1
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Puckrin R, Shafey M, Storek J. The role of allogeneic hematopoietic cell transplantation for chronic lymphocytic leukemia: A review. Front Oncol 2023; 12:1105779. [PMID: 36741737 PMCID: PMC9889653 DOI: 10.3389/fonc.2022.1105779] [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: 11/23/2022] [Accepted: 12/30/2022] [Indexed: 01/20/2023] Open
Abstract
Although the use of allogeneic hematopoietic cell transplantation (HCT) for chronic lymphocytic leukemia (CLL) has declined with the development of novel targeted agents, it continues to play an important role for eligible patients with high-risk or heavily pretreated CLL who lack other treatment options. CLL is susceptible to a potent graft-versus-leukemia (GVL) effect which produces long-lasting remissions in 30-50% of transplanted patients. While allogeneic HCT is associated with significant risks of graft-versus-host disease (GVHD), infection, and non-relapse mortality (NRM), improvements in patient and donor selection, reduced intensity conditioning (RIC), GVHD prophylaxis, and supportive care have rendered this an increasingly safe and effective procedure in the current era. In this review, we discuss recent advances in allogeneic HCT for CLL, with a focus on the optimal evidence-based strategies to maximize benefit and minimize toxicity of this potentially curative cellular therapy.
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Affiliation(s)
| | | | - Jan Storek
- Department of Hematology and Hematologic Malignancies, Tom Baker Cancer Centre and University of Calgary, Calgary, AB, Canada
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2
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Jinnouchi F, Mori Y, Yoshimoto G, Yamauchi T, Nunomura T, Yurino A, Hayashi M, Yuda J, Shima T, Odawara J, Takashima S, Kamezaki K, Kato K, Miyamoto T, Akashi K, Takenaka K. Incidence of refractory cytomegalovirus infection after allogeneic hematopoietic stem cell transplantation. Int J Hematol 2021; 115:96-106. [PMID: 34652633 DOI: 10.1007/s12185-021-03218-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 09/06/2021] [Accepted: 09/06/2021] [Indexed: 10/20/2022]
Abstract
Post-transplant cytomegalovirus (CMV) disease can be almost completely avoided by current infection control procedures. However, CMV reactivation occurs in more than half of patients, and some patients can develop clinically resistant CMV infections. Whether resistance is due to the host's immune status or a viral resistance mutation is challenging to confirm. Therefore, a prospective observational analysis of refractory CMV infection was conducted in 199 consecutive patients who received allogeneic hematopoietic stem cell transplantation at a single institution. Among them, 143 (72%) patients received anti-CMV drugs due to CMV reactivation, and only 17 (8.5%) exhibited refractory CMV infection. These patients had clinically refractory infection. However, viral genome analysis revealed that only one patient exhibited a mutation associated with the anti-CMV drug resistance. Clinical resistance was mainly correlated with host immune factors, and the incidence of resistance caused by gene mutations was low at the early stage after a transplantation.
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Affiliation(s)
- Fumiaki Jinnouchi
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, 812-8582, Japan
| | - Yasuo Mori
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, 812-8582, Japan
| | - Goichi Yoshimoto
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, 812-8582, Japan
| | - Takuji Yamauchi
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, 812-8582, Japan
| | - Takuya Nunomura
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, 812-8582, Japan
| | - Ayano Yurino
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, 812-8582, Japan
| | - Masayasu Hayashi
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, 812-8582, Japan
| | - Junichiro Yuda
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, 812-8582, Japan
| | - Takahiro Shima
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, 812-8582, Japan
| | - Jun Odawara
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, 812-8582, Japan
| | - Shuichiro Takashima
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, 812-8582, Japan
| | - Kenjiro Kamezaki
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, 812-8582, Japan
| | - Koji Kato
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, 812-8582, Japan
| | - Toshihiro Miyamoto
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, 812-8582, Japan
| | - Koichi Akashi
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, 812-8582, Japan
| | - Katsuto Takenaka
- Department of Hematology, Clinical Immunology and Infectious Diseases, Ehime University Graduate School of Medicine, Toon, Ehime, 791-0295, Japan.
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3
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Goldsmith SR, Abid MB, Auletta JJ, Bashey A, Beitinjaneh A, Castillo P, Chemaly RF, Chen M, Ciurea S, Dandoy CE, Díaz MÁ, Fuchs E, Ganguly S, Kanakry CG, Kanakry JA, Kim S, Komanduri KV, Krem MM, Lazarus HM, Liu H, Ljungman P, Masiarz R, Mulroney C, Nathan S, Nishihori T, Page KM, Perales MA, Taplitz R, Romee R, Riches M. Posttransplant cyclophosphamide is associated with increased cytomegalovirus infection: a CIBMTR analysis. Blood 2021; 137:3291-3305. [PMID: 33657221 PMCID: PMC8351903 DOI: 10.1182/blood.2020009362] [Citation(s) in RCA: 70] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 02/13/2021] [Indexed: 12/20/2022] Open
Abstract
Prior studies suggest increased cytomegalovirus (CMV) infection after haploidentical donor transplantation with posttransplant cyclophosphamide (HaploCy). The role of allograft source and posttransplant cyclophosphamide (PTCy) in CMV infection is unclear. We analyzed the effect of graft source and PTCy on incidence of CMV infection, and effects of serostatus and CMV infection on transplant outcomes. We examined patients reported to the Center for International Blood and Marrow Transplantation Research between 2012 and 2017 who had received HaploCy (n = 757), matched related (Sib) with PTCy (SibCy, n = 403), or Sib with calcineurin inhibitor-based prophylaxis (SibCNI, n = 1605). Cumulative incidences of CMV infection by day 180 were 42%, 37%, and 23%, respectively (P < .001). CMV disease was statistically comparable. CMV infection risk was highest for CMV-seropositive recipients (R+), but significantly higher in PTCy recipients regardless of donor (HaploCy [n = 545]: hazard ratio [HR], 50.3; SibCy [n = 279]: HR, 47.7; SibCNI [n = 1065]: HR, 24.4; P < .001). D+/R- patients also had increased risk for CMV infection. Among R+ or those developing CMV infection, HaploCy had worse overall survival and nonrelapse mortality. Relapse was unaffected by CMV infection or serostatus. PTCy was associated with lower chronic graft-versus-host disease (GVHD) overall, but CMV infection in PTCy recipients was associated with higher chronic GVHD (P = .006). PTCy, regardless of donor, is associated with higher incidence of CMV infection, augmenting the risk of seropositivity. Additionally, CMV infection may negate the chronic GVHD protection of PTCy. This study supports aggressive prevention strategies in all receiving PTCy.
