobu Kanda
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Masatsugu Tanaka
- Department of Hematology, Kanagawa Cancer Center, Kanagawa, Japan
| | - Keisuke Kataoka
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Takahide Ara
- Department of Hematology, Hokkaido University Hospital, Hokkaido, Japan
| | - Masashi Sawa
- Department of Hematology and Oncology, Anjo Kosei Hospital, Aichi, Japan
| | - Makoto Onizuka
- Department of Hematology/Oncology, Tokai University School of Medicine, Kanagawa, Japan
| | - Yasushi Onishi
- Department of Hematology, Tohoku University Hospital, Miyagi, Japan
| | - Takafumi Kimura
- Preparation Department, Japanese Red Cross Kinki Block Blood Center, Osaka, Japan
| | - Tatsuo Ichinohe
- Department of Hematology and Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Yoshiko Atsuta
- Japanese Data Center for Hematopoietic Cell Transplantation, Aichi, Japan
- Department of Registry Science for Transplant and Cellular Therapy, Aichi Medical University School of Medicine, Aichi, Japan
| | - Ayumi Shintani
- Department of Medical Statistics, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Satoko Morishima
- Division of Endocrinology, Diabetes and Metabolism, Hematology, Rheumatology, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| |
Collapse
|
4
|
Kloehn J, Kruchen A, Schütze K, Wustrau K, Schrum J, Müller I. Immune Ablation and Stem Cell Rescue in Two Pediatric Patients with Progressive Severe Chronic Graft-Versus-Host Disease. Int J Mol Sci 2022; 23:ijms232315403. [PMID: 36499733 PMCID: PMC9735744 DOI: 10.3390/ijms232315403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 11/29/2022] [Accepted: 12/03/2022] [Indexed: 12/12/2022] Open
Abstract
Transplantation of allogeneic hematopoietic stem cells represents an established treatment for children with high-risk leukemia. However, steroid-refractory chronic graft-versus-host disease (SR-cGvHD) represents a severe life-threatening complication, for which there is no standard therapy. After failing several lines of immunosuppressive and biological treatment, we applied an immunoablative therapy with re-transplantation of purified CD34+ donor stem cells to reset the aberrant immune system. Two pediatric patients, who had been transplanted for high-risk acute lymphoblastic leukemia, underwent the procedure. Interestingly, enough stem cells could be mobilized, harvested, and purified to be used as grafts more than one year after allogeneic transplantation under intensive immunosuppressive therapy and ongoing SR-cGvHD. With a follow-up of 8 and 22 months, respectively, both patients are without immunosuppressive therapy and do not show signs of active disease. Regeneration of skin manifestations started promptly, other damaged organs did not progress and continue to show recovery from severe fibrotic transformation. Bone marrow function is robust and T cell receptor repertoires showed polyclonal immune reconstitution. In conclusion, stem cell harvest and re-transplantation of human CD34+-selected allogeneic stem cells is possible and represents a new therapeutic option in SR-cGvHD by resetting a profoundly disturbed immune network.
Collapse
|
5
|
Novel and Promising Strategies for Therapy of Post-Transplant Chronic GVHD. Pharmaceuticals (Basel) 2022; 15:ph15091100. [PMID: 36145321 PMCID: PMC9503665 DOI: 10.3390/ph15091100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 08/22/2022] [Accepted: 08/31/2022] [Indexed: 11/17/2022] Open
Abstract
Despite the achievements that have increased viability after the transplantation of allogeneic hematopoietic stem cells (aHSCT), chronic graft-versus-host disease (cGVHD) remains the main cause of late complications and post-transplant deaths. At the moment, therapy alternatives demonstrate limited effectiveness in steroid-refractory illness; in addition, we have no reliable data on the mechanism of this condition. The lack of drugs of choice for the treatment of GVHD underscores the significance of the design of new therapies. Improved understanding of the mechanism of chronic GVHD has secured new therapy goals, and organized diagnostic recommendations and the development of medical tests have ensured a general language and routes for studies in this field. These factors, combined with the rapid development of pharmacology, have helped speed up the search of medicines and medical studies regarding chronic GVHD. At present, we can hope for success in curing this formidable complication. This review summarizes the latest clinical developments in new treatments for chronic GVHD.
Collapse
|
6
|
Pavletic SZ, Schultz KR. Durable discontinuation of systemic therapy for chronic graft- versus-host disease: myth or reality? Haematologica 2022; 108:303-305. [PMID: 35615928 PMCID: PMC9890029 DOI: 10.3324/haematol.2022.281114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Indexed: 02/03/2023] Open
Affiliation(s)
- Steven Z. Pavletic
- Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA,S.Z. Pavletic
| | - Kirk R. Schultz
- Pediatric Hematology/Oncology/BMT, BC Children's Hospital, Vancouver, British Columbia, Canada
| |
Collapse
|
7
|
Chen GL, Onstad L, Martin PJ, Carpenter P, Pidala J, Arai S, Cutler C, Hamilton BK, Lee SJ, Arora M. Durable discontinuation of systemic therapy in patients affected by chronic graft- versus-host disease. Haematologica 2022; 108:483-489. [PMID: 35615925 PMCID: PMC9890023 DOI: 10.3324/haematol.2021.279814] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Indexed: 02/03/2023] Open
Abstract
Successful treatment of chronic graft-versus-host disease (GvHD) often requires long-term systemic therapy (ST). Durable discontinuation of ST reflects the resolution of active chronic GvHD. We evaluated the factors associated with durable ST discontinuation, defined as cessation of all ST for ≥12 months, using data from two prospectively followed cohorts from the Chronic GvHD Consortium (n=684). Transplant sources were peripheral blood (89%), bone marrow (6.6%), and cord blood (4.4%) from HLA matched related (37.6%), HLA matched unrelated (45%), and other donor types (18%). Half of the patients received non-myeloablative conditioning. The median time from transplantation to chronic GvHD diagnosis was 7.7 months (range, 1.0-141.3) and the median time from chronic GvHD onset to enrollment into the cohorts was 0.9 months (range, 0.0-12.0). The cumulative incidence estimate of durable ST discontinuation was 32% (95% confidence interval: 28%-37%) at 10 years after enrollment into the cohort. Among patients who discontinued ST, the median time from chronic GvHD diagnosis to durable ST discontinuation was 3.6 years (range, 1.2-10.5). In multivariate analysis, patients who received myeloablative conditioning, had chronic GvHD manifested as moderate/severe lower gastrointestinal involvement, and had a higher (worse) Lee symptom overall score were less likely to attain durable ST discontinuation. In contrast, mild lower gastrointestinal involvement and cord blood (vs. peripheral blood) as the graft source were associated with a greater likelihood of ST discontinuation. Although a minority of patients can discontinue ST permanently, most patients require prolonged ST. Viewing chronic GvHD in this way has implications for management approaches.
Collapse
Affiliation(s)
- George L. Chen
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY,G. Chen
| | - Lynn Onstad
- Clinical Research Division, Fred Hutchinson Cancer Research Center and the Department of Medicine, University of Washington, Seattle, WA
| | - Paul J. Martin
- Clinical Research Division, Fred Hutchinson Cancer Research Center and the Department of Medicine, University of Washington, Seattle, WA
| | - Paul Carpenter
- Clinical Research Division, Fred Hutchinson Cancer Research Center and the Department of Medicine, University of Washington, Seattle, WA
| | - Joseph Pidala
- Blood and Marrow Transplantation and Cellular Immunotherapy. H. Lee Moffitt Cancer Center and Research Institute. Tampa, FL
| | - Sally Arai
- Department of Medicine, Division of Blood and Marrow Transplantation, Stanford University School of Medicine, Stanford, CA
| | - Corey Cutler
- Division of Stem Cell Transplantation and Cellular Therapy, Dana-Farber Cancer Institute, Boston, MA
| | - Betty K. Hamilton
- Blood and Marrow Transplantation, Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Stephanie J. Lee
- Clinical Research Division, Fred Hutchinson Cancer Research Center and the Department of Medicine, University of Washington, Seattle, WA
| | - Mukta Arora
- Division of Hematology, Oncology and Transplantation, University of Minnesota Medical Center, Minneapolis, MN, USA
| |
Collapse
|
8
|
Combined treatment of graft versus host disease using donor regulatory T cells and ruxolitinib. Sci Rep 2022; 12:8348. [PMID: 35589917 PMCID: PMC9120462 DOI: 10.1038/s41598-022-12407-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 04/25/2022] [Indexed: 12/12/2022] Open
Abstract
Donor derived regulatory T lymphocytes and the JAK1/2 kinase inhibitor ruxolitinib are currently being evaluated as therapeutic options in the treatment of chronic graft versus host disease (cGvHD). In this work, we aimed to determine if the combined use of both agents can exert a synergistic effect in the treatment of GvHD. For this purpose, we studied the effect of this combination both in vitro and in a GvHD mouse model. Our results show that ruxolitinib favors the ratio of thymic regulatory T cells to conventional T cells in culture, without affecting the suppressive capacity of these Treg. The combination of ruxolitinib with Treg showed a higher efficacy as compared to each single treatment alone in our GvHD mouse model in terms of GvHD incidence, severity and survival without hampering graft versus leukemia effect. This beneficial effect correlated with the detection in the bone marrow of recipient mice of the infused donor allogeneic Treg after the adoptive transfer.
Collapse
|
9
|
Sobkowiak-Sobierajska A, Lindemans C, Sykora T, Wachowiak J, Dalle JH, Bonig H, Gennery A, Lawitschka A. Management of Chronic Graft-vs.-Host Disease in Children and Adolescents With ALL: Present Status and Model for a Personalised Management Plan. Front Pediatr 2022; 10:808103. [PMID: 35252060 PMCID: PMC8894895 DOI: 10.3389/fped.2022.808103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 01/24/2022] [Indexed: 12/18/2022] Open
Abstract
Herein we review current practice regarding the management of chronic graft-vs.-host disease (cGvHD) in paediatric patients after allogeneic haematopoietic stem cell transplantation (HSCT) for acute lymphoblastic leukaemia (ALL). Topics covered include: (i) the epidemiology of cGvHD; (ii) an overview of advances in our understanding cGvHD pathogenesis; (iii) current knowledge regarding risk factors for cGvHD and prevention strategies complemented by biomarkers; (iii) the paediatric aspects of the 2014 National Institutes for Health-defined diagnosis and grading of cGvHD; and (iv) current options for cGvHD treatment. We cover topical therapy and newly approved tyrosine kinase inhibitors, emphasising the use of immunomodulatory approaches in the context of the delicate counterbalance between immunosuppression and immune reconstitution as well as risks of relapse and infectious complications. We examine real-world approaches of response assessment and tapering schedules of treatment. Furthermore, we report on the optimal timepoints for therapeutic interventions and changes in relation to immune reconstitution and risk of relapse/infection. Additionally, we review the different options for anti-infectious prophylaxis. Finally, we put forth a theory of a holistic view of paediatric cGvHD and its associated manifestations and propose a checklist for individualised risk evaluation with aggregated considerations including site-specific cGvHD evaluation with attention to each individual's GvHD history, previous medical history, comorbidities, and personal tolerance and psychosocial circumstances. To complement this checklist, we present a treatment algorithm using representative patients to inform the personalised management plans for patients with cGvHD after HSCT for ALL who are at high risk of relapse.
