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Li DJ, Berry CE, Wan DC, Longaker MT. Clinical, mechanistic, and therapeutic landscape of cutaneous fibrosis. Sci Transl Med 2024; 16:eadn7871. [PMID: 39321265 DOI: 10.1126/scitranslmed.adn7871] [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: 12/29/2023] [Accepted: 09/03/2024] [Indexed: 09/27/2024]
Abstract
When dysregulated, skin fibrosis can lead to a multitude of pathologies. We provide a framework for understanding the wide clinical spectrum, mechanisms, and management of cutaneous fibrosis encompassing a variety of matrix disorders, fibrohistiocytic neoplasms, injury-induced scarring, and autoimmune scleroses. Underlying such entities are common mechanistic pathways that leverage morphogenic signaling, immune activation, and mechanotransduction to modulate fibroblast function. In light of the limited array of available treatments for cutaneous fibrosis, scientific insights have opened new therapeutic and investigative avenues for conditions that still lack effective interventions.
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Affiliation(s)
- Dayan J Li
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, CA 94305, USA
- Department of Dermatology, Stanford University School of Medicine, Redwood City, CA 94063, USA
| | - Charlotte E Berry
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Derrick C Wan
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Michael T Longaker
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, CA 94305, USA
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA
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2
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Olivieri A, Mancini G. Current Approaches for the Prevention and Treatment of Acute and Chronic GVHD. Cells 2024; 13:1524. [PMID: 39329708 PMCID: PMC11431085 DOI: 10.3390/cells13181524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Revised: 08/27/2024] [Accepted: 09/03/2024] [Indexed: 09/28/2024] Open
Abstract
Whereas aGVHD has strong inflammatory components, cGVHD displays autoimmune and fibrotic features; incidence and risk factors are similar but not identical; indeed, the aGVHD is the main risk factor for cGVHD. Calcineurin Inhibitors (CNI) with either Methotrexate (MTX) or Mycophenolate (MMF) still represent the standard prophylaxis in HLA-matched allogeneic stem cell transplantation (HSCT); other strategies focused on ATG, Post-Transplant Cyclophosphamide (PTCy), Abatacept and graft manipulation. Despite the high rate, first-line treatment for aGVHD is represented by corticosteroids, and Ruxolitinib is the standard second-line therapy; investigational approaches include Microbiota transplant and the infusion of Mesenchymal stem cells. GVHD is a pleiotropic disease involving any anatomical district; also, Ruxolitinib represents the standard for steroid-refractory cGVHD in this setting. It is a pleiotropic disease involving any anatomical district; also, Ruxolitinib represents the standard for steroid-refractory cGVHD in this setting. Extracorporeal Photopheresis (ECP) is still an option used for steroid refractoriness or to achieve a steroid-sparing. For Ruxolitinib-refractory cGVHD, Belumosudil and Axatilimab represent the most promising agents. Bronchiolitis obliterans syndrome (BOS) still represents a challenge; among the compounds targeting non-immune effectors, Alvelestat, a Neutrophil elastase inhibitor, seems promising in BOS. Finally, in both aGVHD and cGVHD, the association of biological markers with specific disease manifestations could help refine risk stratification and the availability of reliable biomarkers for specific treatments.
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Affiliation(s)
- Attilio Olivieri
- Clinica di Ematologia, Università Politecnica delle Marche Ancona, 60126 Ancona, Italy
| | - Giorgia Mancini
- Department of Hematology, AOU delle Marche Ancona, 60126 Ancona, Italy;
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Denk A, Mittermaier C, Weber D, Fante M, Güneş S, Edinger M, Herr W, Wolff D. Efficacy and safety of ruxolitinib in the treatment of chronic graft-versus-host disease: a retrospective analysis. Ann Hematol 2024; 103:3755-3764. [PMID: 38916742 PMCID: PMC11358232 DOI: 10.1007/s00277-024-05697-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 03/04/2024] [Indexed: 06/26/2024]
Abstract
Steroid-refractory chronic graft-versus-host disease (cGvHD) is associated with significant morbidity and mortality, with ruxolitinib being the first drug approved for its treatment. We retrospectively analyzed the safety and efficacy of ruxolitinib for treatment of cGvHD at our center between 07/2015 and 12/2022 and identified 48 patients receiving ruxolitinib as second (18/48) or advanced (30/48) treatment line. Ruxolitinib was started on median day 340 (range 119-595) after cGvHD onset; median duration of administration was 176 (range, 79-294) days with 16/48 patients continuing treatment at last follow-up. National Institutes of Health organ grading and the intensity of immunosuppression were assessed at the start of ruxolitinib treatment and repeated after 1, 3, 6, and 12 months. Response assessment was terminated at the start of any additional new immunosuppressant treatment. The median time of follow-up was 582 (range, 104-1161) days. At the primary analysis after six months on ruxolitinib treatment, the overall response rate was 33%, and failure-free survival was 58%. Infectious adverse events ≥ CTCAE grade III were observed in 10/48 patients. The response rate was not associated with the severity of cGvHD, number of previous treatment lines, or number of additional agents combined with ruxolitinib applying a univariate regression model. At the time of the 12-month follow-up, four patients experienced recurrence of the underlying malignancy and two patients had experienced non-relapse-related mortality. Overall, ruxolitinib was relatively well-tolerated and showed outcomes comparable to the REACH3 trial in a heavily pretreated patient population.