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Affiliation(s)
- Scott R Goldsmith
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St Louis MO
| | - Muhammad Bilal Abid
- Division of Hematology/Oncology and
- Division of Infectious Diseases, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Jeffery J Auletta
- Blood and Marrow Transplant Program and
- Host Defence Program, Division of Hematology/Oncology/Bone Marrow Transplant-Infectious Diseases, Nationwide Children's Hospital, Columbus, OH
| | - Asad Bashey
- Blood and Marrow Transplant Program, Northside Hospital, Atlanta, GA
| | - Amer Beitinjaneh
- Division of Transplantation and Cellular Therapy, University of Miami, Miami, FL
| | - Paul Castillo
- UF Health Shands Children's Hospital, Gainesville, FL
| | | | - Min Chen
- Center for International Blood and Marrow Transplantation Research (CIBMTR), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Stefan Ciurea
- Stem Cell Transplant and Cellular Therapies Service, University of California, Irvine, Orange, CA
| | - Christopher E Dandoy
- Cincinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Miguel Ángel Díaz
- Department of Hematology/Oncology, Hospital Infantil Universitario Niño Jesus, Madrid, Spain
| | - Ephraim Fuchs
- The Sidney Kimmel Comprehensive Cancer Center, John Hopkins, Baltimore, MD
| | - Siddhartha Ganguly
- Division of Hematological Malignancy and Cellular Therapeutics, University of Kansas Health System, Kansas City, KS
| | - Christopher G Kanakry
- Experimental Transplantation and Immunotherapy Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Jennifer A Kanakry
- Experimental Transplantation and Immunotherapy Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Soyoung Kim
- Center for International Blood and Marrow Transplantation Research (CIBMTR), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
- Division of Biostatistics, Institute of Health and Equity, Medical College of Wisconsin, Milwaukee, WI
| | | | - Maxwell M Krem
- Markey Cancer Center, University of Kentucky College of Medicine, Lexington, KY
| | - Hillard M Lazarus
- University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
| | | | - Per Ljungman
- Department of Cellular Therapy and Allogeneic Stem Cell Transplantation, Karolinska University Hospital Huddinge, and
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Richard Masiarz
- Adult Blood and Marrow Stem Cell Transplant Program, Knight Cancer Institute, Oregon Health and Science University, Portland, OR
| | - Carolyn Mulroney
- University of California, San Diego Medical Center, La Jolla, CA
| | - Sunita Nathan
- Section of Bone Marrow Transplant and Cell Therapy, Rush University Medical Center, Chicago, IL
| | - Taiga Nishihori
- Department of Blood & Marrow Transplant and Cellular Immunotherapy (BMT CI), Moffitt Cancer Center, Tampa, FL
| | - Kristin M Page
- Division of Pediatric Blood and Marrow Transplantation, Duke University Medical Center, Durham, NC
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Randy Taplitz
- Division of Infectious Diseases, City of Hope National Medical Center, Duarte, CA
| | - Rizwan Romee
- Stem Cell Transplantation Program, Dana Farber Cancer Institute, Boston, MA; and
| | - Marcie Riches
- Center for International Blood and Marrow Transplantation Research (CIBMTR), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
- Division of Hematology/Oncology, The University of North Carolina at Chapel Hill, Chapel Hill, NC
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4
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Pasic I, Lipton JH, Kim DD, Viswabandya A, Kumar R, Lam W, Law AD, Mattsson J, Michelis FV. Post-transplant cyclophosphamide combined with anti-thymocyte globulin for graft-vs-host disease prophylaxis improves survival and lowers non-relapse mortality in older patients undergoing allogeneic hematopoietic cell transplantation. Ann Hematol 2020; 99:1377-1387. [DOI: 10.1007/s00277-020-04033-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 04/10/2020] [Indexed: 12/19/2022]
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5
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Finazzi MC, Boschini C, Craddock C, Rambaldi A, Ward J, Malladi RK. Characteristics of graft-versus-host disease occurring after alemtuzumab-containing allogeneic stem cell transplants: incidence, organ involvement, risk factors and survival. Br J Haematol 2019; 188:550-559. [PMID: 31713861 DOI: 10.1111/bjh.16200] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 06/25/2019] [Indexed: 11/29/2022]
Abstract
T-cell depletion with alemtuzumab represents an effective form of graft-versus-host disease (GVHD) prophylaxis after allogeneic haematopoietic stem cell transplantation (allo-HSCT); however, little is known regarding the impact of in vivo alemtuzumab on either the incidence or clinical characteristics of acute and chronic GVHD. We therefore studied 201 consecutive adult patients who received an alemtuzumab-based, reduced-intensity conditioned (RIC) allograft. With a median follow-up of 24 months, the cumulative incidence of classic acute and late acute (persistent, recurrent and late onset) GVHD grades II-IV (grades III-IV) was 34% (13%) and 20% (8%) respectively; the cumulative incidence of classic chronic GVHD and overlap syndrome were 4% and 7% respectively. A previous diagnosis of classic acute GVHD is a risk factor for chronic GVHD (hazard ratio 10·91, 95% confidence interval 2·35-50·63, P = 0·0023) while late onset acute GVHD is not a risk factor for later development of chronic GVHD. Unrelated donor transplant is a risk factor for the development of classic acute GVHD but not for late onset or chronic GVHD. In conclusion, this study describes a distinctive pattern of GVHD following alemtuzumab-RIC allografts, identifies the risk factors for GVHD development and provides prognostic information of patients with GVHD.
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Affiliation(s)
- Maria C Finazzi
- Haematology and Bone Marrow Transplant Unit, Azienda Socio Sanitaria Papa Giovanni XXIII, Bergamo, Italy.,Department of Oncology and Haematology, Università degli Studi di Milano, Milan, Italy
| | - Cristina Boschini
- Haematology and Bone Marrow Transplant Unit, Azienda Socio Sanitaria Papa Giovanni XXIII, Bergamo, Italy
| | - Charles Craddock
- Centre for Clinical Haematology, Queen Elizabeth Hospital, Birmingham, UK.,University of Birmingham, Birmingham, UK
| | - Alessandro Rambaldi
- Department of Oncology and Haematology, Università degli Studi di Milano, Milan, Italy
| | - Janice Ward
- Centre for Clinical Haematology, Queen Elizabeth Hospital, Birmingham, UK.,University of Birmingham, Birmingham, UK
| | - Ram K Malladi
- Centre for Clinical Haematology, Queen Elizabeth Hospital, Birmingham, UK.,University of Birmingham, Birmingham, UK
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6
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Krishna BA, Wills MR, Sinclair JH. Advances in the treatment of cytomegalovirus. Br Med Bull 2019; 131:5-17. [PMID: 31580403 PMCID: PMC6821982 DOI: 10.1093/bmb/ldz031] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 08/02/2019] [Accepted: 08/15/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Human cytomegalovirus (HCMV) is a threat to immunologically weak patients. HCMV cannot yet be eliminated with a vaccine, despite recent advances. SOURCES OF DATA Sources of data are recently published research papers and reviews about HCMV treatments. AREAS OF AGREEMENT Current antivirals target the UL54 DNA polymerase and are limited by nephrotoxicity and viral resistance. Promisingly, letermovir targets the HCMV terminase complex and has been recently approved by the FDA and EMA. AREAS OF CONTROVERSY Should we screen newborns for HCMV, and use antivirals to treat sensorineural hearing loss after congenital HCMV infection? GROWING POINTS Growing points are developing drugs against latently infected cells. In addition to small molecule inhibitors, a chemokine-based fusion toxin protein, F49A-FTP, has shown promise in killing both lytically and latently infected cells. AREAS TIMELY FOR DEVELOPING RESEARCH We need to understand what immune responses are required to control HCMV, and how best to raise these immune responses with a vaccine.
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Affiliation(s)
- B A Krishna
- Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.,Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - M R Wills
- Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - J H Sinclair
- Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
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7
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Andersen NS, Bornhäuser M, Gramatzki M, Dreger P, Vitek A, Karas M, Michallet M, Moreno C, van Gelder M, Henseler A, de Wreede LC, Schönland S, Kröger N, Schetelig J. Reduced intensity conditioning regimens including alkylating chemotherapy do not alter survival outcomes after allogeneic hematopoietic cell transplantation in chronic lymphocytic leukemia compared to low-intensity non-myeloablative conditioning. J Cancer Res Clin Oncol 2019; 145:2823-2834. [DOI: 10.1007/s00432-019-03014-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 08/22/2019] [Indexed: 12/16/2022]
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8
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Gene-knocked out chimeric antigen receptor (CAR) T cells: Tuning up for the next generation cancer immunotherapy. Cancer Lett 2018; 423:95-104. [DOI: 10.1016/j.canlet.2018.03.010] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Revised: 03/06/2018] [Accepted: 03/07/2018] [Indexed: 12/15/2022]
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9
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Neumann T, Schneidewind L, Thiele T, Pink D, Schulze M, Schmidt C, Krüger W. No indication of increased infection rates using low-dose alemtuzumab instead of anti-thymocyte globulin as graft-versus-host disease prophylaxis before allogeneic stem cell transplantation. Transpl Infect Dis 2017; 20. [PMID: 29178248 DOI: 10.1111/tid.12822] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2017] [Revised: 08/20/2017] [Accepted: 08/25/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Alemtuzumab as part of the conditioning protocol is effective in reducing graft-versus-host disease (GvHD), but may be associated with increased infection rates, especially when using high doses (ie, 100 mg). METHODS We performed a retrospective, single-center, case-control study analyzing the rates of neutropenic fever, cytomegalovirus (CMV) reactivation, Epstein-Barr virus (EBV) reactivation, clinical manifest toxoplasmosis, and clinical manifest human herpesvirus-6 (HHV6) infection using low-dose alemtuzumab in comparison with anti-thymocyte globulin (ATG) as GvHD prophylaxis before allogeneic stem cell transplantation. Forty-four patients transplanted from unrelated donors between 2001 and 2012 were matched by age, diagnosis, and conditioning regimen and treated either with alemtuzumab 10 mg at day -2 (respectively, 20 mg in case of mismatch transplantation) or ATG. ATG Fresenius (10 mg/kg for 3 days) or Thymoglobulin (2 mg/kg for 3 days) were used. RESULTS Rates of CMV reactivation, EBV reactivation, and clinical manifest HHV6 infection or toxoplasmosis did not differ significantly between both groups until 2 years after transplantation. No case of post-transplant lymphoproliferative disorder was observed. Also, rates of neutropenic fever during inpatient treatment after transplantation did not differ significantly in both groups. CONCLUSION We saw no indication of increased infections rates when using low-dose alemtuzumab as GvHD prophylaxis before allogeneic stem cell transplantation in this retrospective analysis.