Collapse
Affiliation(s)
| | - Caroline Lindemans
- Department of Pediatrics, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands.,Pediatric Blood and Bone Marrow Transplantation, Princess Máxima Center, Utrecht, Netherlands
| | - Tomas Sykora
- Department of Pediatric Hematology and Oncology - Haematopoietic Stem Cell Transplantation Unit, National Institute of Children's Diseases and Medical Faculty, Comenius University, Bratislava, Slovakia
| | - Jacek Wachowiak
- Department of Pediatric Oncology, Hematology and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Jean-Hugues Dalle
- Hematology and Immunology Department, Robert-Debré Hospital, Assistance Publique-Hôpitaux de Paris and University of Paris, Paris, France
| | - Halvard Bonig
- Goethe University Medical Center, Institute of Transfusion Medicine and Immunohematology, and German Red Cross Blood Center Frankfurt, Frankfurt, Germany
| | - Andrew Gennery
- Medical School, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Anita Lawitschka
- Stem Cell Transplantation Unit, St. Anna Children's Hospital, Medical University Vienna, Vienna, Austria.,St. Anna Children's Cancer Research Institute, Vienna, Austria
| |
Collapse
|
10
|
Day100 Score predicts moderate-severe cGVHD, transplant mortality, and survival after hematopoietic cell transplantation. Blood Adv 2021; 6:2309-2318. [PMID: 34920451 PMCID: PMC9006267 DOI: 10.1182/bloodadvances.2021005675] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 11/10/2021] [Indexed: 11/27/2022] Open
Abstract
We report a simple 4 variables-based laboratory score taken on day +100 to predict transplant outcomes. The Day100 score stratifies patients into 3 groups for moderate-severe GVHD and TRM.
The aim of this study was to develop a predictive score for moderate-severe chronic graft-versus-host disease (cGVHD) on day +100 after allogeneic stem cell transplantation (HSCT). We studied 1292 patients allografted between 1990 and 2016, alive on day +100 after transplant, without cGVHD, and with full biochemistry laboratory values available. Patients were randomly assigned to a training and a validation cohort (ratio 1:1). In the training cohort, a multivariate analysis identified 4 independent predictors of moderate-severe cGVHD: gamma-glutamyl transferase ≥75 UI/l, creatinine ≥1 mg/dl, cholinesterase ≤4576 UI/l, and albumin ≤4 g/dl. A score of 1 was assigned to each variable, producing a low (0 to 1), intermediate (2 to 3), and high (4) score. The cumulative incidence of moderate-severe cGVHD was 12%, 20%, and 52% (P < .0001) in the training cohort, and 13%, 24%, and 33% (P = .002) in the validation cohort, respectively. The 5-year cumulative incidence of transplant-related mortality (TRM) was 5%, 14%, 27% (P < .0001) and 5%, 16%, 31% (P < .0001), respectively. The 5-year survival was 64%, 57%, 54% (P = .009) and 70%, 59%, 42% (P = .0008) in the 2 cohorts, respectively. In conclusion, Day100 score predicts cGVHD, TRM, and survival and, if validated in a separate group of patients, could be considered for trials of preemptive therapy.
Collapse
|
11
|
Novitzky-Basso I, AlHayli S, Shin E, Pasic I, Al-Shaibani Z, Lam W, Law A, Michelis FV, Gerbitz A, Viswabandya A, Lipton JH, Kumar R, Mattsson J, Kim DDH. Refined hepatic grading system in chronic graft-versus-host disease improves prognostic risk stratification of long-term outcomes. Eur J Haematol 2021; 106:508-519. [PMID: 33421199 DOI: 10.1111/ejh.13576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 01/06/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Hepatic grading systems for categorizing severity in chronic graft-versus-host disease (cGvHD) were determined arbitrarily, leading us to initiate the present study to provide objective evidence for the determination of optimal cutoff values and devise a hepatic grading system to predict prognosis. METHODS Of 842 patients who received allogeneic hematopoietic stem transplant (HCT), 336 patients diagnosed with cGvHD were evaluated for overall survival (OS) and non-relapse mortality (NRM) after cGVHD development. Multiple statistical parameters were evaluated to define optimal cutoff values of liver profile, including negative predictive value (NPV), positive predictive value (PPV), accuracy, and p-values as measures of risk stratification power. RESULTS We found that alkaline phosphatase (ALP) ≥ 146 IU/L (NPV: 83.4%; PPV: 32.8%; accuracy: 52.7%) and bilirubin ≥ 14 µmol/L (NPV: 81.8%; PPV: 39.4%; accuracy 68.1%) significantly correlated with OS. We developed a refined hepatic cGvHD grading score (RHS), stratifying patients into a low-RHS group with RHS score 0, OS at 3 years (n = 162) to 80.5%, compared to high-RHS group with score 1-2 (n = 172) 62.7%. Regarding NRM, score 0 segregated NRM at 3 years to 11.9%, compared with score 1-2 19.6%, P = .1. CONCLUSIONS Refined hepatic score is promising for stratifying patients with cGVHD and liver involvement according to long-term outcomes.
Collapse
Affiliation(s)
- Igor Novitzky-Basso
- Department of Medical Oncology and Hematology, Hans Messner Allogeneic Stem Cell Transplant Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Saud AlHayli
- Department of Medical Oncology and Hematology, Hans Messner Allogeneic Stem Cell Transplant Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Elizabeth Shin
- Department of Medical Oncology and Hematology, Hans Messner Allogeneic Stem Cell Transplant Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Ivan Pasic
- Department of Medical Oncology and Hematology, Hans Messner Allogeneic Stem Cell Transplant Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Zeyad Al-Shaibani
- Department of Medical Oncology and Hematology, Hans Messner Allogeneic Stem Cell Transplant Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Wilson Lam
- Department of Medical Oncology and Hematology, Hans Messner Allogeneic Stem Cell Transplant Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Arjun Law
- Department of Medical Oncology and Hematology, Hans Messner Allogeneic Stem Cell Transplant Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Fotios V Michelis
- Department of Medical Oncology and Hematology, Hans Messner Allogeneic Stem Cell Transplant Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Armin Gerbitz
- Department of Medical Oncology and Hematology, Hans Messner Allogeneic Stem Cell Transplant Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Auro Viswabandya
- Department of Medical Oncology and Hematology, Hans Messner Allogeneic Stem Cell Transplant Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Jeffrey H Lipton
- Department of Medical Oncology and Hematology, Hans Messner Allogeneic Stem Cell Transplant Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Rajat Kumar
- Department of Medical Oncology and Hematology, Hans Messner Allogeneic Stem Cell Transplant Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Jonas Mattsson
- Department of Medical Oncology and Hematology, Hans Messner Allogeneic Stem Cell Transplant Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Dennis Dong Hwan Kim
- Department of Medical Oncology and Hematology, Hans Messner Allogeneic Stem Cell Transplant Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
| |
Collapse
|
12
|
Manrai M, George E, Kapoor R. Profile of Hepatobiliary Dysfunction in Hematopoietic Stem Cell Transplant Recipients - An Indian Perspective. J Clin Exp Hepatol 2021; 11:14-20. [PMID: 33679044 PMCID: PMC7897852 DOI: 10.1016/j.jceh.2020.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 06/22/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND/AIMS Hematopoietic stem cell transplantation (HSCT) is an established curative modality for various hematological malignancies and other diseases. Hepatobiliary dysfunction and subsequent sequelae constitute a common cause of morbidity and mortality in post-transplant scenario. However, data among Indian HSCT recipients is lacking. METHODS One hundred and one HSCT recipients (37 prospective and 64 retrospective) were followed up for hepatobiliary dysfunction in the post-transplant period. The causes for hepatobiliary dysfunction were categorized as sinusoidal obstruction syndrome (SOS), formerly known as veno-occlusive disease (VOD); acute and chronic graft-versus- host disease (GVHD); drug-induced liver injury (DILI); viral infections and miscellaneous causes including bacterial, fungal and unknown causes based on clinical and laboratory evidence. RESULTS Among the 101 transplants, 56.44% (n = 57) were allogenic transplants, and 43.56% (n = 44) were autologous transplants. Hepatobiliary dysfunction was observed among 71 (70.30%) patients in first 30 days and overall, among 78 (77.23%) patients. Incidence of hepatobiliary dysfunction was higher among allogenic transplant patients compared to autologous transplants (91.23% vs. 59.09%, p < 0.001). The most common cause of hepatobiliary dysfunction reported was Drug-induced liver injury (DILI). In most cases, however, hepatobiliary dysfunction was multifactorial. Sinusoidal obstruction syndrome (15.79%), acute liver GVHD (31.58%), chronic liver GVHD (33.33%) and viral infection/reactivation (26.32%) were reported only in allogenic transplant patients. 15 (14.85%) patients died of which 14 patients had hepatobiliary dysfunction, commonest cause being infections. CONCLUSION Our study reported a higher incidence of hepatobiliary dysfunction among Indian population post HSCT and was associated with significant mortality. In majority of the cases, the cause is multifactorial and pose a diagnostic dilemma and challenges in therapy.
Collapse
Key Words
- ALP, Alkaline phosphatase
- ALT, Alanine transaminase
- AST, Aspartate transaminase
- DILI, Drug-induced liver injury
- DNA, Deoxy ribonucleic acid
- GVHD, Graft versus host disease
- HAV, Hepatitis A virus
- HBV, Hepatitis B virus
- HCV, Hepatitis C virus
- HEV, Hepatitis E virus
- HLA, Human leukocyte antigen
- HSCT, Hematopoietic stem cell transplantation
- PCR, Polymerase Chain Reaction
- RNA, Ribonucleic acid
- SOS, Sinusoidal obstruction syndrome
- ULN, Upper limit of normal
- drug induced liver injury
- graft vs host disease
- hematopoietic stem cell transplantation
- hepatobiliary manifestations
- sinusoidal obstruction syndrome
Collapse
Affiliation(s)
- Manish Manrai
- Department of Internal Medicine, Armed Forces Medical College, Pune, India
| | - Emil George
- Department of Internal Medicine, INHS Dhanvantari, Port Blair, Andaman & Nicobar Islands, India,Address for correspondence: Dr Emil George, Graded Specialist (Medicine), Department of Internal Medicine, INHS Dhanvantari, Minnie Bay, Port Blair, Andaman & Nicobar Islands, 744103, India.
| | - Rajan Kapoor
- Department of Internal Medicine, Command Hospital, Kolkata, West Bengal, India
| |
Collapse
|
13
|
Waller EK, Miklos D, Cutler C, Arora M, Jagasia MH, Pusic I, Flowers ME, Logan AC, Nakamura R, Chang S, Clow F, Lal ID, Styles L, Jaglowski S. Ibrutinib for Chronic Graft-versus-Host Disease After Failure of Prior Therapy: 1-Year Update of a Phase 1b/2 Study. Biol Blood Marrow Transplant 2019; 25:2002-2007. [PMID: 31260802 DOI: 10.1016/j.bbmt.2019.06.023] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 06/24/2019] [Accepted: 06/24/2019] [Indexed: 12/14/2022]
Abstract
Chronic graft-versus-host disease (cGVHD) is a life-threatening complication of allogeneic stem cell transplantation. In a Phase 1b/2, open-label study (PCYC-1129; ClinicalTrials.gov identifier NCT02195869) involving 42 patients with active cGVHD who were steroid-dependent or -refractory, the activity and safety of ibrutinib, a once-daily inhibitor of Bruton's tyrosine kinase, was demonstrated. Here we report extended follow-up for patients in this study. After a median follow-up of 26 months (range, .53 to 36.7 months), best overall response rate in the all treated population was 69% (29 of 42), with 13 patients (31%) achieving a complete response and 16 patients (38%) achieving a partial response. Sustained responses of ≥20, ≥32, and ≥44 weeks were seen in 20 (69%), 18 (62%), and 16 (55%) of the 29 responders, respectively. Of 26 patients with ≥2 involved organs, 19 (73%) showed responses in ≥2 organs. Six of 10 patients (60%) with ≥3 involved organs showed responses in ≥3 organs. Eleven of 18 patients (61%) who had sclerosis at baseline showed a sclerotic response (39% with complete response, 22% with partial response). Twenty-seven of 42 patients (64%) reached a corticosteroid dose of <.15 mg/kg/day during the study; 8 discontinued corticosteroid treatment and remained off corticosteroid at study closure. Safety findings for this updated analysis were consistent with the safety profile seen at the time of the original analysis. Common grade ≥3 adverse events (AEs) were pneumonia (n = 6), fatigue (n = 5), and diarrhea (n = 4). The onset of new grade ≥3 AEs decreased from 71% in the first year of treatment to 25% in the second year (n = 12). AEs leading to discontinuation occurred in 18 patients (43%). At a median follow-up of >2 years, ibrutinib continued to produce durable responses in patients with cGVHD who had failed previous systemic therapy. In this pretreated, high-risk population, clinically meaningful benefit and an acceptable safety profile were observed with additional follow-up for ibrutinib. These results demonstrate a substantial advance in the therapeutic management of patients with cGVHD.