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Affiliation(s)
- Alexander Denk
- Department of Internal Medicine IIIHematology and Oncology, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Cornelia Mittermaier
- Department of Internal Medicine IIIHematology and Oncology, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Daniela Weber
- Department of Internal Medicine IIIHematology and Oncology, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Matthias Fante
- Department of Internal Medicine IIIHematology and Oncology, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | | | - Matthias Edinger
- Department of Internal Medicine IIIHematology and Oncology, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Wolfgang Herr
- Department of Internal Medicine IIIHematology and Oncology, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Daniel Wolff
- Department of Internal Medicine IIIHematology and Oncology, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany.
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Kim N, Min GJ, Im KI, Nam YS, Song Y, Lee JS, Oh EJ, Chung NG, Jeon YW, Lee JW, Cho SG. Repeated Infusions of Bone-Marrow-Derived Mesenchymal Stem Cells over 8 Weeks for Steroid-Refractory Chronic Graft-versus-Host Disease: A Prospective, Phase I/II Clinical Study. Int J Mol Sci 2024; 25:6731. [PMID: 38928436 PMCID: PMC11204151 DOI: 10.3390/ijms25126731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2024] [Revised: 06/14/2024] [Accepted: 06/15/2024] [Indexed: 06/28/2024] Open
Abstract
Chronic graft-versus-host disease (cGVHD) is a long-term complication of allogeneic hematopoietic stem cell transplantation associated with poor quality of life and increased morbidity and mortality. Currently, there are several approved treatments for patients who do not respond to steroids, such as ruxolitinib. Nevertheless, a significant proportion of patients fail second-line treatment, indicating the need for novel approaches. Mesenchymal stem cells (MSCs) have been considered a potential treatment approach for steroid-refractory cGVHD. To evaluate the safety and efficacy of repeated infusions of MSCs, we administered intravenous MSCs every two weeks to ten patients with severe steroid-refractory cGVHD in a prospective phase I clinical trial. Each patient received a total of four doses, with each dose containing 1 × 106 cells/kg body weight from the same donor and same passage. Patients were assessed for their response to treatment using the 2014 National Institutes of Health (NIH) response criteria during each visit. Ten patients with diverse organ involvement were enrolled, collectively undergoing 40 infusions as planned. Remarkably, the MSC infusions were well tolerated without severe adverse events. Eight weeks after the initial MSC infusion, all ten patients showed partial responses characterized by the amelioration of clinical symptoms and enhancement of their quality of life. The overall response rate was 60%, with a complete response rate of 20% and a partial response (PR) rate of 40% at the last follow-up. Overall survival was 80%, with a median follow-up of 381 days. Two patients died due to relapse of their primary disease. Immunological analyses revealed a reduction in inflammatory markers, including Suppression of Tumorigenicity 2 (ST2), C-X-C motif chemokine ligand (CXCL)10, and Secreted phosphoprotein 1(SPP1), following the MSC treatment. Repeated MSC infusions proved to be both feasible and safe, and they may be an effective salvage therapy in patients with steroid-refractory cGVHD. Further large-scale clinical studies with long-term follow-up are needed in the future to determine the role of MSCs in cGVHD.