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Affiliation(s)
- Thomas Neumann
- Department of Haematology, Oncology, Transplantation, University Medical Centre, Ernst-Moritz-Arndt University, Greifswald, Germany
| | - Laila Schneidewind
- Department of Haematology, Oncology, Transplantation, University Medical Centre, Ernst-Moritz-Arndt University, Greifswald, Germany
| | - Thomas Thiele
- Institute of Immunology and Transfusion Medicine, University Medical Centre, Ernst-Moritz-Arndt University, Greifswald, Germany
| | - Daniel Pink
- Department of Haematology, Oncology, HELIOS Klinikum Bad Saarow, Bad Saarow, Germany
| | - Meike Schulze
- Department of Internal Medicine, Wolgast Hospital, Wolgast, Germany
| | - Christian Schmidt
- Department of Haematology, Oncology, Transplantation, University Medical Centre, Ernst-Moritz-Arndt University, Greifswald, Germany
| | - William Krüger
- Department of Haematology, Oncology, Transplantation, University Medical Centre, Ernst-Moritz-Arndt University, Greifswald, Germany
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10
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Kharfan-Dabaja MA, Moukalled N, Reljic T, El-Asmar J, Kumar A. Reduced intensity is preferred over myeloablative conditioning allogeneic HCT in chronic lymphocytic leukemia whenever indicated: A systematic review/meta-analysis. Hematol Oncol Stem Cell Ther 2017; 11:53-64. [PMID: 29197550 DOI: 10.1016/j.hemonc.2017.11.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 11/05/2017] [Indexed: 02/03/2023] Open
Abstract
Despite availability of new and more effective therapies for chronic lymphocytic leukemia, presently this disease remains incurable unless eligible patients are offered an allogeneic hematopoietic cell transplant. Recent published clinical practice recommendations on behalf of the American Society for Blood and Marrow Transplantation relegated the role of for allogeneic hematopoietic cell transplantation to later stages of the disease. To our knowledge, no randomized controlled trial has been performed to date comparing myeloablative versus reduced intensity conditioning regimens in chronic lymphocytic leukemia patients eligible for the procedure. We performed a systematic review/meta-analysis to assess the efficacy of allogeneic hematopoietic cell transplantation when using myeloablative or reduced intensity conditioning regimens. We report the results in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Based on lower non-relapse mortality and slightly better overall survival rates, reduced intensity conditioning regimens appear to be the most desirable choice whenever the procedure is indicated for this disease. It appears highly unlikely that a RCT will be ever performed comparing reduced intensity vs. myeloablative allogeneic hematopoietic cell transplantation in chronic lymphocytic leukemia. In the absence of such a study, results of this systematic review/meta-analysis represent the best available evidence supporting this recommendation whenever indicated in patients with chronic lymphocytic leukemia.
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Affiliation(s)
- Mohamed A Kharfan-Dabaja
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, USA; Department of Oncologic Sciences, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Nour Moukalled
- Department of Internal Medicine, Division of Hematology-Oncology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Tea Reljic
- Program for Comparative Effectiveness Research, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Jessica El-Asmar
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Ambuj Kumar
- Program for Comparative Effectiveness Research, University of South Florida Morsani College of Medicine, Tampa, FL, USA.
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11
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Montserrat E, Dreger P. Treatment of Chronic Lymphocytic Leukemia With del(17p)/TP53 Mutation: Allogeneic Hematopoietic Stem Cell Transplantation or BCR-Signaling Inhibitors? CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2016; 16 Suppl:S74-81. [DOI: 10.1016/j.clml.2016.02.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 02/09/2016] [Indexed: 12/15/2022]
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12
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Current state of hematopoietic cell transplantation in CLL as smart therapies emerge. Best Pract Res Clin Haematol 2016; 29:54-66. [DOI: 10.1016/j.beha.2016.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2015] [Revised: 06/29/2016] [Accepted: 08/04/2016] [Indexed: 11/20/2022]
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13
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Neumann T, Schneidewind L, Thiele T, Schulze M, Klenner AF, Busemann C, Pink D, Greinacher A, Dölken G, Krüger WH. Reduced platelet transfusions and earlier platelet engraftment using alemtuzumab-based conditioning regimen in allogeneic stem cell transplantation. J Cancer Res Clin Oncol 2016; 142:1091-7. [PMID: 26779644 DOI: 10.1007/s00432-016-2114-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 01/04/2016] [Indexed: 11/24/2022]
Abstract
PURPOSE In patients undergoing allogeneic stem cell transplantation, conditioning regimens containing alemtuzumab instead of anti-thymocyte globulin (ATG) may result in an earlier platelet engraftment and a reduced number of platelet transfusions. METHODS We performed a retrospective, single-center, case-control study analyzing time to engraftment and transfusion needs using alemtuzumab in comparison with ATG as part of conditioning protocol. RESULTS Median values for time to platelet engraftment, number of transfused platelet concentrates and number of transfused red cell concentrates were 12 versus 19.5 days (p < 0.001), 2 versus 14 (p < 0.001) and 6 versus 14.5 (p = 0.003) in the alemtuzumab and ATG group. Time to leukocyte engraftment did not differ with median 15 days in both groups. Patients in the ATG group showed a significant higher decrease in platelet count during conditioning (68 vs. 29 %, p = 0.001), leading to significant lower median platelet counts at the day of stem cell infusion (38 vs. 95.5 Gpt/l, p = 0.008), and higher values for median C-reactive protein after first antibody infusion (69.0 vs. 43.6 mg/l, p = 0.001) compared with alemtuzumab group. Test for significance was done by using Wilcoxon rank-sum test. Subgroup analysis considering the type of ATG used (Thymoglobulin vs. ATG Fresenius) revealed that differences between alemtuzumab and ATG group were more due to effects of ATG Fresenius than Thymoglobulin. CONCLUSIONS The use of alemtuzumab in comparison with ATG as part of the conditioning regimen may be an approach to reduce the number of transfused platelet and red cell concentrates after allogeneic stem cell transplantation.
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Affiliation(s)
- Thomas Neumann
- Department of Hematology, Oncology, Transplantation, University Medical Center, Ernst-Moritz-Arndt University, Greifswald, Germany.