Collapse
|
14
|
Shapiro RM, Shin E, Law AD, Lam W, Michelis FV, Viswabandya A, Kumar R, Lipton JH, Messner H, Mattsson J, Kim DDH. Combination of the Centre for International Blood and Marrow Transplant Registry Risk Score and the Global Severity Score Enhances Prognostic Risk Stratification in Patients Receiving Frontline Therapy for Chronic Graft-versus-Host Disease. Biol Blood Marrow Transplant 2019; 25:1761-1769. [PMID: 31170520 DOI: 10.1016/j.bbmt.2019.05.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 05/13/2019] [Accepted: 05/26/2019] [Indexed: 11/18/2022]
Abstract
The Centre for International Blood and Marrow Transplant Registry (CIBMTR) score has been shown to be prognostic for overall survival (OS) and nonrelapse mortality (NRM) but has been shown in several single-center studies to classify a large proportion of patients with chronic graft-versus-host disease (cGVHD) in the lower risk groups (RG1 to RG2), thereby limiting its prognostic utility for those patients. We evaluate the CIBMTR score, the Global Severity Score (GSS), and a novel risk score developed to improve on the limitations of the CIBMTR with respect to clinically relevant outcomes, including failure-free survival (FFS), in patients receiving frontline systemic treatment for cGVHD. We identified 277 patients between 2002 and 2012 at the Princess Margaret Cancer Centre in Toronto, Canada, who developed cGVHD and were treated with at least 1 line of systemic therapy. cGVHD was graded by GSS, and patients were stratified by CIBMTR. We evaluated OS, NRM, relapse, and FFS within GSS grade groups, as well as CIBMTR RGs, and used a novel prognostic risk score. The median FFS duration was 164 days in the severe GSS group versus 238 days in the moderate-grade group and 304 days in mild-grade group (P= .001). The median FFS duration was 501 days in CIBMTR RG1 versus 291 days in RG2 and 166 days in RG3 to RG6 (P = .003). A novel risk score combining the GSS and CIBMTR scores was prognostic of OS, NRM, and FFS and was able to subdivide patients with cGVHD in CIBMTR RG1 to RG2 into distinct prognostic risk categories. The CIBMTR risk score and the GSS are well correlated with FFS, OS, and NRM following frontline systemic treatment for cGVHD. A new risk score model combining the CIBMTR risk score and the GSS could enhance risk stratification in the lower CIBMTR risk groups.
Collapse
Affiliation(s)
- Roman M Shapiro
- Adult Hematology Program, University of Toronto, Toronto, Ontario, Canada
| | - Elizabeth Shin
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Arjun Datt Law
- Allogeneic Blood and Marrow Transplant Program, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Wilson Lam
- Allogeneic Blood and Marrow Transplant Program, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Fotios V Michelis
- Allogeneic Blood and Marrow Transplant Program, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Auro Viswabandya
- Allogeneic Blood and Marrow Transplant Program, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Rajat Kumar
- Allogeneic Blood and Marrow Transplant Program, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Jeffrey H Lipton
- Allogeneic Blood and Marrow Transplant Program, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Hans Messner
- Allogeneic Blood and Marrow Transplant Program, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Jonas Mattsson
- Allogeneic Blood and Marrow Transplant Program, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada; Department of Oncology and Pathology, Karolinska Institute, Stockholm, Sweden
| | - Dennis Dong Hwan Kim
- Allogeneic Blood and Marrow Transplant Program, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada.
| |
Collapse
|
15
|
Dierov D, Webb N, Fatmi S, Nwanne C, Ciolino C, Mosesso K, Nieves J, Perales MA, Prockop SE, Ponce DM. Establishing a standardized system for review and adjudication of chronic graft-vs-host disease data in accordance with the National Institutes Consensus criteria. ACTA ACUST UNITED AC 2019; 2. [PMID: 31886456 DOI: 10.1002/acg2.62] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
GVHD is a frequent complication following allo-HCT. The NIH consensus group established new guidelines for the evaluation of chronic GVHD. However, GVHD assessment remains challenging due its complexity and requirement for laborious evaluation. We, therefore, established a standardized approach for the assessment of chronic GVHD in accordance with the NCC guidelines. At a single institution, all allograft recipients were evaluated for GVHD within the first-year post allo-HCT following a 3-step workflow (real-time assessment, consensus review, and documentation). A GVHD adjudication committee was created and a dynamic electronic GVHD data capture form was developed guiding the clinician through a comprehensive review of systems following the NCC guidelines. We found that the assessment and reporting of GVHD reached 100% compliance. The establishment of an institutional GVHD adjudication committee enabled standardized assessment of GVHD. Our workflow can be adopted by other centers to create a similar framework for dedicated GVHD evaluation.
Collapse
Affiliation(s)
- Djamilia Dierov
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Nicholas Webb
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Samira Fatmi
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Chamberlain Nwanne
- Health Informatics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Cristi Ciolino
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kara Mosesso
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jimmy Nieves
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Miguel-Angel Perales
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY.,Weill Cornell Medical College, New York, NY
| | - Susan E Prockop
- Department of Pediatrics, Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Doris M Ponce
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY.,Weill Cornell Medical College, New York, NY
| |
Collapse
|
16
|
Csanadi M, Agh T, Tordai A, Webb T, Jeyakumaran D, Sengupta N, Schain F, Mattsson J. A systematic literature review of incidence, mortality, and relapse of patients diagnosed with chronic graft versus host disease. Expert Rev Hematol 2019; 12:311-323. [DOI: 10.1080/17474086.2019.1605288] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
| | - Tamas Agh
- Syreon Research Institute, Budapest, Hungary
| | - Attila Tordai
- Department of Pathophysiology, Semmelweis University, Budapest, Hungary
| | - Thomas Webb
- Janssen Research & Development, High Wycombe, UK
| | | | | | | | - Jonas Mattsson
- Division of Medical Oncology and Hematology, Department of Medicine, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
17
|
Fung SSM, Elbaz U, Mireskandari K, Ali A. Graft versus host disease: a pediatric perspective. EXPERT REVIEW OF OPHTHALMOLOGY 2019. [DOI: 10.1080/17469899.2019.1598860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Simon SM Fung
- Department of Ophthalmology, Stein Eye Institute, University of California, Los Angeles, CA, USA
| | - Uri Elbaz
- Department of Ophthalmology, Rabin Medical Center, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Kamiar Mireskandari
- Department of Ophthalmology and Vision Sciences, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Asim Ali
- Department of Ophthalmology and Vision Sciences, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
18
|
FL/GCSF/AMD3100-mobilized Hematopoietic Stem Cells Induce Mixed Chimerism With Nonmyeloablative Conditioning and Transplantation Tolerance. Transplantation 2019; 103:1360-1371. [PMID: 30747856 DOI: 10.1097/tp.0000000000002657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Mobilization of hematopoietic stem cells (HSCs) has become the preferred approach for HSC transplantation. AMD3100, a competitive inhibitor of C-X-C motif chemokine receptor-4, has been found to be a rapid mobilizing agent. The present study evaluated approaches to optimize the product collected. METHODS Mobilized peripheral blood mononuclear cells (mPBMCs) from B6 mice were transplanted to recipient BALB/c mice conditioned with ablative or nonmyeloablative approaches. RESULTS The optimal dose of AMD3100 was found to be 5.0 mg/kg. Optimal HSC mobilization was observed when AMD3100 (day 10) was coadministered with Flt3 ligand (FL) (days 1-10) and granulocyte colony-stimulating factor (GCSF) (days 4-10). There was a 228.8-fold increase of HSC with FL/GCSF/AMD3100 compared with AMD3100 treatment alone. When unmodified mPBMCs were transplanted into ablated allogeneic recipients, all recipients expired by day 40 from severe acute graft versus host disease (GVHD). When T cells were depleted from mPBMC, long-term survival and engraftment were achieved in majority of the recipients. When PBMC mobilized by FL/GCSF/AMD3100 were transplanted into recipients conditioned nonmyeloablatively with anti-CD154/rapamycin plus 100, 200, and 300 cGy of total body irradiation, 42.9%, 85.7%, and 100% of mice engrafted, respectively. Donor chimerism was durable, multilineage, and stable. Lymphocytes from mixed chimeras showed no response to host or donor antigens, suggesting functional bidirection T-cell tolerance in vitro. Most importantly, none of the engrafted mice exhibited clinical features of GVHD. CONCLUSIONS FL/GCSF/AMD3100 is an efficient treatment to maximally mobilize HSC. Durable engraftment and donor-specific tolerance can be achieved with mPBMC in nonmyeloablative conditioning without GVHD.
Collapse
|
19
|
Solomon SR, Sizemore CA, Ridgeway M, Zhang X, Brown S, Holland HK, Morris LE, Solh M, Bashey A. Safety and efficacy of rituximab-based first line treatment of chronic GVHD. Bone Marrow Transplant 2018; 54:1218-1226. [PMID: 30518977 DOI: 10.1038/s41409-018-0399-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 09/22/2018] [Accepted: 11/08/2018] [Indexed: 11/09/2022]
Abstract
Initial therapy of chronic GVHD (cGvHD) has not changed for over three decades, despite limited efficacy and long-term toxicity. We have previously shown in a small pilot study the feasibility of rituximab-based first-line therapy of cGVHD. To better assess safety and efficacy, we now evaluate 69 patients that received rituximab as part of their initial treatment. Median follow-up for surviving patients was 47 (11-81) months. Resolution of cGVHD occurred in 49 patients with median time to IST discontinuation of 349 (138-920) days. The cumulative incidence (CI) of cGHVD resolution was 41%, 69 and 77% at 1-, 2- and 3-years, respectively. No systemic corticosteroids were used in 27 patients, and 67% received ≤ 10 mg/kg cumulative exposure. Overall survival (OS) at 1-, 2- and 3-years following cGVHD diagnosis was 87, 79 and 77% respectively; corresponding rates of non-relapse mortality (NRM) were 10%, 16 and 19%. The probability of being alive and free of cGVHD at 1-, 2-, and 3-years was 36, 55, and 57% respectively. This study demonstrates the feasibility and efficacy of rituximab-based first-line cGVHD treatment. This approach demonstrates significant activity and avoids long courses of corticosteroids in most patients.