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Affiliation(s)
- Nayoun Kim
- Institute for Translational Research and Molecular Imaging, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (N.K.); (G.-J.M.); (K.-I.I.); (Y.-S.N.); (Y.S.); (J.-S.L.)
| | - Gi-June Min
- Institute for Translational Research and Molecular Imaging, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (N.K.); (G.-J.M.); (K.-I.I.); (Y.-S.N.); (Y.S.); (J.-S.L.)
- Department of Hematology, Seoul St. Mary’s Hematology Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (N.-G.C.); (J.W.L.)
| | - Keon-Il Im
- Institute for Translational Research and Molecular Imaging, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (N.K.); (G.-J.M.); (K.-I.I.); (Y.-S.N.); (Y.S.); (J.-S.L.)
| | - Young-Sun Nam
- Institute for Translational Research and Molecular Imaging, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (N.K.); (G.-J.M.); (K.-I.I.); (Y.-S.N.); (Y.S.); (J.-S.L.)
| | - Yunejin Song
- Institute for Translational Research and Molecular Imaging, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (N.K.); (G.-J.M.); (K.-I.I.); (Y.-S.N.); (Y.S.); (J.-S.L.)
| | - Jun-Seok Lee
- Institute for Translational Research and Molecular Imaging, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (N.K.); (G.-J.M.); (K.-I.I.); (Y.-S.N.); (Y.S.); (J.-S.L.)
| | - Eun-Jee Oh
- Department of Laboratory Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea;
| | - Nack-Gyun Chung
- Department of Hematology, Seoul St. Mary’s Hematology Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (N.-G.C.); (J.W.L.)
| | - Young-Woo Jeon
- Department of Hematology, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea;
| | - Jong Wook Lee
- Department of Hematology, Seoul St. Mary’s Hematology Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (N.-G.C.); (J.W.L.)
| | - Seok-Goo Cho
- Institute for Translational Research and Molecular Imaging, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (N.K.); (G.-J.M.); (K.-I.I.); (Y.-S.N.); (Y.S.); (J.-S.L.)
- Department of Hematology, Seoul St. Mary’s Hematology Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (N.-G.C.); (J.W.L.)
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Murray J, Liptrott S, Canesi M, Mooyaart J, Kisch A, Piepenbroek B, Stringer J. Survey of European Blood and Marrow Transplant (EBMT) nurses to explore the current topical skin management of chronic cutaneous graft versus host disease in the real-world clinical environment. Eur J Oncol Nurs 2024; 69:102547. [PMID: 38467081 DOI: 10.1016/j.ejon.2024.102547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 02/16/2024] [Accepted: 03/03/2024] [Indexed: 03/13/2024]
Abstract
PURPOSE To understand the current practice in relation to the management of topical therapy for cutaneous chronic Graft versus Host Disease (ccGvHD) and access to extracorporeal photopheresis (ECP) within European allogeneic haematopoietic cell transplantation centres by a survey of nurses. METHOD This was a multicentre cross-national study at eligible European Blood and Marrow Transplant centres. Eligibility required more than 30% of treated patients having allogeneic haematopoietic cell transplant. Centres performing only autologous stem cell transplants were excluded from the study. RESULTS 12% of respondents were unaware of whether their centre had a policy or not for monitoring chronic cutaneous graft versus host disease. Over half had the affiliation of a dermatologist for referral, but only 19% had access to a specialist nurse. Patient education was routinely provided in most of the centres (86%). Results suggested as the severity of a patient's chronic cutaneous graft versus host disease increased, there was a reduction in the amount of topical emollients and steroids employed. Following topical therapies, systemic treatments, and other modalities such as ECP were employed with less focus directed towards topical care. CONCLUSIONS Topical treatment is the backbone of any treatment paradigm for chronic cutaneous graft versus host disease, however, there is no universally agreed algorithm. Improved skin care may lead to a reduction in the amount of systemic therapy required, thus increasing patients' quality of life. There is little standardisation in the topical management of chronic cutaneous graft versus host disease, despite skin being the most cited organ affected by chronic graft versus host disease, this should be addressed.