| | - Laila Schneidewind
- Department of Urology, University Medical Center, Ernst-Moritz-Arndt University, Greifswald, Germany
| | - Thomas Thiele
- Institute of Immunology and Transfusion Medicine, University Medical Center, Ernst-Moritz-Arndt University, Greifswald, Germany
| | - Meike Schulze
- Department of Hematology, Oncology, Transplantation, University Medical Center, Ernst-Moritz-Arndt University, Greifswald, Germany
| | - Anne F Klenner
- Department of Hematology, Oncology, Transplantation, University Medical Center, Ernst-Moritz-Arndt University, Greifswald, Germany
| | - Christoph Busemann
- Department of Hematology, Oncology, Transplantation, University Medical Center, Ernst-Moritz-Arndt University, Greifswald, Germany
| | - Daniel Pink
- Department of Hematology, Oncology, HELIOS Klinikum Bad Saarow, Bad Saarow, Germany
| | - Andreas Greinacher
- Institute of Immunology and Transfusion Medicine, University Medical Center, Ernst-Moritz-Arndt University, Greifswald, Germany
| | - Gottfried Dölken
- Department of Hematology, Oncology, Transplantation, University Medical Center, Ernst-Moritz-Arndt University, Greifswald, Germany
| | - William H Krüger
- Department of Hematology, Oncology, Transplantation, University Medical Center, Ernst-Moritz-Arndt University, Greifswald, Germany
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14
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Poirot L, Philip B, Schiffer-Mannioui C, Le Clerre D, Chion-Sotinel I, Derniame S, Potrel P, Bas C, Lemaire L, Galetto R, Lebuhotel C, Eyquem J, Cheung GWK, Duclert A, Gouble A, Arnould S, Peggs K, Pule M, Scharenberg AM, Smith J. Multiplex Genome-Edited T-cell Manufacturing Platform for "Off-the-Shelf" Adoptive T-cell Immunotherapies. Cancer Res 2015; 75:3853-64. [PMID: 26183927 DOI: 10.1158/0008-5472.can-14-3321] [Citation(s) in RCA: 413] [Impact Index Per Article: 45.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 06/10/2015] [Indexed: 12/28/2022]
Abstract
Adoptive immunotherapy using autologous T cells endowed with chimeric antigen receptors (CAR) has emerged as a powerful means of treating cancer. However, a limitation of this approach is that autologous CAR T cells must be generated on a custom-made basis. Here we show that electroporation of transcription activator-like effector nuclease (TALEN) mRNA allows highly efficient multiplex gene editing in primary human T cells. We use this TALEN-mediated editing approach to develop a process for the large-scale manufacturing of T cells deficient in expression of both their αβ T-cell receptor (TCR) and CD52, a protein targeted by alemtuzumab, a chemotherapeutic agent. Functionally, T cells manufactured with this process do not mediate graft-versus-host reactions and are rendered resistant to destruction by alemtuzumab. These characteristics enable the administration of alemtuzumab concurrently or prior to engineered T cells, supporting their engraftment. Furthermore, endowing the TALEN-engineered cells with a CD19 CAR led to efficient destruction of CD19(+) tumor targets even in the presence of the chemotherapeutic agent. These results demonstrate the applicability of TALEN-mediated genome editing to a scalable process, which enables the manufacturing of third-party CAR T-cell immunotherapies against arbitrary targets. As such, CAR T-cell immunotherapies can therefore be used in an "off-the-shelf" manner akin to other biologic immunopharmaceuticals
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Affiliation(s)
| | - Brian Philip
- Department of Haematology, UCL Cancer Institute, University College London, London, United Kingdom
| | | | | | | | | | | | | | | | | | | | | | - Gordon Weng-Kit Cheung
- Department of Haematology, UCL Cancer Institute, University College London, London, United Kingdom
| | | | | | | | - Karl Peggs
- Department of Haematology, UCL Cancer Institute, University College London, London, United Kingdom
| | - Martin Pule
- Department of Haematology, UCL Cancer Institute, University College London, London, United Kingdom
| | - Andrew M Scharenberg
- Department of Pediatrics, University of Washington, Seattle Children's Research Institute, Seattle, Washington
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15
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Outcomes of Cord Blood Transplantation Using Reduced-Intensity Conditioning for Chronic Lymphocytic Leukemia: A Study on Behalf of Eurocord and Cord Blood Committee of Cellular Therapy and Immunobiology Working Party, Chronic Malignancies Working Party of the European Society for Blood and Marrow Transplantation, and the Societé Française de Greffe de Moelle et Therapie Cellulaire. Biol Blood Marrow Transplant 2015; 21:1515-23. [PMID: 25958294 DOI: 10.1016/j.bbmt.2015.04.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 04/29/2015] [Indexed: 01/04/2023]
Abstract
Outcomes after umbilical cord blood transplantation (UCBT) for chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL) are unknown. We analyzed outcomes of 68 patients with poor-risk CLL/SLL who underwent reduced-intensity (RIC) UCBT from 2004 to 2012. The median age was 57 years and median follow-up 36 months; 17 patients had del 17p/p53mutation, 19 patients had fludarabine-refractory disease, 11 relapsed after autologous stem cell transplantation, 8 had diagnosis of prolymphocytic leukemia, 4 had Richter syndrome, and 8 underwent transplantation with progressive or refractory disease. The most common RIC used was cyclophosphamide, fludarabine, and total body irradiation (TBI) in 82%; 15 patients received antithymocyte globulin. Most of the cord blood grafts were HLA mismatched and 76% received a double UCBT. Median total nucleated cells collected was 4.7 × 10(7)/kg. The cumulative incidences (CI) of neutrophil and platelet engraftment were 84% and 72% at 60 and 180 days respectively; day 100 graft-versus-host disease (GVHD) (grade II to IV) was 43% and 3-year chronic GVHD was 32%. The CI of relapse, nonrelapse mortality, overall survival, and progression-free survival (PFS) at 3 years were 16%, 39%, 54%, and 45%, respectively. Fludarabine-sensitive disease at transplantation and use of low-dose TBI regimens were associated with acceptable PFS. In conclusion, use of RIC-UCBT seems to be feasible in patients with poor-risk CLL/SLL and improved outcomes were observed in patients with fludarabine-sensitive disease who received low-dose TBI regimens.
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16
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Marsh RA, Rao MB, Gefen A, Bellman D, Mehta PA, Khandelwal P, Chandra S, Jodele S, Myers KC, Grimley M, Dandoy C, El-Bietar J, Kumar AR, Leemhuis T, Zhang K, Bleesing JJ, Jordan MB, Filipovich AH, Davies SM. Experience with Alemtuzumab, Fludarabine, and Melphalan Reduced-Intensity Conditioning Hematopoietic Cell Transplantation in Patients with Nonmalignant Diseases Reveals Good Outcomes and That the Risk of Mixed Chimerism Depends on Underlying Disease, Stem Cell Source, and Alemtuzumab Regimen. Biol Blood Marrow Transplant 2015; 21:1460-70. [PMID: 25865646 DOI: 10.1016/j.bbmt.2015.04.009] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Accepted: 04/02/2015] [Indexed: 10/23/2022]
Abstract
Alemtuzumab, fludarabine, and melphalan reduced-intensity conditioning (RIC) regimens are increasingly used for the hematopoietic cell transplantation (HCT) of pediatric and young adult patients with nonmalignant diseases. Early experience suggests that these regimens are associated with good survival but a high incidence of mixed chimerism, which we have previously shown to be influenced by the alemtuzumab schedule. We hypothesized that the underlying diagnosis and donor graft source would also affect the development of mixed chimerism and that the majority of patients would survive RIC HCT without graft loss. To examine this, we conducted a retrospective study of 206 patients with metabolic diseases, non-Fanconi anemia marrow failure disorders, and primary immune deficiencies who underwent 210 consecutive RIC HCT procedures at Cincinnati Children's Hospital. Ninety-seven percent of the patients engrafted. Mixed donor and recipient chimerism developed in 46% of patients. Patients with marrow failure had a low risk of mixed chimerism (hazard ratio [HR], .208; 95% confidence interval [CI], .061 to .709; P = .012). The risk of mixed chimerism was high in patients who received a cord blood graft (HR, 3.122; 95% CI, 1.236 to 7.888; P = .016). As expected, patients who received a proximal or higher dose per kilogram of alemtuzumab schedule also experienced higher rates of mixed chimerism (all HR > 2, all P < .05). At the time of last follow-up (median, 654 days; range, 13 to 3337), over 75% of patients had greater than 90% whole blood donor chimerism. A second transplantation was performed in 5% of patients. Three-year survival without retransplantation was 84% (95% CI, 71% to 98%) for patients who underwent transplantation with an HLA-matched sibling donor. Survival without retransplantation was negatively affected by lack of a matched related donor, increasing age, and development of grades III and IV acute graft-versus-host disease. We conclude that alemtuzumab, fludarabine, and melphalan RIC HCT offers good results for many patients and that the risk of developing mixed chimerism is influenced by underlying diagnosis, graft source, and alemtuzumab dosing.
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Affiliation(s)
- Rebecca A Marsh
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
| | - Marepalli B Rao
- Division of Epidemiology and Biostatistics, Department of Environmental Health, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Aharon Gefen
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Denise Bellman
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Parinda A Mehta
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Pooja Khandelwal
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Sharat Chandra
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Sonata Jodele
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kasiani C Myers
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Michael Grimley
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Christopher Dandoy
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Javier El-Bietar
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Ashish R Kumar
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Tom Leemhuis
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kejian Zhang
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jack J Bleesing
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Michael B Jordan
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Division of Immunobiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Alexandra H Filipovich
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Stella M Davies
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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17
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Jardine L, Publicover A, Bigley V, Hale G, Pearce K, Dickinson A, Jackson G, Collin M. A comparative study of reduced dose alemtuzumab in matched unrelated donor and related donor reduced intensity transplants. Br J Haematol 2015; 168:874-81. [PMID: 25640315 PMCID: PMC4737113 DOI: 10.1111/bjh.13239] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Accepted: 10/15/2014] [Indexed: 11/29/2022]
Abstract
In vivo T cell depletion with 100 mg alemtuzumab prevents graft-versus-host disease (GVHD) in reduced intensity conditioned transplants but is associated with delayed immune reconstitution, a higher risk of infection and relapse. De-escalation studies have shown that a reduced dose of 30 mg is as effective as 100 mg in preventing GVHD in matched related donor (MRD) transplants. Dose reduction in matched unrelated donor (MUD) transplants is feasible but the comparative efficacy of alemtuzumab in this setting is not known and opinions vary widely concerning the optimal level of GVHD prophylaxis that should be achieved. Through retrospective analysis we made an objective comparison of MUD transplants receiving an empirically reduced dose of 60 mg, with MRD transplants receiving a 30 mg dose. We observed proportionate levels of alemtuzumab according to dose but an inverse relationship with body surface area particularly in MRD transplants. MUD transplants experienced more acute and chronic GVHD, higher T cell chimerism, more sustained use of ciclosporin and less need for donor lymphocyte infusion than MRD transplants. Thus, doubling the dose of alemtuzumab to 60 mg did not provide equivalent prevention of GVHD after MUD transplant although there was no difference in non-relapse mortality or survival compared with MRD transplants.