Collapse
Affiliation(s)
- Scott R Solomon
- The Blood and Marrow Transplant Program at Northside Hospital, Atlanta, GA, USA.
| | - Connie A Sizemore
- The Blood and Marrow Transplant Program at Northside Hospital, Atlanta, GA, USA
| | - Michelle Ridgeway
- The Blood and Marrow Transplant Program at Northside Hospital, Atlanta, GA, USA
| | - Xu Zhang
- The University of Texas, Health Science Center at Houston, Houston, TX, USA
| | - Stacey Brown
- The Blood and Marrow Transplant Program at Northside Hospital, Atlanta, GA, USA
| | - H Kent Holland
- The Blood and Marrow Transplant Program at Northside Hospital, Atlanta, GA, USA
| | - Lawrence E Morris
- The Blood and Marrow Transplant Program at Northside Hospital, Atlanta, GA, USA
| | - Melhem Solh
- The Blood and Marrow Transplant Program at Northside Hospital, Atlanta, GA, USA
| | - Asad Bashey
- The Blood and Marrow Transplant Program at Northside Hospital, Atlanta, GA, USA
| |
Collapse
|
20
|
Mawardi H, Hashmi SK, Elad S, Aljurf M, Treister N. Chronic graft‐versus‐host disease: Current management paradigm and future perspectives. Oral Dis 2018; 25:931-948. [DOI: 10.1111/odi.12936] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 07/04/2018] [Accepted: 07/04/2018] [Indexed: 12/14/2022]
Affiliation(s)
- Hani Mawardi
- Faculty of Dentistry King AbdulAziz University Jeddah Kingdom of Saudi Arabia
- AlFarabi Private College Jeddah Kingdom of Saudi Arabia
| | - Shahrukh K. Hashmi
- Department of Medicine Mayo Clinic Rochester Minnesota
- Oncology Center KFSHRC Riyadh Kingdom of Saudi Arabia
| | - Sharon Elad
- Department of Dentistry University of Rochester Rochester New York
| | | | - Nathaniel Treister
- Division of Oral Medicine and Dentistry, Brigham and Women's Hospital Boston Massachusetts
- Department of Oral Medicine, Infection and Immunity Harvard School of Dental Medicine Boston Massachusetts
| |
Collapse
|
21
|
EBMT-NIH-CIBMTR Task Force position statement on standardized terminology & guidance for graft-versus-host disease assessment. Bone Marrow Transplant 2018; 53:1401-1415. [PMID: 29872128 PMCID: PMC6786777 DOI: 10.1038/s41409-018-0204-7] [Citation(s) in RCA: 241] [Impact Index Per Article: 40.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 03/05/2018] [Accepted: 04/03/2018] [Indexed: 11/21/2022]
Abstract
Several international recommendations address the assessment of graft-versus-host disease (GvHD) after hematopoietic cell transplantation (HCT). This position statement by GvHD experts from the European Society for Blood and Marrow Transplantation (EBMT), the National Institutes of Health (NIH) and the Center for International Blood and Marrow Transplant Research (CIBMTR) reviews the existing guidelines for both acute and chronic GvHD, addresses potential confusions that arise in daily practice and proposes consensus definitions for many key terms. We provide a historical perspective on the currently available guidelines and recommend the Mount Sinai Acute GvHD International Consortium (MAGIC) criteria for acute GvHD and the NIH 2014 criteria for chronic GvHD as the most comprehensive and detailed criteria available. This statement also offers practical guidance for the implementation of these recommendations and a set of consensus definitions for commonly used GvHD terms in order to facilitate future clinical and translational research. To assist the dissemination of these recommendations, a web-application based on this position statement is available (https://www.uzleuven.be/egvhd). We believe that adherence to a common set of GvHD assessment criteria is vitally important to improve the quality of data, compare results of retrospective studies and prospective clinical trials, and make therapeutic recommendations based on quality evidence.
Collapse
|
22
|
Chen CT, Liu CY, Yu YB, Liu CJ, Hsiao LT, Gau JP, Chiou TJ, Liu JH, Liu YC. Characteristics and risk of chronic graft-versus-host disease of liver in allogeneic hematopoietic stem cell transplant recipients. PLoS One 2017; 12:e0185210. [PMID: 28934311 PMCID: PMC5608321 DOI: 10.1371/journal.pone.0185210] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 09/10/2017] [Indexed: 12/21/2022] Open
Abstract
Chronic graft-versus-host-disease (cGvHD) is a serious complication of allogeneic hematopoietic stem cell transplantation (allo-HSCT). Among various organ-specific cGvHD, the cGvHD of liver is less well-characterized. In this study, we applied the National Institutes of Health 2014 scoring criteria of cGvHD to analyze a retrospective cohort of 362 allo-HSCT recipients focusing on cGvHD of liver. The overall incidence of liver cGvHD with a score of 3 by 1.5 years post-transplant was 5.8% (21/362). Poor outcome, in terms of overall survival (OS), were observed in patients with scores of 3 liver cGvHD, comparing to those with scores less than 3 (hazard ratio [HR] 2.037, 95% confidence interval [CI] 1.123-3.696, P = 0.019). In multivariate analysis, male gender (HR 4.004, P = 0.042) and chronic hepatitis C virus (HCV) infection status (HR 19.087, P < 0.001) were statistically significant risk factors for scores of 3 liver cGvHD. Our results indicate that liver cGvHD with scores of 3 has a grave prognosis following allo-HSCT, and that HCV carrier status and male are risk factors. Early recognition of this devastating complication might help in prompt immunosuppressive therapy and reducing late poor outcome.
Collapse
Affiliation(s)
- Chien-Ting Chen
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chun-Yu Liu
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Division of Medical Oncology, Department of Oncology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yuan-Bin Yu
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chia-Jen Liu
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Liang-Tsai Hsiao
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Jyh-Pyng Gau
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Tzeon-Jye Chiou
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Division of Transfusion Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jing-Hwang Liu
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yao-Chung Liu
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- * E-mail:
| |
Collapse
|
23
|
Curtis LM, Pirsl F, Steinberg SM, Mitchell SA, Baird K, Cowen EW, Mays J, Buxbaum NP, Pichard DC, Im A, Avila D, Taylor T, Fowler DH, Gress RE, Pavletic SZ. Predictors for Permanent Discontinuation of Systemic Immunosuppression in Severely Affected Chronic Graft-Versus-Host Disease Patients. Biol Blood Marrow Transplant 2017; 23:1980-1988. [PMID: 28797782 DOI: 10.1016/j.bbmt.2017.08.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 08/03/2017] [Indexed: 01/30/2023]
Abstract
Predicting the duration of systemic therapy in patients with chronic graft-versus-host disease (cGVHD) is of critical clinical importance when counseling patients and for treatment planning. cGVHD characteristics associated with this outcome have not been studied in severely affected patients. The National Institutes of Health (NIH) cGVHD scoring provides a standardized set of organ severity measures that could represent clinically useful and reproducible predictive characteristics. We analyzed 227 previously treated patients most with moderate (n = 54) or severe (n = 170) cGVHD defined by NIH criteria who were prospectively enrolled in a natural history protocol (NCT00092235). Patients received a median of 4 prior systemic therapy regimens and were seen at the NIH for a single time-point visit and were then monitored for survival and ability to discontinue cGVHD systemic therapy. With a median follow-up of 71.1 months, the cumulative incidence of systemic therapy discontinuation was 9.5% (95% confidence interval, 6.0% to 13.9%) at 2 years and 27.7% (95% confidence interval, 20.9% to 34.8%) by 5 years after the initial visit. Factors associated with a higher incidence of immunosuppression discontinuation included lower NIH global severity (P = .019) and lung (P = .030) scores and less extensive deep sclerosis (<37% body surface area, P = .024). Lower patient- and clinician-reported 0 to 10 severity NIH scores and noncyclosporine prophylaxis regimens were also associated with higher incidence of immunosuppression discontinuation (P <.05). In conclusion, we found low success rates for immune suppression discontinuation in previously treated patients who were severely affected with cGVHD. NIH scoring and clinical measures provide new standardized disease-specific tools to predict discontinuation of systemic therapy.
Collapse
Affiliation(s)
- Lauren M Curtis
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Filip Pirsl
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Seth M Steinberg
- Biostatistics and Data Management Section, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Sandra A Mitchell
- Outcomes Research Branch Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Kristin Baird
- Pediatric Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Edward W Cowen
- Dermatology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Jacqueline Mays
- National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland
| | - Nataliya P Buxbaum
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Dominique C Pichard
- Dermatology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Annie Im
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland; Division of Hematology and Oncology, University of Pittsburgh Cancer Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Daniele Avila
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Tiffani Taylor
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Daniel H Fowler
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Ronald E Gress
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Steven Z Pavletic
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland.
| |
Collapse
|
24
|
Low incidence of severe cGvHD and late NRM in a phase II trial of thymoglobulin, tacrolimus and sirolimus for GvHD prevention. Bone Marrow Transplant 2017; 52:1304-1310. [PMID: 28581472 DOI: 10.1038/bmt.2017.95] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2016] [Revised: 03/17/2017] [Accepted: 04/14/2017] [Indexed: 12/22/2022]
Abstract
Chronic GvHD (cGvHD) is the leading cause of late non-relapse mortality (NRM) and morbidity after allogeneic hematopoietic stem cell transplant (AHSCT). We analyzed the late effects of a phase II trial testing the efficacy of intermediate dose rabbit anti-thymocyte globulin (Thymoglobulin Thymo) in combination with tacrolimus and sirolimus (TTS) in 47 patients (pts) for the prevention of acute and chronic GvHD after unrelated AHSCT. The median follow-up was 45.2 months. The cumulative incidence of NIH severe cGvHD at 48 months was 6.4% with no new occurrences past 6 months for the entire follow-up period. The overall cumulative incidence of cGvHD was 44.7%. Out of 20 pts who are alive and disease-free at the last follow-up, only 4 pts continue to need systemic immune suppression. We observed low late NRM with only 3 transplant-related deaths after 6 months post transplant. At 4 years of follow-up, the overall cumulative incidence of NRM and disease relapse was 27.7% and 30.0%, respectively. PFS and overall survival (OS) at 4 years were 42 and 47%. At long term follow-up, TTS was associated with low incidence of severe cGvHD and late NRM.
Collapse
|
25
|
Lazaryan A, Arora M. Evolving concepts in prognostic scoring of chronic GvHD. Bone Marrow Transplant 2017; 52:1361-1366. [PMID: 28346419 DOI: 10.1038/bmt.2017.50] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 01/03/2017] [Accepted: 02/16/2017] [Indexed: 01/27/2023]
Abstract
Chronic GvHD (cGvHD) remains one of the most complex and challenging complications after allogeneic hematopoietic cell transplantation. Emerging knowledge about the clinical manifestations and associated organ involvement of cGvHD has led to the establishment of prognostic parameters for post-transplant survival among affected allograft recipients. Studies employing the pre-National Institutes of Health (NIH) consensus data on cGvHD incidence and its risks have led to development of the CIBMTR's cGvHD risk stratification, which serves as the most refined and validated prognostic tool for estimating survival of patients with cGvHD. However, cGvHD global severity scoring has recently evolved as a powerful prognostic tool for patient survival in the post-NIH consensus era. Current use of the substantially redefined NIH criteria of cGvHD diagnosis and measurements of its severity makes it challenging to interpret prognostic scoring systems generated in the pre-NIH era. Some of the pre-NIH prognostic parameters, however, appear to retain their significance in predicting survival independently from the NIH global severity score. Thus, future analyses of prospective cohorts of patients with cGvHD defined by NIH consensus criteria will be critical in reconciling and integrating various prognostic scoring systems of cGvHD.