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Affiliation(s)
- Laura Jardine
- Institute of Cellular MedicineNewcastle UniversityNewcastle upon TyneUK
- Newcastle upon Tyne Hospitals NHS Foundation TrustNewcastle upon TyneUK
| | | | - Venetia Bigley
- Institute of Cellular MedicineNewcastle UniversityNewcastle upon TyneUK
- Newcastle upon Tyne Hospitals NHS Foundation TrustNewcastle upon TyneUK
| | | | - Kim Pearce
- Institute of Cellular MedicineNewcastle UniversityNewcastle upon TyneUK
| | - Anne Dickinson
- Institute of Cellular MedicineNewcastle UniversityNewcastle upon TyneUK
| | - Graham Jackson
- Newcastle upon Tyne Hospitals NHS Foundation TrustNewcastle upon TyneUK
| | - Matthew Collin
- Institute of Cellular MedicineNewcastle UniversityNewcastle upon TyneUK
- Newcastle upon Tyne Hospitals NHS Foundation TrustNewcastle upon TyneUK
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18
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Kharfan-Dabaja MA. Predictors of outcome in reduced intensity allogeneic hematopoietic cell transplantation for chronic lymphocytic leukemia: summarizing the evidence and highlighting the limitations. Immunotherapy 2015; 7:47-56. [DOI: 10.2217/imt.14.100] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Several studies have reported the prognostic significance of various clinical, genetic, biologic and molecular markers on postallogeneic hematopoietic cell transplantation outcomes such as nonrelapse mortality, relapse and survival. Notwithstanding limitations, existence of refractory/progressive disease at allografting yields worse nonrelapse mortality, more relapse and inferior overall survival. Advanced age results in higher nonrelapse mortality and increased relapse risk. Presence of poor-risk cytogenetics increases post-transplant relapse risk, but its impact on overall survival appears controversial. Developing prognostic models using large multicenter data could help better understand the effect of these and other variables on post-transplant outcomes. Newly discovered mutations as well as response (or not) to new potent therapies, such as ibrutinib or others, would likely be incorporated in such models.
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Affiliation(s)
- Mohamed A Kharfan-Dabaja
- Department of Blood & Marrow Transplantation, H Lee Moffitt Cancer Center, 12902 Magnolia Drive, FOB-3, Tampa, FL 33612, USA
- Department of Oncologic Sciences, University of South Florida College of Medicine, 12901 Bruce B Downs Boulevard, Tampa, FL 33612, USA
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19
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Sauter CS, Chou JF, Papadopoulos EB, Perales MA, Jakubowski AA, Young JW, Scordo M, Giralt S, Castro-Malaspina H. A prospective study of an alemtuzumab containing reduced-intensity allogeneic stem cell transplant program in patients with poor-risk and advanced lymphoid malignancies. Leuk Lymphoma 2014; 55:2739-47. [PMID: 24528216 DOI: 10.3109/10428194.2014.894185] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Reduced-intensity conditioning (RIC) regimens for allogeneic stem cell transplant (allo-SCT) have used alemtuzumab to abrogate the risk of graft-versus-host disease (GVHD). Thirty-eight patients with advanced lymphoma underwent a prospective phase II study of melphalan, fludarabine and alemtuzumab containing RIC allo-SCT from 20 matched related and 18 unrelated donors with cyclosporine-A as GVHD prophylaxis. The cumulative incidence of grade II-IV acute GVHD at 3 months was 10.5% and three evaluable patients experienced chronic GVHD. Progression-free (PFS) and overall (OS) survival at 5 years was 25% (95% confidence interval [CI]: 13-40%) and 44% (95% CI: 28-59%), respectively. Previous high-dose therapy and autologous stem cell transplant (HDT-ASCT) and elevated lactate dehydrogenase (LDH) at the time of allo-SCT resulted in inferior OS. Within this cohort of patients with high-risk lymphoma, alemtuzumab containing RIC resulted in a low risk of GVHD and a high incidence of progression of disease, especially in those with poor-risk features defined by elevated LDH pre-allo-SCT and previous HDT-ASCT.
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Affiliation(s)
- Craig S Sauter
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center , New York, NY , USA
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20
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Bryant A, Nivison-Smith I, Pillai ES, Kennedy G, Kalff A, Ritchie D, George B, Hertzberg M, Patil S, Spencer A, Fay K, Cannell P, Berkahn L, Doocey R, Spearing R, Moore J. Fludarabine Melphalan reduced-intensity conditioning allotransplanation provides similar disease control in lymphoid and myeloid malignancies: analysis of 344 patients. Bone Marrow Transplant 2013; 49:17-23. [DOI: 10.1038/bmt.2013.142] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Revised: 06/27/2013] [Accepted: 08/01/2013] [Indexed: 11/09/2022]
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21
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Shaffer BC, Modric M, Stetler-Stevenson M, Arthur DC, Steinberg SM, Liewehr DJ, Fowler DH, Gale RP, Bishop MR, Pavletic SZ. Rapid complete donor lymphoid chimerism and graft-versus-leukemia effect are important in early control of chronic lymphocytic leukemia. Exp Hematol 2013; 41:772-8. [PMID: 23689118 PMCID: PMC3769491 DOI: 10.1016/j.exphem.2013.04.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Revised: 04/12/2013] [Accepted: 04/18/2013] [Indexed: 01/29/2023]
Abstract
Eradication of minimal residual disease (MRD) after allotransplantation in persons with chronic lymphocytic leukemia (CLL) is associated with lower rates of relapse. Rapid engraftment of donor lymphocyte elements can contribute to MRD control, but it remains unclear whether this strategy will benefit patients. In this study, we report the incidence of MRD eradication and graft-versus-host disease (GvHD) in persons with rapid versus later donor T lymphocyte engraftment after lymphodepleting chemotherapy and reduced intensity conditioning (RIC) allotransplantation. Twenty-seven subjects received lymphodepleting chemotherapy to facilitate donor engraftment followed by fludarabine and cyclophosphamide RIC and a blood cell allograft. MRD was monitored by multicolor flow cytometry after transplantation. Complete donor T lymphoid chimerism (TLC) and myeloid chimerism (MC) were achieved in 25 subjects at a median of 28 days (range, 14-60 days) and 21 days (range, 14-180 days), respectively. Achieving complete donor TLC by day 14 versus day 28 or later correlated with occurrence of grade 2 or higher acute GvHD (90% [95% confidence interval {CI}, 78-100%] versus 35% [95% CI, 16-54%]; p = 0.014) and better control of MRD in the bone marrow at day 100, median 0% (range, 0-0.1%) versus 8.5% (range, 0-92%; p = 0.016). Among 11 persons with early donor TLC, none had progressive disease, and seven died of treatment -related mortality (TRM). In persons with later development of TLC, 8 of 16 had progressive disease and 2 died of TRM. Time to donor myeloid chimerism had no effect on outcomes. Rapid establishment of donor TLC resulted in more complete eradication of early MRD, but greater incidence of acute GvHD and TRM in persons with CLL undergoing RIC allotransplantation.
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Affiliation(s)
- Brian C Shaffer
- Experimental Transplantation and Immunology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA.