Collapse
Affiliation(s)
- A Lazaryan
- Department of Medicine, Division of Hematology, Oncology and Transplantation, University of Minnesota Medical Center, Minneapolis, MN, USA
| | - M Arora
- Department of Medicine, Division of Hematology, Oncology and Transplantation, University of Minnesota Medical Center, Minneapolis, MN, USA
| |
Collapse
|
26
|
Improved prognostic stratification power of CIBMTR risk score with the addition of absolute lymphocyte and eosinophil counts at the onset of chronic GVHD. Ann Hematol 2017; 96:805-815. [PMID: 28214979 DOI: 10.1007/s00277-017-2939-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 01/30/2017] [Indexed: 10/20/2022]
Abstract
The CIBMTR chronic graft-versus-host disease (cGVHD) risk score can be refined and improved for better prognostic stratification. Three hundred and seven consecutive patients diagnosed with cGVHD by the NIH consensus criteria were retrospectively reviewed and had the CIBMTR risk score applied and analyzed. The CIBMTR risk score was successfully validated in our cohort (n = 307). The 3-year overall survival (OS) rates in each risk group (RG) were 82.5 ± 11.3% (RG1), 79.4 ± 3.0% (RG2), 71.8 ± 6.3% (RG3), and 27.3 ± 13.4% (RG4). A significantly lower OS rate and higher non-relapse mortality (NRM) were noted in RG4 compared to the other RGs. However, there were no differences in OS or NRM among RG1 to 3. To improve prognostic stratification power of the CIBMTR risk score, we incorporated the absolute lymphocyte (ALC) and eosinophil count (EC) at time of cGVHD into the CIBMTR risk score. Lower ALC (<1.0 × 109/L, HR 1.94, p = 0.014) and lower EC (<0.5 × 109/L, HR 3.27, p = 0.014) were confirmed as adverse risk factors for OS. Patients were stratified into four revised risk groups (rRG). The 3-year OS rates were 93.3 ± 6.4% (rRG1, score 0-3), 84.9 ± 3.4% (rRG2, score 4-6), 70.9 ± 4.4% (rRG3, score 7-9), and 32.0 ± 1.1% (rRG4, score ≥ 10) (p < 0.001). The 3-year NRM rates were 0.0% (rRG1), 6.7 ± 0.4% (rRG2), 18.4 ± 0.7% (rRG3), and 57.7 ± 5.1% (rRG4) (p < 0.001). The revised CIBMTR risk score was superior to the original CIBMTR risk score for OS (p < 0.001). The revised CIBMTR risk score including ALC and EC at the onset of cGVHD improved the prognostic stratification power of the CIBMTR risk score for long-term outcomes.
Collapse
|
27
|
Bohmann EM, Fehn U, Holler B, Weber D, Holler E, Herr W, Hoffmann P, Edinger M, Wolff D. Altered immune reconstitution of B and T cells precedes the onset of clinical symptoms of chronic graft-versus-host disease and is influenced by the type of onset. Ann Hematol 2016; 96:299-310. [PMID: 27942862 DOI: 10.1007/s00277-016-2881-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 11/14/2016] [Indexed: 10/20/2022]
Abstract
We analyzed lymphocyte subpopulations and cytokines 3 months after allogeneic hematopoietic stem cell transplantation aiming to identify predictive cellular and serum markers for chronic graft-versus-host disease (cGVHD). Samples of 49 patients (pts) (no cGVHD (n = 14), subsequent quiescent onset (n = 16), de novo onset of cGVHD (n = 19)) were analyzed in the absence of active GVHD by flow cytometry and enzyme-linked immunosorbent assay. All mean absolute cell counts are presented as cells per microliter; relative cell counts are presented as percentage of lymphocytes. Pts with subsequent de novo cGVHD had significantly higher relative and absolute counts of CD4+ T cells including higher absolute counts of CD4+ memory T cells (22.36%; 206.55/μl; 136/μl, respectively) compared to pts with subsequent quiescent onset of cGVHD (12.41%; 83.42/μl; 54.3/μl) and pts without cGVHD (10.55%) with regard to relative counts of CD4+ T cells. Similarly, significantly more relative and absolute regulatory T cell numbers (CD4+FOXP3+) were detected in pts with de novo onset of cGVHD (3.08% and 24.63/μl) compared to those in pts without (1.25% and 9.06/μl) or with quiescent onset of cGVHD (1.15% and 6.91/μl). Finally, relative B cell counts, including naïve and memory B cells, were also significantly decreased in pts developing quiescent cGVHD (0.85, 0.73, 0.12% resp.) when compared to pts with de novo onset (5.61, 5.24, 0.38%). The results demonstrate that alterations in immune reconstitution are already present before onset of clinical symptoms and differ between de novo and quiescent onset of disease.
Collapse
Affiliation(s)
- E-M Bohmann
- Department of Internal Medicine III, University Hospital of Regensburg, F.J. Strauss Allee 11, 93053, Regensburg, Germany
| | - U Fehn
- Department of Internal Medicine III, University Hospital of Regensburg, F.J. Strauss Allee 11, 93053, Regensburg, Germany.,Regensburg Center for Interventional Immunology, University of Regensburg, Regensburg, Germany
| | - B Holler
- Department of Internal Medicine III, University Hospital of Regensburg, F.J. Strauss Allee 11, 93053, Regensburg, Germany
| | - D Weber
- Department of Internal Medicine III, University Hospital of Regensburg, F.J. Strauss Allee 11, 93053, Regensburg, Germany
| | - E Holler
- Department of Internal Medicine III, University Hospital of Regensburg, F.J. Strauss Allee 11, 93053, Regensburg, Germany.,Regensburg Center for Interventional Immunology, University of Regensburg, Regensburg, Germany
| | - W Herr
- Department of Internal Medicine III, University Hospital of Regensburg, F.J. Strauss Allee 11, 93053, Regensburg, Germany
| | - P Hoffmann
- Department of Internal Medicine III, University Hospital of Regensburg, F.J. Strauss Allee 11, 93053, Regensburg, Germany.,Regensburg Center for Interventional Immunology, University of Regensburg, Regensburg, Germany
| | - M Edinger
- Department of Internal Medicine III, University Hospital of Regensburg, F.J. Strauss Allee 11, 93053, Regensburg, Germany.,Regensburg Center for Interventional Immunology, University of Regensburg, Regensburg, Germany
| | - D Wolff
- Department of Internal Medicine III, University Hospital of Regensburg, F.J. Strauss Allee 11, 93053, Regensburg, Germany. .,Regensburg Center for Interventional Immunology, University of Regensburg, Regensburg, Germany.
| |
Collapse
|
28
|
Fransolet G, Ehx G, Somja J, Delens L, Hannon M, Muller J, Dubois S, Drion P, Caers J, Humblet-Baron S, Delvenne P, Beguin Y, Conteduca G, Baron F. Azacytidine mitigates experimental sclerodermic chronic graft-versus-host disease. J Hematol Oncol 2016; 9:53. [PMID: 27377819 PMCID: PMC4932697 DOI: 10.1186/s13045-016-0281-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 06/21/2016] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Previous studies have demonstrated that regulatory T cells (Tregs) play a protective role in the pathogenesis of chronic graft-versus-host disease (cGVHD). Tregs constitutively express the gene of the transcription factor Foxp3 whose CNS2 region is heavily methylated in conventional CD4(+) T cells (CD4(+)Tconvs) but demethylated in Tregs. METHODS Here, we assessed the impact of azacytidine (AZA) on cGVHD in a well-established murine model of sclerodermic cGVHD (B10.D2 (H-2d) → BALB/cJ (H-2d)). RESULTS The administration of AZA every 48 h from day +10 to day +30 at the dose of 0.5 mg/kg or 2 mg/kg mitigated chronic GVHD. Further, AZA-treated mice exhibited higher blood and thymic Treg frequencies on day +35, as well as higher demethylation levels of the Foxp3 enhancer and the IL-2 promoter in splenocytes at day +52. Interestingly, Tregs from AZA-treated mice expressed more frequently the activation marker CD103 on day +52. AZA-treated mice had also lower counts of CD4(+)Tconvs and CD8(+) T cells from day +21 to day +35 after transplantation, as well as a lower proportion of CD4(+)Tconvs expressing the Ki67 antigen on day +21 demonstrating an anti-proliferating effect of the drug on T cells. CONCLUSIONS Our results indicate that AZA prevented sclerodermic cGVHD in a well-established murine model of cGVHD. These data might serve as the basis for a pilot study of AZA administration for cGVHD prevention in patients at high risk for cGVHD.
Collapse
Affiliation(s)
- Gilles Fransolet
- Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA)-I3, Laboratory of Hematology, University of Liège, Liège, Belgium
| | - Grégory Ehx
- Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA)-I3, Laboratory of Hematology, University of Liège, Liège, Belgium
| | - Joan Somja
- GIGA-R, Department of Pathology, University of Liège, Liège, Belgium
| | - Loïc Delens
- Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA)-I3, Laboratory of Hematology, University of Liège, Liège, Belgium
| | - Muriel Hannon
- Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA)-I3, Laboratory of Hematology, University of Liège, Liège, Belgium
| | - Joséphine Muller
- Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA)-I3, Laboratory of Hematology, University of Liège, Liège, Belgium
| | - Sophie Dubois
- Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA)-I3, Laboratory of Hematology, University of Liège, Liège, Belgium.,Department of Medicine, Division of Hematology, CHU of Liège, Liège, Belgium
| | - Pierre Drion
- GIGA-R, Animal care unit, University of Liège, Liège, Belgium
| | - Jo Caers
- Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA)-I3, Laboratory of Hematology, University of Liège, Liège, Belgium.,Department of Medicine, Division of Hematology, CHU of Liège, Liège, Belgium.,Department of Hematology, University of Liège, CHU Sart-Tilman, 4000, Liège, Belgium
| | - Stéphanie Humblet-Baron
- Translational Immunology Laboratory, VIB, Leuven, Belgium.,Department of Microbiology and Immunology, KU Leuven-University of Leuven, Leuven, Belgium
| | - Philippe Delvenne
- GIGA-R, Department of Pathology, University of Liège, Liège, Belgium
| | - Yves Beguin
- Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA)-I3, Laboratory of Hematology, University of Liège, Liège, Belgium.,Department of Medicine, Division of Hematology, CHU of Liège, Liège, Belgium.,Department of Hematology, University of Liège, CHU Sart-Tilman, 4000, Liège, Belgium
| | - Giuseppina Conteduca
- Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA)-I3, Laboratory of Hematology, University of Liège, Liège, Belgium
| | - Frédéric Baron
- Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA)-I3, Laboratory of Hematology, University of Liège, Liège, Belgium. .,Department of Medicine, Division of Hematology, CHU of Liège, Liège, Belgium. .,Department of Hematology, University of Liège, CHU Sart-Tilman, 4000, Liège, Belgium.
| |
Collapse
|
29
|
Risk Factors and Outcome of Chronic Graft-versus-Host Disease after Allogeneic Stem Cell Transplantation-Results from a Single-Center Observational Study. Biol Blood Marrow Transplant 2016; 22:1781-1791. [PMID: 27343720 DOI: 10.1016/j.bbmt.2016.06.020] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Accepted: 06/20/2016] [Indexed: 12/22/2022]
Abstract
Chronic graft versus host disease (cGVHD) is the most frequent long-term complication after allogeneic stem cell transplantation (allo-SCT) and results in impaired quality of life and increased long-term morbidity and mortality. We analyzed 243 patients with cGVHD, documented according to the 2005 revised National Institutes of Health consensus criteria, to identify risk factors for the occurrence of cGVHD and outcomes for the patients with cGVHD. Patients without evidence of cGVHD (n = 147) were used as controls. Performing univariate and multivariate Cox regression analyses, we identified prior acute GVHD grades III or IV (hazard ratio [HR], 2.01; P = .005), use of peripheral blood stem cell graft (HR, 2.10; P = .03), and HLA-mismatched allo-SCT from unrelated donor (HR, 1.57; P = .02) as independent risk factors for cGVHD. Performing Kaplan-Meier analyses, progressive compared with de novo and quiescent onset of cGVHD and a platelet count of less than 100/nL compared with more than 100/nL at the time of cGVHD onset were associated with a significantly increased cumulative incidence of transplantation-related mortality (TRM) and significantly decreased overall survival. Furthermore, we found a significantly higher incidence of TRM in patients with severe cGVHD compared with patients without cGVHD (58% versus 11%, P < .0001). However, in subgroup analysis, patients with severe cGVHD and involvement of the lung, liver, or gastrointestinal (GI) tract had a 6.5-fold significantly higher incidence of TRM (72%), whereas patients with severe cGVHD lacking lung, liver, or GI involvement had only a 2.8-fold significantly higher incidence of TRM (31%) compared with patients without cGVHD (11%; P < .0001 and P = .03). Patients without lung, liver, or GI involvement did not have a significantly different TRM compared with patients with moderate cGVHD (31% versus 25%, P = .52). In conclusion, we confirm prior known risk factors for the occurrence of cGVHD and subsequent mortality and we provide evidence that the presence of lung, liver, or GI involvement in patients with severe cGVHD defines a subgroup with high mortality after allo-SCT; however, in the absence of these risk factors, the outcome appears not to be impaired compared with moderate cGVHD.
Collapse
|
30
|
Solomon SR, Sizemore CA, Ridgeway M, Zhang X, Smith J, Brown S, Holland HK, Morris LE, Bashey A. Corticosteroid-Free Primary Treatment of Chronic Extensive Graft-versus-Host Disease Incorporating Rituximab. Biol Blood Marrow Transplant 2015; 21:1576-82. [DOI: 10.1016/j.bbmt.2015.04.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 04/27/2015] [Indexed: 11/17/2022]
|
31
|
Socié G. Disease severity in chronic graft-versus-host disease: doctors' gut feeling versus biostatistics? Haematologica 2015; 99:1534-6. [PMID: 25271311 DOI: 10.3324/haematol.2014.113878] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Affiliation(s)
- Gerard Socié
- Head of the Hematology / Immunology /Oncology Division, Head of the Transplant Program, Inserm U1160, University Paris VII & AP-HP, Hospital Saint Louis, 1 Avenue Claude Vellefaux, Paris, France
| |
Collapse
|
32
|
Jagasia MH, Greinix HT, Arora M, Williams KM, Wolff D, Cowen EW, Palmer J, Weisdorf D, Treister NS, Cheng GS, Kerr H, Stratton P, Duarte RF, McDonald GB, Inamoto Y, Vigorito A, Arai S, Datiles MB, Jacobsohn D, Heller T, Kitko CL, Mitchell SA, Martin PJ, Shulman H, Wu RS, Cutler CS, Vogelsang GB, Lee SJ, Pavletic SZ, Flowers MED. National Institutes of Health Consensus Development Project on Criteria for Clinical Trials in Chronic Graft-versus-Host Disease: I. The 2014 Diagnosis and Staging Working Group report. Biol Blood Marrow Transplant 2015; 21:389-401.e1. [PMID: 25529383 PMCID: PMC4329079 DOI: 10.1016/j.bbmt.2014.12.001] [Citation(s) in RCA: 1743] [Impact Index Per Article: 193.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2014] [Accepted: 12/01/2014] [Indexed: 12/13/2022]
Abstract
The 2005 National Institutes of Health (NIH) Consensus Conference proposed new criteria for diagnosing and scoring the severity of chronic graft-versus-host disease (GVHD). The 2014 NIH consensus maintains the framework of the prior consensus with further refinement based on new evidence. Revisions have been made to address areas of controversy or confusion, such as the overlap chronic GVHD subcategory and the distinction between active disease and past tissue damage. Diagnostic criteria for involvement of mouth, eyes, genitalia, and lungs have been revised. Categories of chronic GVHD should be defined in ways that indicate prognosis, guide treatment, and define eligibility for clinical trials. Revisions have been made to focus attention on the causes of organ-specific abnormalities. Attribution of organ-specific abnormalities to chronic GVHD has been addressed. This paradigm shift provides greater specificity and more accurately measures the global burden of disease attributed to GVHD, and it will facilitate biomarker association studies.
Collapse
Affiliation(s)
- Madan H Jagasia
- Department of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Hildegard T Greinix
- Department of Internal Medicine, Medical University of Vienna, Vienna, Austria
| | - Mukta Arora
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Kirsten M Williams
- Center for Cancer Research National Cancer Institute, National Institutes of Health, Bethesda, Maryland; Department of Blood and Marrow Transplantation, Children's National Health System, Washington, District of Columbia
| | - Daniel Wolff
- Department of Internal Medicine, University of Regensburg, Regensburg, Germany
| | - Edward W Cowen
- Center for Cancer Research National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Jeanne Palmer
- Department of Hematology Oncology/Blood and Marrow Transplant, Mayo Clinic Arizona, Phoenix, Arizona
| | - Daniel Weisdorf
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Nathaniel S Treister
- Department of Surgery, Division of Oral Medicine and Dentistry, Brigham and Women's Hospital, Boston, Massachusetts
| | - Guang-Shing Cheng
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Holly Kerr
- Hematology Department, BC Cancer Agency, Vancouver, British Columbia, Canada
| | - Pamela Stratton
- Pediatric and Reproductive Endocrinology Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
| | - Rafael F Duarte
- Department of Hematology, Institut Catala d'Oncologia, Barcelona, Spain
| | - George B McDonald
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Yoshihiro Inamoto
- Division of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Afonso Vigorito
- Hematology and Hemotherapy Center, Hemocentro Unicamp, Campinas, Sao Paulo, Brazil
| | - Sally Arai
- Department of Blood and Marrow Transplantation, Stanford University Medical Center, Stanford, California
| | - Manuel B Datiles
- The Eye Clinic, National Eye Institute, National Institutes of Health, Bethesda, Maryland
| | - David Jacobsohn
- Department of Blood and Marrow Transplantation, Children's National Health System, Washington, District of Columbia
| | - Theo Heller
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Disease, National Institutes of Health, Bethesda, Maryland
| | - Carrie L Kitko
- Blood and Marrow Transplant Program, University of Michigan Comprehensive Cancer Center, Ann Arbor, Michigan
| | - Sandra A Mitchell
- Department of Applied Research Cancer Control and Population Sciences, National Institutes of Health, Bethesda, Maryland
| | - Paul J Martin
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Howard Shulman
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Roy S Wu
- Cancer Therapy Evaluation Program, National Institutes of Health, Bethesda, Maryland
| | - Corey S Cutler
- Division of Hematologic Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Georgia B Vogelsang
- Oncology Department, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Stephanie J Lee
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Steven Z Pavletic
- Center for Cancer Research National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Mary E D Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington.
| |
Collapse
|
33
|
Margaix-Muñoz M, Bagán JV, Jiménez Y, Sarrión MG, Poveda-Roda R. Graft-versus-host disease affecting oral cavity. A review. J Clin Exp Dent 2015; 7:e138-45. [PMID: 25810826 PMCID: PMC4368002 DOI: 10.4317/jced.51975] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Accepted: 08/31/2014] [Indexed: 12/15/2022] Open
Abstract
Graft versus host disease (GVHD) is one of the most frequent and serious complications of hematopoietic stem cell transplantation, and is regarded as the leading cause of late mortality unrelated to the underlying malignant disease. GVHD is an autoimmune and alloimmune disorder that usually affects multiple organs and tissues, and exhibits a variable clinical course. It can manifest in either acute or chronic form. The acute presentation of GVHD is potentially fatal and typically affects the skin, gastrointestinal tract and liver. The chronic form is characterized by the involvement of a number of organs, including the oral cavity. Indeed, the oral cavity may be the only affected location in chronic GVHD. The clinical manifestations of chronic oral GVHD comprise lichenoid lesions, hyperkeratotic plaques and limited oral aperture secondary to sclerosis. The oral condition is usually mild, though moderate to severe erosive and ulcerated lesions may also be seen. The diagnosis is established from the clinical characteristics, though confirmation through biopsy study is sometimes needed. Local corticosteroids are the treatment of choice, offering overall response rates of close to 50%. Extracorporeal photopheresis and systemic corticosteroids in turn constitute second line treatment. Oral chronic GVHD is not considered a determinant factor for patient survival, which is close to 52% five years after diagnosis of the condition. Key words:Chronic graft-versus-host disease, oral chronic graft-versus-host disease, pathogenics, management, survival.
Collapse
Affiliation(s)
- Maria Margaix-Muñoz
- DDS, PhD. Associate Professor of Oral Medicine. Department of Stomatology, University of Valencia. Valencia, Spain
| | - José V Bagán
- MD, DDS, PhD. Charmain of Oral Medicine. Department of Stomatology, University of Valencia. Head of Stomatology and Maxillofacial Surgery Service, University General Hospital of Valencia. Valencia, Spain
| | - Yolanda Jiménez
- MD, DDS, PhD. Assistant Professor of Stomatology. Department of Stomatology, University of Valencia. Valencia, Spain
| | - María-Gracia Sarrión
- DDS, PhD. Associate Professor of Oral Medicine. Department of Stomatology, University of Valencia. Valencia, Spain
| | - Rafael Poveda-Roda
- MD, DDS, PhD. Staff physician. Stomatology and Maxillofacial Surgery Service. Valencia University General Hospital. Valencia, Spain
| |
Collapse
|
34
|
Flowers MED, Martin PJ. How we treat chronic graft-versus-host disease. Blood 2015; 125:606-15. [PMID: 25398933 PMCID: PMC4304105 DOI: 10.1182/blood-2014-08-551994] [Citation(s) in RCA: 215] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 11/06/2014] [Indexed: 02/07/2023] Open
Abstract
Chronic graft-versus-host disease (GVHD) remains a common and potentially life-threatening complication of allogeneic hematopoietic stem cell transplantation (HCT). The 2-year cumulative incidence of chronic GVHD requiring systemic treatment is ~30% to 40% by National Institutes of Health criteria. The risk of chronic GVHD is higher and the duration of treatment is longer after HCT with mobilized blood cells than with marrow cells. Clinical manifestations can impair activities of daily living and often linger for years. Hematology and oncology specialists who refer patients to centers for HCT are often subsequently involved in the management of chronic GVHD when patients return to their care after HCT. Treatment of these patients can be optimized under shared care arrangements that enable referring physicians to manage long-term administration of immunosuppressive medications and supportive care with guidance from transplant center experts. Keys to successful collaborative management include early recognition in making the diagnosis of chronic GVHD, comprehensive evaluation at the onset and periodically during the course of the disease, prompt institution of systemic and topical treatment, appropriate monitoring of the response, calibration of treatment intensity over time in order to avoid overtreatment or undertreatment, and the use of supportive care to prevent complications and disability.
Collapse
Affiliation(s)
- Mary E D Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center and Department of Medicine, University of Washington, Seattle, WA
| | - Paul J Martin
- Clinical Research Division, Fred Hutchinson Cancer Research Center and Department of Medicine, University of Washington, Seattle, WA
| |
Collapse
|
35
|
Jagasia MH, Greinix HT, Arora M, Williams KM, Wolff D, Cowen EW, Palmer J, Weisdorf D, Treister NS, Cheng GS, Kerr H, Stratton P, Duarte RF, McDonald GB, Inamoto Y, Vigorito A, Arai S, Datiles MB, Jacobsohn D, Heller T, Kitko CL, Mitchell SA, Martin PJ, Shulman H, Wu RS, Cutler CS, Vogelsang GB, Lee SJ, Pavletic SZ, Flowers MED. National Institutes of Health Consensus Development Project on Criteria for Clinical Trials in Chronic Graft-versus-Host Disease: I. The 2014 Diagnosis and Staging Working Group report. BIOLOGY OF BLOOD AND MARROW TRANSPLANTATION : JOURNAL OF THE AMERICAN SOCIETY FOR BLOOD AND MARROW TRANSPLANTATION 2014. [PMID: 25529383 DOI: 10.1016/j.bbmt.2014.12.001.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The 2005 National Institutes of Health (NIH) Consensus Conference proposed new criteria for diagnosing and scoring the severity of chronic graft-versus-host disease (GVHD). The 2014 NIH consensus maintains the framework of the prior consensus with further refinement based on new evidence. Revisions have been made to address areas of controversy or confusion, such as the overlap chronic GVHD subcategory and the distinction between active disease and past tissue damage. Diagnostic criteria for involvement of mouth, eyes, genitalia, and lungs have been revised. Categories of chronic GVHD should be defined in ways that indicate prognosis, guide treatment, and define eligibility for clinical trials. Revisions have been made to focus attention on the causes of organ-specific abnormalities. Attribution of organ-specific abnormalities to chronic GVHD has been addressed. This paradigm shift provides greater specificity and more accurately measures the global burden of disease attributed to GVHD, and it will facilitate biomarker association studies.