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22
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Zhang L, Zhang YZ. Reduced-intensity conditioning allogeneic stem cell transplantation in malignant lymphoma: current status. Cancer Biol Med 2013; 10:1-9. [PMID: 23691438 PMCID: PMC3643681 DOI: 10.7497/j.issn.2095-3941.2013.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Accepted: 02/20/2013] [Indexed: 11/23/2022] Open
Abstract
Allogeneic stem cell transplantation (allo-SCT) is a potential cure for patients with malignant lymphoma that is based on the graft-versus-lymphoma (GVL) effect. Myeloablative conditioning allo-SCT is associated with high mortality and morbidity, particularly in patients older than 45 years, heavily pretreated patients (prior hematopoietic stem cell transplantation or more than two lines of conventional chemotherapy) or patients affected by other comorbidities. Therefore, conventional allo-SCT is restricted to younger patients (<50 to 55 years) in good physical condition. Over the last decade, allo-SCT with reduced-intensity conditioning (RIC-allo-SCT) has been increasingly used to treat patients with lymphoma. This treatment is associated with lower toxicity and substantial decrease in the incidence of transplant-related mortality, and has the potential to lead to long-term remissions. Therefore, patients who are not suitable to undergo conventional allo-SCT can benefit from the potentially curative GVL effects of allo-SCT. Although RIC-allo-SCT has improved the survival of lymphoma patients, high post-transplant relapse rates or disease progression mainly results in treatment failure. Thus, further improvement is clearly needed. The role and timing of RIC-allo-SCT in the treatment of lymphoma remains unclear. Therefore, more prospective studies should clarify the effectiveness of this method. In this article, we review the recent literature on RIC-allo-SCT as a treatment for major lymphoma subtypes. Areas that require further investigation in the context of clinical trials are also highlighted.
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Affiliation(s)
- Le Zhang
- Department of Hematology, Tianjin Medical University Cancer Institute and Hospital, Key Laboratory of Cancer Prevention and Therapy, Ministry of Education; Key Laboratory of Cancer Prevention and Therapy, Tianjin; State Key Laboratory of Breast Cancer Research, Tianjin 300070, China
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23
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Kanda Y, Oshima K, Kako S, Fukuda T, Uchida N, Miyamura K, Kondo Y, Nakao S, Nagafuji K, Miyamoto T, Kurokawa M, Okoshi Y, Chiba S, Ohashi Y, Takaue Y, Taniguchi S. In vivo T-cell depletion with alemtuzumab in allogeneic hematopoietic stem cell transplantation: Combined results of two studies on aplastic anemia and HLA-mismatched haploidentical transplantation. Am J Hematol 2013; 88:294-300. [PMID: 23450467 DOI: 10.1002/ajh.23392] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Revised: 01/03/2013] [Accepted: 01/08/2013] [Indexed: 11/08/2022]
Abstract
We evaluated the efficacy of in vivo T-cell depletion with alemtuzumab in two prospective studies according to the International Conference on Harmonisation (ICH)-Good Clinical Practice (ICH-GCP) guidelines; one was for patients with aplastic anemia (AA study) and the other was for patients who were undergoing hematopoietic stem cell transplantation (HSCT) from a 2- or 3-antigen-mismatched haploidentical donor (MM study). The final dose of alemtuzumab in these studies was 0.16 mg/kg/day for 6 days. At this dose, all of the 12 and 11 patients in the AA and MM studies, respectively, achieved initial engraftment and the incidences of Grade II-IV acute graft-versus-host disease (GVHD) were 0% and 18%. While cytomegalovirus (CMV) frequently reactivated, none of the patients developed fatal CMV disease. Transplantation-related mortality within 1 year after HSCT was observed in only two and one patients, respectively. The numbers of CD4+ and CD8+ T-cells and T-cell receptor rearrangement excision circles remained low within 1 year after HSCT. These findings suggest that the use of alemtuzumab at this dose in a conditioning regimen enables safe allogeneic HSCT even from a 2- or 3-antigen-mismatched donor. However, the use of a lower dose of alemtuzumab should be explored in future studies to accelerate immune recovery after HSCT.
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Affiliation(s)
- Yoshinobu Kanda
- Division of Hematology, Saitama Medical Center; Jichi Medical University; Saitama Japan
| | - Kumi Oshima
- Division of Hematology, Saitama Medical Center; Jichi Medical University; Saitama Japan
| | - Shinichi Kako
- Division of Hematology, Saitama Medical Center; Jichi Medical University; Saitama Japan
| | - Takahiro Fukuda
- Stem Cell Transplantation Division; National Cancer Center Hospital; Tokyo Japan
| | - Naoyuki Uchida
- Department of Hematology; Toranomon Hospital; Minato-Ku Tokyo Japan
| | - Koichi Miyamura
- Department of Hematology; Japanese Red Cross Nagoya First Hospital; Nagoya Japan
| | - Yukio Kondo
- Cellular Transplantation Biology; Kanazawa University Graduate School of Medical Science; Japan
| | - Shinji Nakao
- Cellular Transplantation Biology; Kanazawa University Graduate School of Medical Science; Japan
| | - Koji Nagafuji
- Division of Hematology and Oncology, Department of Medicine; Kurume University School of Medicine; Japan
| | - Toshihiro Miyamoto
- Department of Medicine and Biosystemic Science; Kyushu University Graduate School of Medical Sciences; Fukuoka Japan
| | - Mineo Kurokawa
- Department of Hematology and Oncology, Graduate School of Medicine; University of Tokyo; Tokyo Japan
| | - Yasushi Okoshi
- Department of Hematology; University of Tsukuba; Tsukuba Japan
| | - Shigeru Chiba
- Department of Hematology; University of Tsukuba; Tsukuba Japan
| | - Yasuo Ohashi
- Department of Biostatistics, School of Public Health; University of Tokyo; Tokyo Japan
| | - Yoichi Takaue
- Institute for Research, St. Luke's International Hospital; Tokyo Japan
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24
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Richardson SE, Khan I, Rawstron A, Sudak J, Edwards N, Verfuerth S, Fielding AK, Goldstone A, Kottaridis P, Morris E, Benjamin R, Peggs KS, Thomson KJ, Vandenberghe E, Mackinnon S, Chakraverty R. Risk-stratified adoptive cellular therapy following allogeneic hematopoietic stem cell transplantation for advanced chronic lymphocytic leukaemia. Br J Haematol 2013; 160:640-8. [PMID: 23293871 DOI: 10.1111/bjh.12197] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Accepted: 11/05/2012] [Indexed: 12/14/2022]
Abstract
Following reduced intensity-conditioned allogeneic stem cell transplantation (RIC allo-SCT) for chronic lymphocytic leukaemia (CLL), there is an inverse relationship between relapse and extensive chronic graft-versus-host disease (GVHD). We evaluated outcomes in 50 consecutive patients with CLL using the approach of alemtuzumab-based RIC allo-SCT and pre-emptive donor lymphocyte infusions (DLI) for mixed chimerism or minimal residual disease (MRD), with the intention of reducing the risk of GVHD. Forty two patients had high-risk disease, including 30% with 17p deletion (17p-). Of patients who were not in complete remission (CR) entering transplant, 83% subsequently achieved MRD-negative CR. Both MRD detection and uncorrected mixed chimerism were associated with greater risks of treatment failure. Nine of sixteen patients receiving DLI for persistent or relapsed disease subsequently attained MRD-negative CR. With a median follow-up of 4.3 years, 4-year current progression-free survival was 65% and overall survival was 75% (60% and 61% in respectively, patients with 17p-). DLI was associated with a 29% cumulative incidence of severe GVHD and mortality of 6.4%. At last follow-up, 83% of patients in CR were off all immunosuppressive treatment. In conclusion, the directed delivery of allogeneic cellular therapy has the potential to induce durable remissions in high-risk CLL without incurring excessive GVHD.
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25
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Oscier D, Dearden C, Eren E, Erem E, Fegan C, Follows G, Hillmen P, Illidge T, Matutes E, Milligan DW, Pettitt A, Schuh A, Wimperis J. Guidelines on the diagnosis, investigation and management of chronic lymphocytic leukaemia. Br J Haematol 2012; 159:541-64. [PMID: 23057493 DOI: 10.1111/bjh.12067] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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26
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Jaglowski SM, Byrd JC. Novel therapies and their integration into allogeneic stem cell transplant for chronic lymphocytic leukemia. Biol Blood Marrow Transplant 2012; 18:S132-8. [PMID: 22226097 DOI: 10.1016/j.bbmt.2011.11.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Over the past decade, numerous advances have been made in elucidating the biology of and improving treatment for chronic lymphocytic leukemia (CLL). These studies have led to identification of select CLL patient groups that generally have short survival dating from time of treatment or initial disease relapse who benefit from more aggressive therapeutic interventions. Allogeneic transplantation represents the only potentially curative option for CLL, but fully ablative regimens applied in the past have been associated with significant morbidity and mortality. Reduced-intensity preparative regimens has made application of allogeneic transplant to CLL patients much more feasible and increased the number of patients proceeding to this modality. Arising from this has been establishment of guidelines where allogeneic stem cell transplantation should be considered in CLL. Introduction of new targeted therapies with less morbidity, which can produce durable remissions has the potential to redefine where transplantation is initiated in CLL. This review briefly summarizes the field of allogeneic stem cell transplant in CLL and the interface of new therapeutics with this modality.
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Affiliation(s)
- Samantha M Jaglowski
- Department of Internal Medicine, Division of Hematology and Oncology, Comprehensive Cancer Center at The Ohio State University, Columbus, Ohio, USA
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Peggs KS. Chimeric antigen receptors: a costimulatory boost promotes immunological memory to B-cell malignancies. Expert Rev Anticancer Ther 2011; 11:1667-70. [PMID: 22050014 DOI: 10.1586/era.11.159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Cellular immunotherapies offer perhaps the best proof of concept of the ability of immune cells to eradicate malignancy. However, the majority of these data derive from either the use of expanded tumor-infiltrating lymphocytes to treat metastatic melanoma or the use of donor lymphocytes in relapsed hematological malignancies following allogeneic hematopoietic stem cell transplantation. Genetic engineering of T cells to redirect specificity against tumor-associated antigens potentially overcomes one of the major hurdles to more widespread application. Despite early evidence of possible activity, limited in vivo expansion and persistence of adoptively transferred cells has been associated with disappointing clinical efficacy. A report from Porter and colleagues now demonstrates more fully the potential of such genetic modification in a patient with chronic lymphocytic leukemia, illustrating that when delivered in the right setting with appropriate costimulatory signaling, these cells can expand and persist, and in doing so effect quite remarkable anti-tumor activity.
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Affiliation(s)
- Karl S Peggs
- Department of Haematology, UCL Cancer Institute, Paul O'Gorman Building, University College London, 72 Huntley Street, London, WC1E 6BT, UK.
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Medd P, Monk I, Danby R, Malladi R, Clifford R, Ellis A, Roberts D, Hatton C, Vyas P, Littlewood T, Peniket A. Methotrexate dose delivery is more important than ciclosporin level in graft-versus-host disease prophylaxis following T-replete reduced-intensity sibling allogeneic stem cell transplant. Int J Hematol 2011; 94:266-278. [DOI: 10.1007/s12185-011-0920-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2011] [Revised: 08/11/2011] [Accepted: 08/12/2011] [Indexed: 11/28/2022]
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Ljungman P, Hakki M, Boeckh M. Cytomegalovirus in hematopoietic stem cell transplant recipients. Hematol Oncol Clin North Am 2011; 25:151-69. [PMID: 21236396 DOI: 10.1016/j.hoc.2010.11.011] [Citation(s) in RCA: 256] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
This article examines the clinical manifestations of and risk factors for cytomegalovirus (CMV). Prevention of CMV infection and disease are also explored. Antiviral resistance and management of CMV are examined.
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Affiliation(s)
- Per Ljungman
- Department of Hematology, Karolinska University Hospital, Stockholm, Sweden
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Roddie C, Peggs KS. Donor lymphocyte infusion following allogeneic hematopoietic stem cell transplantation. Expert Opin Biol Ther 2011; 11:473-87. [PMID: 21269237 DOI: 10.1517/14712598.2011.554811] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Allogeneic hematopoietic stem cell transplantation (SCT) is the treatment of choice for many malignant hematological disorders. Following recent improvements in non-relapse-related mortality rates, relapse has become the commonest cause of treatment failure. Infusion of donor lymphocytes can potentially enhance immune-mediated antitumor activity and offers a salvage option for some patients. This paper reviews the current literature on the efficacy of this therapeutic strategy. AREAS COVERED The biology of adoptive cellular therapy with allogeneic immune cells to treat relapse across a spectrum of diseases in both the full intensity and reduced intensity hematopoietic SCT settings is explored. The review discusses the current limitations of the approach and reviews several new experimental strategies which aim to segregate the desired graft-versus-tumor effect from the deleterious effects of more widespread graft-versus-host reactivity. EXPERT OPINION Durable responses to DLI have been noted in chronic myeloid leukemia and responses have also been described in acute leukemia, multiple myeloma and chronic lymphoproliferative disorders. The new challenge in transplantation is to optimize DLI therapy in order to further improve patient outcomes.
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Affiliation(s)
- Claire Roddie
- UCL Cancer Institute, Department of Haematology, Paul O'Gorman Building, 72 Huntley Street, London, WC1E 6BT, UK
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31
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Hallam S, Gribben JG. Stem cell transplantation in chronic lymphocytic leukaemia - steering a safe course over shifting sands. Best Pract Res Clin Haematol 2011; 23:109-19. [PMID: 20620975 DOI: 10.1016/j.beha.2009.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
There is no clear consensus regarding the optimal management of chronic lymphocytic leukaemia. Many patients are diagnosed at an advanced age and will die with chronic lymphocytic leukaemia, but of other unrelated causes. A significant minority are diagnosed at an earlier age, or with more aggressive disease, and despite chemotherapy, are likely to die of chronic lymphocytic leukaemia. The infusion of autologous or allogeneic haemopoietic stem cells, following a variety of conditioning regimes, offers the possibility of longer remissions or even cure. We explore the key questions facing clinicians in this field: Who is it best to transplant? When is it best to transplant? How is it best to transplant?
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Affiliation(s)
- Simon Hallam
- Institute of Cancer, Bart's and the London School of Medicine, Charterhouse Square, London, EC1M 6BQ, UK
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Perales MA. Adoptive Therapy of Cytomegalovirus-Specific T Lymphocytes: Is Less More? Clin Infect Dis 2011; 52:58-60. [DOI: 10.1093/cid/ciq055] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Miguel-Angel Perales
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, and Weill Medical College of Cornell University, New York, New York
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Porter DL, Alyea EP, Antin JH, DeLima M, Estey E, Falkenburg JHF, Hardy N, Kroeger N, Leis J, Levine J, Maloney DG, Peggs K, Rowe JM, Wayne AS, Giralt S, Bishop MR, van Besien K. NCI First International Workshop on the Biology, Prevention, and Treatment of Relapse after Allogeneic Hematopoietic Stem Cell Transplantation: Report from the Committee on Treatment of Relapse after Allogeneic Hematopoietic Stem Cell Transplantation. Biol Blood Marrow Transplant 2010; 16:1467-503. [PMID: 20699125 PMCID: PMC2955517 DOI: 10.1016/j.bbmt.2010.08.001] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2010] [Accepted: 08/03/2010] [Indexed: 12/31/2022]
Abstract
Relapse is a major cause of treatment failure after allogeneic hematopoietic stem cell transplantation (alloHSCT). Treatment options for relapse have been inadequate, and the majority of patients ultimately die of their disease. There is no standard approach to treating relapse after alloHSCT. Withdrawal of immune suppression and donor lymphocyte infusions are commonly used for all diseases; although these interventions are remarkably effective for relapsed chronic myelogenous leukemia, they have limited efficacy in other hematologic malignancies. Conventional and novel chemotherapy, monoclonal antibody therapy, targeted therapies, and second transplants have been utilized in a variety of relapsed diseases, but reports on these therapies are generally anecdotal and retrospective. As such, there is an immediate need for well-designed, disease-specific trials for treatment of relapse after alloHSCT. This report summarizes current treatment options under investigation for relapse after alloHSCT in a disease-specific manner. In addition, recommendations are provided for specific areas of research necessary in the treatment of relapse after alloHSCT.
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MESH Headings
- Hematologic Neoplasms/therapy
- Hematopoietic Stem Cell Transplantation
- Hodgkin Disease/therapy
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/therapy
- Leukemia, Myeloid, Acute/therapy
- Lymphocyte Transfusion
- Lymphoma, Non-Hodgkin
- Multiple Myeloma/therapy
- Neoplasm Recurrence, Local/therapy
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/therapy
- Recurrence
- Transplantation, Homologous
- Treatment Failure
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Affiliation(s)
- David L Porter
- University of Pennsylvania Medical Center, Philadelphia, 19104, USA.