Collapse
Affiliation(s)
- Madan H Jagasia
- Department of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Hildegard T Greinix
- Department of Internal Medicine, Medical University of Vienna, Vienna, Austria
| | - Mukta Arora
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Kirsten M Williams
- Center for Cancer Research National Cancer Institute, National Institutes of Health, Bethesda, Maryland; Department of Blood and Marrow Transplantation, Children's National Health System, Washington, District of Columbia
| | - Daniel Wolff
- Department of Internal Medicine, University of Regensburg, Regensburg, Germany
| | - Edward W Cowen
- Center for Cancer Research National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Jeanne Palmer
- Department of Hematology Oncology/Blood and Marrow Transplant, Mayo Clinic Arizona, Phoenix, Arizona
| | - Daniel Weisdorf
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Nathaniel S Treister
- Department of Surgery, Division of Oral Medicine and Dentistry, Brigham and Women's Hospital, Boston, Massachusetts
| | - Guang-Shing Cheng
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Holly Kerr
- Hematology Department, BC Cancer Agency, Vancouver, British Columbia, Canada
| | - Pamela Stratton
- Pediatric and Reproductive Endocrinology Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
| | - Rafael F Duarte
- Department of Hematology, Institut Catala d'Oncologia, Barcelona, Spain
| | - George B McDonald
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Yoshihiro Inamoto
- Division of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Afonso Vigorito
- Hematology and Hemotherapy Center, Hemocentro Unicamp, Campinas, Sao Paulo, Brazil
| | - Sally Arai
- Department of Blood and Marrow Transplantation, Stanford University Medical Center, Stanford, California
| | - Manuel B Datiles
- The Eye Clinic, National Eye Institute, National Institutes of Health, Bethesda, Maryland
| | - David Jacobsohn
- Department of Blood and Marrow Transplantation, Children's National Health System, Washington, District of Columbia
| | - Theo Heller
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Disease, National Institutes of Health, Bethesda, Maryland
| | - Carrie L Kitko
- Blood and Marrow Transplant Program, University of Michigan Comprehensive Cancer Center, Ann Arbor, Michigan
| | - Sandra A Mitchell
- Department of Applied Research Cancer Control and Population Sciences, National Institutes of Health, Bethesda, Maryland
| | - Paul J Martin
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Howard Shulman
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Roy S Wu
- Cancer Therapy Evaluation Program, National Institutes of Health, Bethesda, Maryland
| | - Corey S Cutler
- Division of Hematologic Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Georgia B Vogelsang
- Oncology Department, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Stephanie J Lee
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Steven Z Pavletic
- Center for Cancer Research National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Mary E D Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington.
| |
Collapse
|
36
|
Herrera AF, Kim HT, Bindra B, Jones KT, Alyea EP, Armand P, Cutler CS, Ho VT, Nikiforow S, Blazar BR, Ritz J, Antin JH, Soiffer RJ, Koreth J. A phase II study of bortezomib plus prednisone for initial therapy of chronic graft-versus-host disease. Biol Blood Marrow Transplant 2014; 20:1737-43. [PMID: 25017765 DOI: 10.1016/j.bbmt.2014.06.040] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Accepted: 06/30/2014] [Indexed: 12/21/2022]
Abstract
Chronic graft-versus-host disease (GVHD) induces significant morbidity and mortality after allogeneic hematopoietic stem cell transplantation. Corticosteroids are standard initial therapy, despite limited efficacy and long-term toxicity. Based on our experience using bortezomib as effective acute GVHD prophylaxis, we hypothesized that proteasome-inhibition would complement the immunomodulatory effects of corticosteroids to improve outcomes in chronic GVHD (cGVHD). We undertook a single-arm phase II trial of bortezomib plus prednisone for initial therapy of cGVHD. Bortezomib was administered at 1.3 mg/m(2) i.v. on days 1, 8, 15, and 22 of each 35-day cycle for 3 cycles (15 weeks). Prednisone was dosed at .5 to 1 mg/kg/day, with a suggested taper after cycle 1. All 22 enrolled participants were evaluable for toxicity; 20 were evaluable for response. Bortezomib plus prednisone therapy was well tolerated, with 1 occurrence of grade 3 sensory peripheral neuropathy possibly related to bortezomib. The overall response rate at week 15 in evaluable participants was 80%, including 2 (10%) complete and 14 (70%) partial responses. The organ-specific complete response rate was 73% for skin, 53% for liver, 75% for gastrointestinal tract, and 33% for joint, muscle, or fascia involvement. The median prednisone dose decreased from 50 mg/day to 20 mg/day at week 15 (P < .001). The combination of bortezomib and prednisone for initial treatment of cGVHD is feasible and well tolerated. We observed a high response rate to combined bortezomib and prednisone therapy; however, in this single-arm study, we could not directly measure the impact of bortezomib. Proteasome inhibition may offer benefit in the treatment of cGVHD and should be further evaluated.
Collapse
Affiliation(s)
- Alex F Herrera
- Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Haesook T Kim
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Bhavjot Bindra
- Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Kyle T Jones
- Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Edwin P Alyea
- Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Philippe Armand
- Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Corey S Cutler
- Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Vincent T Ho
- Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Sarah Nikiforow
- Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Bruce R Blazar
- Blood and Marrow Transplantation, University of Minnesota Masonic Cancer Center, Minneapolis, Minnesota
| | - Jerome Ritz
- Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Joseph H Antin
- Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Robert J Soiffer
- Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - John Koreth
- Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, Massachusetts.
| |
Collapse
|
37
|
Inamoto Y, Martin PJ, Storer BE, Palmer J, Weisdorf DJ, Pidala J, Flowers MED, Arora M, Jagasia M, Arai S, Chai X, Pavletic SZ, Vogelsang GB, Lee SJ. Association of severity of organ involvement with mortality and recurrent malignancy in patients with chronic graft-versus-host disease. Haematologica 2014; 99:1618-23. [PMID: 24997150 DOI: 10.3324/haematol.2014.109611] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
The National Institutes of Health global score for chronic graft-versus-host disease was devised by experts but was not based on empirical data. We hypothesized that analysis of prospectively collected data would enable derivation of a more accurate model for estimating mortality risk. We analyzed 574 adult patients with chronic graft-versus-host disease enrolled in a multicenter, observational study, using multivariate time-varying analysis accounting for serial changes in severity of involvement of eight individual organ sites over time. In the training set, severity of skin, mouth, gastrointestinal tract, liver and lung involvement were independently associated with the risk of non-relapse mortality. Weighted mortality points were assigned to individual organs based on the hazard ratios and were summed. The population was divided into three risk groups based on the total mortality points. The three new risk groups were validated in an independent validation set, but did not show better discriminative performance than the National Institutes of Health global score. As compared to a moderate or mild global score, a severe global score was associated with increased risks of non-relapse and overall mortality across time but not with a decreased risk of recurrent malignancy. The National Institutes of Health global score predicts patients' mortality risk throughout the course of their chronic graft-versus-host disease. Further research is required in order to improve outcomes in patients with severe chronic graft-versus-host disease, since their risk of mortality remains elevated.
Collapse
Affiliation(s)
- Yoshihiro Inamoto
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Paul J Martin
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Barry E Storer
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Jeanne Palmer
- Division of Hematology and Oncology, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Daniel J Weisdorf
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, MN, USA
| | - Joseph Pidala
- Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA
| | - Mary E D Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Mukta Arora
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, MN, USA
| | - Madan Jagasia
- Hematology and Stem Cell Transplant Program, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sally Arai
- Division of Blood and Marrow Transplantation, Stanford University Medical Center, Stanford, CA, USA
| | - Xiaoyu Chai
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | | | | | - Stephanie J Lee
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | | |
Collapse
|
38
|
Abstract
Chronic graft-versus-host disease (GVHD) is a frequent and potentially life-threatening complication of allogeneic hematopoietic stem cell transplantation. Increased transplantation of older patients and the more frequent use of unrelated donors has led to increased numbers of patients with this painful complication. Recent advances have been made in understanding the pathophysiology of chronic GVHD and in establishing precise criteria for diagnosis and classification of disease manifestations. These advances will hopefully pave the way for improving both the prophylaxis and treatment of chronic GVHD.
Collapse
|
39
|
Abstract
Chronic graft-versus-host disease (GVHD) is a frequent and potentially life-threatening complication of allogeneic hematopoietic stem cell transplantation. Increased transplantation of older patients and the more frequent use of unrelated donors has led to increased numbers of patients with this painful complication. Recent advances have been made in understanding the pathophysiology of chronic GVHD and in establishing precise criteria for diagnosis and classification of disease manifestations. These advances will hopefully pave the way for improving both the prophylaxis and treatment of chronic GVHD.
Collapse
|
40
|
Moon JH, Sohn SK, Lambie A, Ellis L, Hamad N, Uhm J, Gupta V, Lipton JH, Messner HA, Kuruvilla J, Kim D. Validation of National Institutes of Health Global Scoring System for Chronic Graft-Versus-Host Disease (GVHD) According to Overall and GVHD-Specific Survival. Biol Blood Marrow Transplant 2014; 20:556-63. [DOI: 10.1016/j.bbmt.2014.01.010] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Accepted: 01/10/2014] [Indexed: 02/06/2023]
|
41
|
Human chorionic gonadotropin and indolamine 2,3-dioxygenase in patients with GVHD. Bone Marrow Transplant 2014; 49:800-5. [PMID: 24686986 DOI: 10.1038/bmt.2014.59] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Revised: 02/12/2013] [Accepted: 02/13/2014] [Indexed: 01/21/2023]
Abstract
GVHD is a major complication following allogeneic hematopoietic SCT, and is associated with substantial morbidity and mortality. Based on the results of our previous clinical study with females treated with human chorionic gonadotropin (hCG) as preconditioning therapy for in vitro fertilization, we hypothesized that low-dose hCG stimulates indoleamine-2,3-dioxygenase (IDO), IL 10 and regulatory T cells (Treg), thereby suppressing clinical manifestations of chronic GVHD. Active chronic GVHD localized at skin, subcutaneous tissue, joints or gastrointestinal tract that was refractory or intolerant to glucocorticoid therapy improved substantially in 12 of 20 patients treated with hCG for 8 weeks (off-label), enabling a glucocorticoid dose reduction of 28% (average). Twelve of 19 patients with chronic GVHD of the skin responded to hCG therapy with a reduction of 25% (average) in their total skin score. HCG treatment increased IDO expression at median by sevenfold in peripheral mononuclear cells and IL10 levels in serum up to twofold at median from the pretreatment baseline. Further, an expansion of the Treg cell population was measured in one patient, which is also associated with the induction of tolerance. This novel application of low-dose hCG was well tolerated and is of clinical interest for GVHD treatment.
Collapse
|
42
|
Bacigalupo A. Antithymocyte globulin in the conditioning regimen: why not? Biol Blood Marrow Transplant 2014; 20:597-8. [PMID: 24641827 DOI: 10.1016/j.bbmt.2014.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 03/11/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Andrea Bacigalupo
- Division of Hematology, IRCCS Azienda Ospedaleria Universitaria San Martino-IST, Genoa, Italy.
| |
Collapse
|
43
|
Fraile P, Pilar F, Vazquez L, Lourdes V, Caballero D, Dolores C, Garcia-Cosmes P, Pedro GC, López L, Lucia L, San Miguel J, Jesus SM, Tabernero JM, Jose Matias T. Chronic graft-versus-host disease of the kidney in patients with allogenic hematopoietic stem cell transplant. Eur J Haematol 2013; 91:129-34. [PMID: 23710658 DOI: 10.1111/ejh.12149] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2013] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Allogenic hematopoietic stem cell transplant (allo-HSCT) is the treatment of choice for several hematological diseases. Although rare, patients could present nephrotic syndrome as a clinical feature of chronic graft-versus-host disease (cGVHD). The objective of our study is to screen patients with allo-HSCT to determine who developed a glomerular pathology in the context of cGVHD. PATIENTS AND METHODS We studied patients who underwent allo-HSCT treatment in our center between October 1995 and October 2012 and who developed glomerular pathology. cGVHD was defined as a pathology when it appeared after 100 d post-allo-HSCT. RESULTS Five hundred eighty-three allo-HSCT were performed. The prevalence of cGVHD of the kidney was 1.03%. All patients with cGVHD of the kidney were hosts who received peripheral blood from an identical HLA match donor. GVHD prophylaxis with calcineurin inhibitors plus methotrexate was administered in five cases, and prophylaxis with sirolimus was used in another case. cGVHD of the kidney was seen to appear after the removal of the prophylaxis for GVHD, within 33 ± 11.54 months intervals after allo-HSCT in five patients and in another patient, it appeared despite immunosuppressive therapy being administered. All patients had proteinuria, within 11.82 ± 9.03 g/d ranges. The kidney biopsies revealed membranous glomerulonephritis (four patients), focal segmental glomerulonephritis (one patient) and lupus nephropathy class III (one patient). It seems, immunosuppressive therapy achieved complete remission, within the first year of treatment in four patients. Although in three of them, the proteinuria recurred when we tried to remove the therapy; two patients have recently started treatment, being in partial remission now. CONCLUSIONS cGVHD of the kidney is a rare complication after allo-HSCT, related with the removal of the immunosuppression. Monitoring proteinuria in these patients may be useful. In our patients, a complete remission was achieved; although the removal of the immunosuppression may lead to the appearance of outbreaks. We must reconsider the treatment of glomerular pathology secondary to cGVHD.
Collapse
Affiliation(s)
- Pilar Fraile
- Service of Nephrology, University Hospital of Salamanca, Salamanca, Spain.
| | - Fraile Pilar
- Service of Nephrology, University Hospital of Salamanca, Salamanca, Spain.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
44
|
Michael M, Shimoni A, Nagler A. Novel immunosuppression compounds and experimental therapies for chronic graft-versus-host disease. Acta Haematol 2013; 130:34-43. [PMID: 23392110 DOI: 10.1159/000345836] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2012] [Accepted: 10/30/2012] [Indexed: 01/09/2023]
Abstract
Chronic graft-versus-host disease (GVHD) is a severe complication of allogeneic stem cell transplantation, with a substantial impact on the quality of life and survival, still lacking with regard to an optimal therapeutic strategy. Corticosteroids are considered the standard of care for first-line treatment of chronic GVHD, but only a minority of the patients responds to them durably. Management of steroid-refractory chronic GVHD is not well defined. This review surveys novel treatment strategies, such as therapies that expand regulatory T cells, target B cells or target the processes implicated in fibrosis that may allow more effective control of chronic GVHD in the future. Most therapies are based solely on phase II trials or on retrospective analyses with a wide range of overall responses. Large, well-designed prospective studies are eagerly needed to establish better treatments, as well as valid biomarkers to identify the likelihood of the response to a drug in advance.
Collapse
Affiliation(s)
- Maria Michael
- Hematology Division & Bone Marrow Transplantation, Chaim Sheba Medical Center, Sackler Medical School, Tel Aviv University, Tel Hashomer, Israel
| | | | | |
Collapse
|
45
|
Validation of NIH consensus criteria for diagnosis and severity-grading of chronic graft-versus-host disease. Int J Hematol 2013; 97:263-71. [PMID: 23371545 DOI: 10.1007/s12185-013-1268-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Revised: 12/28/2012] [Accepted: 01/15/2013] [Indexed: 10/27/2022]
Abstract
To validate the National Institutes of Health (NIH) consensus criteria for chronic GVHD, we retrospectively reviewed 143 patients who developed GVHD later than 100 days after allogeneic hematopoietic stem cell transplantation. Their GVHD was reclassified and the severity was graded according to the criteria. Only four patients (2.8 %) could not be reclassified into any type of GVHD. In the remaining 139 patients, reclassified subtypes were late acute GVHD in 52 patients (37.4 %), classic chronic GVHD in 33 (23.7 %), and overlap syndrome in 54 (38.8 %). Of 87 patients with classic chronic GVHD or overlap syndrome, the severity was graded as mild in 21 patients (24 %), moderate in 53 (61 %), and severe in 13 (15 %). The proportions of moderate (70 %) and severe (20 %) disease were significantly higher in patients with overlap syndrome than those with classic chronic GVHD (46 and 6 %, respectively; P < 0.001). Univariate and multivariate analyses of subtypes and severity did not identify any significant prognostic values in any of the transplant outcomes, such as transplant-related mortality, overall survival, GVHD-specific survival, or discontinuation of systemic immunosuppressants. These findings suggest that the NIH consensus criteria are useful for classification of chronic GVHD, but have limited significance in predicting clinical outcomes. The validity of these criteria remains inconclusive, and future prospective studies will be required to refine them.
Collapse
|
46
|
Tecchio C, Mosna F, Andreini A, Paoli L, Di Bella R, de Sabata D, Sorio M, Pizzolo G, Benedetti F. The National Institutes of Health criteria for classification and scoring of chronic graft versus host disease: long-term follow-up of a single center series. Leuk Lymphoma 2012; 54:1020-7. [PMID: 23035648 DOI: 10.3109/10428194.2012.733877] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
We assessed the retrospective applicability and prognostic value of the National Institutes of Health (NIH) classification of chronic graft versus host disease (cGVHD) in 159 consecutive patients after allogeneic hematopoietic stem cell transplant (HSCT). Seventy-four patients (46.5%) were affected by late-acute GVHD (n = 19; 25.7%), classic cGVHD (n = 44; 59.4%) and overlap syndrome (n = 11; 14.9%). Overall, patients with NIH-defined cGVHD (i.e. classic cGVHD and overlap syndrome) had better 10-year overall survival (OS) as compared to patients without GVHD (76.9% vs. 47.4%, p = 0.0002) or with late-acute GVHD (47.4%, p = 0.001). Relapse mortality (RM) was lower in patients with NIH-defined cGVHD than in patients without GVHD (14.5% vs. 38.7%, p = 0.001), but comparable to that of late-acute type (19.4%, p = 0.31). Non-relapse mortality (NRM) was lower in patients with NIH-defined cGVHD as compared to late-acute GVHD (10.0% vs. 41.1%, p = 0.0005), as well as patients without GVHD (22.2%, p = 0.045). At multivariate analysis, NIH-defined cGVHD remained independently predictive for lower RM, but not for NRM. Thus, the new NIH classification identifies two subtypes of GVHD (late-acute and chronic) with different long-term outcomes and impact on RM and NRM.
Collapse
Affiliation(s)
- Cristina Tecchio
- Section of Hematology and Bone Marrow Transplant Unit, Department of Medicine, University of Verona , Verona , Italy
| | | | | | | | | | | | | | | | | |
Collapse
|
47
|
Development of a Population-Based Cost-Effectiveness Model of Chronic Graft-Versus-Host Disease in Spain. Clin Ther 2012; 34:1774-87. [DOI: 10.1016/j.clinthera.2012.06.029] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Revised: 06/21/2012] [Accepted: 06/29/2012] [Indexed: 11/20/2022]
|
48
|
Hymes SR, Alousi AM, Cowen EW. Graft-versus-host disease: part II. Management of cutaneous graft-versus-host disease. J Am Acad Dermatol 2012; 66:535.e1-16; quiz 551-2. [PMID: 22421124 DOI: 10.1016/j.jaad.2011.11.961] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2011] [Revised: 11/18/2011] [Accepted: 11/19/2011] [Indexed: 10/28/2022]
Abstract
Dermatologists are ideally suited to manage the various cutaneous sequelae of graft-versus-host disease (GVHD) outlined in part I of this review. However, the complexity of the patient with GVHD, including comorbidities, potential drug interactions related to polypharmacy, and the lack of evidence-based treatment guidelines, are significant challenges to optimizing patient care. In this section, we will provide an outline for the role of the dermatologist in a multispecialty approach to caring for patients with GVHD.
Collapse
Affiliation(s)
- Sharon R Hymes
- Department of Dermatology, University of Texas MD Anderson Cancer Center, Houston, Texas 77030-4009, USA.
| | | | | |
Collapse
|
49
|
Blazar B, White ES, Couriel D. Understanding chronic GVHD from different angles. Biol Blood Marrow Transplant 2012; 18:S184-8. [PMID: 22226105 DOI: 10.1016/j.bbmt.2011.10.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Bruce Blazar
- Pediatric Blood and Marrow Transplantation Program, University of Minnesota, Ann Arbor, MI 48109, USA
| | | | | |
Collapse
|
50
|
Caballero-Velázquez T, Sánchez-Abarca LI, Gutierrez-Cosio S, Blanco B, Calderon C, Herrero C, Carrancio S, Serrano C, del Cañizo C, San Miguel JF, Pérez-Simón JA. The novel combination of sirolimus and bortezomib prevents graft-versus-host disease but maintains the graft-versus-leukemia effect after allogeneic transplantation. Haematologica 2012; 97:1329-37. [PMID: 22532520 DOI: 10.3324/haematol.2011.058677] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND We have previously shown that bortezomib induces a depletion of alloreactive T cells and allows the expansion of T cells with suppressive properties. In the current study, we analyzed the potential synergistic effect of bortezomib in conjunction with sirolimus in order to reduce-graft-versus-host disease without hampering graft-versus-leukemia effect in the allogeneic transplant setting. DESIGN AND METHODS We evaluated the effect of sirolimus, bortezomib or the combination of both in the proliferation and activation of in vitro stimulated T lymphocytes. Pathways involved in this synergy were also analyzed using Western blot assays. Finally, BALB/c mice receiving C57BL/6 allogeneic donor bone marrow with splenocytes were used to measure in vivo the effect of this novel combination on the risk of graft-versus-host disease. RESULTS The combination of both drugs synergistically inhibited both activation and proliferation of stimulated T cells. Also, the production of Th1 cytokines (IFN γ, IL-2 and TNF) was significantly inhibited. This effect was due, at least in part, to the inhibition of Erk and Akt phosphorylation. In vivo, the combination reduced the risk of graft-versus-host disease without hampering graft-versus-leukemia effect, as shown in mice receiving graft-versus-host disease prophylaxis with sirolimus plus bortezomib being infused with tumor WEHI cells plus C57BL/6 donor BM and splenocytes. CONCLUSIONS The current study reveals a synergistic effect of the combination sirolimus and bortezomib to prevent graft-versus-host disease while maintaining the graft-versus-leukemia effect.
Collapse
Affiliation(s)
- Teresa Caballero-Velázquez
- Servicio de Hematología, Hospital Universitario Virgen del Rocio/CSIC/Universidad de Sevilla, Instituto de Biomedicina de Sevilla (IBIS), Spain
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|