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Allogeneic transplantation for chronic lymphocytic leukemia. Mediterr J Hematol Infect Dis 2010; 2:e2010026. [PMID: 21415973 PMCID: PMC3033136 DOI: 10.4084/mjhid.2010.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2010] [Accepted: 08/08/2010] [Indexed: 01/21/2023] Open
Abstract
Even if Chronic lymphocytic leukemia (CLL) often has an indolent behavior with good responsiveness to cytoreductive treatment, about 20% of the patients, so called “poor-risk” patients, show an aggressive course and die within a few years despite early intensive therapies. Criteria for poor-risk disease according to the European Bone Marrow Transplantation (EBMT) CLL Transplant Consensus are: purine analogue refractoriness, early relapse after purine analogue combination therapy, CLL with p53 lesion requiring treatment. Allogeneic transplant has potential curative role in CLL, however burden with very high transplant related mortality (TRM) rates of 38–50%. A major advance in reducing the short-term morbidity and mortality of allogeneic stem cell transplantation (SCT) has been the introduction of non-myeloablative or reduced intensity conditioning (RIC) regimens to allow engraftment of allogeneic stem cells. There is no doubt that the crucial therapeutic principle of allo-SCT in CLL is graft versus leukemia (GVL) activity. The major complications of allogeneic SCT in CLL are: chronic graft-versus-host-disease (GVHD) affecting quality of life, high graft rejection and infection rates correlated with preexisting immunosuppression. Disease relapse remains the major cause of failure after RIC allo-HCT in CLL patients. Sensitive minimal residual disease (MRD) quantification has strong prognostic impact after transplant.
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Abstract
This article examines the clinical manifestations of and risk factors for cytomegalovirus (CMV). Prevention of CMV infection and disease are also explored. Antiviral resistance and management of CMV are examined.
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Pavletic SZ, Kumar S, Mohty M, de Lima M, Foran JM, Pasquini M, Zhang MJ, Giralt S, Bishop MR, Weisdorf D. NCI First International Workshop on the Biology, Prevention, and Treatment of Relapse after Allogeneic Hematopoietic Stem Cell Transplantation: report from the Committee on the Epidemiology and Natural History of Relapse following Allogeneic Cell Transplantation. Biol Blood Marrow Transplant 2010; 16:871-90. [PMID: 20399876 DOI: 10.1016/j.bbmt.2010.04.004] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2010] [Accepted: 04/07/2010] [Indexed: 11/19/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (alloHSCT) is increasingly being used for treatment of hematologic malignancies, and the immunologic graft-versus-tumor effect (GVT) provides its therapeutic effectiveness. Disease relapse remains a cause of treatment failure in a significant proportion of patients undergoing alloHSCT without improvements over the last 2-3 decades. We summarize here current data and outline future research regarding the epidemiology, risk factors, and outcomes of relapse after alloHSCT. Although some factors (eg, disease status at alloHSCT or graft-versus-host disease [GVHD] effects) are common, other disease-specific factors may be unique. The impact of reduced-intensity regimens on relapse and survival still need to be assessed using contemporary supportive care and comparable patient populations. The outcome of patients relapsing after an alloHSCT generally remains poor even though interventions including donor leukocyte infusions can benefit some patients. Trials examining targeted therapies along with improved safety of alloHSCT may result in improved outcomes, yet selection bias necessitates prospective assessment to gauge the real contribution of any new therapies. Ongoing chronic GVHD (cGVHD) or other residual post-alloHSCT morbidities may limit the applicability of new therapies. Developing strategies to promptly identify patients as alloHSCT candidates, while malignancy is in a more treatable stage, could decrease relapses rates after alloHSCT. Better understanding and monitoring of minimal residual disease posttransplant could lead to novel preemptive treatments of relapse. Analyses of larger cohorts through multicenter collaborations or registries remain essential to probe questions not amenable to single center or prospective studies. Studies need to provide data with detail on disease status, prior treatments, biologic markers, and posttransplant events. Stringent statistical methods to study relapse remain an important area of research. The opportunities for improvement in prevention and management of post-alloHSCT relapse are apparent, but clinical discipline in their careful study remains important.
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Abstract
PURPOSE OF REVIEW Graft-versus-host disease (GVHD) remains a major cause of morbidity and mortality after allogeneic hematopoietic cell transplantation (HCT), despite improvements in our understanding of its pathophysiology as well as the generation of new monoclonal antibodies, immunomodulatory chemotherapy, cellular therapeutics and supportive care. Herein, we review therapies that have proven effective as well as newer agents that have recently improved GVHD response rates and survival following HCT. RECENT FINDINGS Novel approaches to prevent or treat GVHD are often based on evidence from experimental models. Our understanding of the pathophysiology of GVHD may lead to the development of innovative strategies that target both soluble and cellular effectors. Among such agents are sirolimus, anti-tumor necrosis factor antibodies, anti-LFA-3-IgG fusion protein, extracorporeal photopheresis, mesenchymal stem cells and regulatory T cells. SUMMARY Obstacles to the improvement of HCT include the tight linkage between GVHD toxicity and the beneficial graft-versus-leukemia (GVL) effect, as well as the impairment of immune reconstitution by immunomodulatory drugs leading to life-threatening infections. The design of newer phase I/II clinical trials are underway. Future therapies are likely to include modulation of cell types that play key roles in the GVH process, including regulatory T cells, dendritic cells, natural killer T cells and B cells.
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Delgado J, Pillai S, Phillips N, Brunet S, Pratt G, Briones J, Lovell R, Martino R, Ewing J, Sureda A, Milligan D, Sierra J. Does reduced-intensity allogeneic transplantation confer a survival advantage to patients with poor prognosis chronic lymphocytic leukaemia? A case–control retrospective analysis. Ann Oncol 2009; 20:2007-12. [DOI: 10.1093/annonc/mdp259] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Allogeneic hematopoietic cell transplantation for chronic lymphocytic leukemia: ready for prime time? Blood 2009; 114:2581-8. [PMID: 19641189 DOI: 10.1182/blood-2009-05-206821] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The development of reduced intensity conditioning regimens has increased the number of patients diagnosed with chronic lymphocytic leukemia that are referred for allogeneic hematopoietic cell transplantation (allo-HCT). However, given the toxicity of allo-HCT, it should only be offered to eligible patients whose life expectancy is significantly reduced by the disease. Accordingly, the European Group of Blood and Marrow Transplantation has recently identified those patients in whom allo-HCT could be a reasonable therapeutic approach. In this review, we have evaluated the outcome of chronic lymphocytic leukemia patients undergoing allo-HCT, either after conventional or reduced intensity conditioning regimens, in the context of current nontransplantation strategies. We have also analyzed the most important predisposing factors that might interfere with the procedure as well as posttransplantation complications that are particularly common in these patients. Finally, we have addressed the most relevant factors when deciding what patients should be considered for allo-HCT and the timing of the procedure.
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van der Bij A, Betjes M, Weening J, Cornelissen J, Mes T, Osterhaus A, Beersma M. BK virus nephropathy in an immunodeficient patient with chronic lymphocytic leukemia. J Clin Virol 2009; 45:341-4. [PMID: 19477682 DOI: 10.1016/j.jcv.2009.04.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2009] [Accepted: 04/23/2009] [Indexed: 12/16/2022]
Abstract
BACKGROUND BK virus, genus polyomavirus, is known as an important cause of nephropathy (BKVN) in renal transplant patients. Cases of BKVN in native kidneys are rare. OBJECTIVES To report a case of BKVN in a patient with chronic lymphocytic leukemia (CLL) and to examine viral and immune parameters. STUDY DESIGN Quantitative BK virus DNA in plasma and relevant immune parameters were recorded in one CLL patient with BKVN and ten consecutive CLL patients without BKVN. RESULTS BKVN in the native kidneys of a CLL patient was histologically confirmed. The presence of BKVN correlated with immunologic parameters as well as factors known to cause renal tissue injury. BK viral load levels in the patient steadily increased and exceeded those of the control CLL patients. CONCLUSIONS The results document a pathogenic role for BK virus in native kidneys of immuno-compromised CLL patients and indicate a role for quantitative BK virus DNA detection for early management of BKVN in native kidneys.
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Affiliation(s)
- Akke van der Bij
- Department of Virology, Erasmus Medical Center, Rotterdam, The Netherlands
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Does extra alemtuzumab remove the graft-versus-leukemia effect after allogeneic stem cell transplantation in chronic lymphocytic leukemia? Biol Blood Marrow Transplant 2009; 15:517-8. [PMID: 19285641 DOI: 10.1016/j.bbmt.2008.12.511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2008] [Accepted: 12/23/2008] [Indexed: 11/21/2022]
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