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Affiliation(s)
- John Murray
- Christie NHS Trust Hospital, Manchester, United Kingdom.
| | | | - Marta Canesi
- Fondazione IRCCS San Gerardo dei Tintori Paediatric Dept, University Milano Bicocca, Monza, Italy
| | | | - Annika Kisch
- Department of Haematology, Oncology and Radiation Physics, Skane University Hospital, Lund, Sweden and Institute of Health Sciences, Lund University, Sweden
| | | | - Jacqui Stringer
- Christie NHS Trust Hospital, Manchester, United Kingdom; University of Manchester, Manchester, United Kingdom
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Hong J, Fraebel J, Yang Y, Tkacyk E, Kitko C, Kim TK. Understanding and treatment of cutaneous graft-versus-host-disease. Bone Marrow Transplant 2023; 58:1298-1313. [PMID: 37730800 DOI: 10.1038/s41409-023-02109-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 08/28/2023] [Accepted: 09/08/2023] [Indexed: 09/22/2023]
Abstract
The skin is the outermost mechanical barrier where dynamic immune reactions take place and is the most commonly affected site in both acute and chronic graft-versus-host disease (GVHD). If not properly treated, pain and pruritis resulting from cutaneous GVHD can increase the risk of secondary infection due to erosions, ulcerations, and damage of underlying tissues. Furthermore, resulting disfiguration can cause distress and significantly impact patients' quality of life. Thus, a deeper understanding of skin-specific findings of GVHD is needed. This review will highlight some promising results of recent pre-clinical studies on the pathophysiology of skin GVHD and summarize the diagnostic and staging/grading procedures according to the clinical manifestations of skin GVHD. In addition, we will summarize outcomes of various GVHD treatments, including skin-specific response rates.
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Affiliation(s)
- Junshik Hong
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Johnathan Fraebel
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Yenny Yang
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Eric Tkacyk
- Veterans Affairs Tennessee Valley Health Care, Nashville, TN, USA
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Carrie Kitko
- Monroe Carell Jr Children's Hospital, Vanderbilt Division of Pediatric Hematology-Oncology, Nashville, TN, USA
- Vanderbilt-Ingram Cancer Center, Nashville, TN, USA
| | - Tae Kon Kim
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
- Veterans Affairs Tennessee Valley Health Care, Nashville, TN, USA.
- Vanderbilt-Ingram Cancer Center, Nashville, TN, USA.
- Vanderbilt Center for Immunobiology, Vanderbilt University Medical Center, Nashville, TN, USA.
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Linn SM, Novitzky-Basso I, Patriquin C, Pasic I, Lam W, Law A, Michelis FV, Gerbitz A, Viswabandya A, Lipton J, Kumar R, Mattsson J, Barth D, Kim DDH. Single centre retrospective analysis of extracorporeal photopheresis (ECP) therapy in patients heavily pre-treated for chronic graft-versus-host disease (cGvHD) with steroid failure. Leuk Res 2023; 134:107387. [PMID: 37734221 DOI: 10.1016/j.leukres.2023.107387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 09/02/2023] [Accepted: 09/06/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Extracorporeal photopheresis (ECP) is recommended as a second- or later-line therapy for chronic GvHD (cGvHD). Benefits include reasonable response with avoidance of intense systemic immunosuppression, which can translate into lowering the risk of systemic toxicity and opportunistic infection. METHODS We evaluated 75 patients treated with ECP for cGvHD from 2007 to 2021 at Princess Margaret Cancer Centre, and analyzed overall response rate (ORR) and clinical benefit (CB) at 3, 6 and 12 months plus other long-term treatment outcomes. RESULTS With a median follow-up of 72 months, a gradual increase in ORR was noted over time: 21% (16 out of 75 patients), 57% (36/63) and 70% (32/46) at month 3, 6 and 12, respectively. Gradual increase in CB was also observed over time with CB rate of 23% (17/75), 62% (39/63), and 76% (35/46) at months 3, 6 and 12, respectively. A total of 27 failures (36%) were noted, due to: 1) ECP resistance requiring switch to other therapy (n = 14, 19%), 2) non-relapse mortality (n = 10, 13%), 3) relapse of primary disease (n = 1, 1%) or 4) ECP procedure-related complication (n = 1, 1%, line infection), with 20 deaths (27%) observed. Failure-free survival (FFS) and overall survival (OS) rates were 68.3% and 85.9% at 12 months, respectively. After starting ECP, the proportions of patients who completely discontinued steroids were 17%, 32%, and 64% at months 3, 6 and 12, respectively. CONCLUSION ECP is an effective treatment option for heavily pre-treated cGvHD patients.
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Affiliation(s)
- Swe Mar Linn
- Hans Messner Allogeneic Transplant Program, Division of Medical Oncology and Haematology, Princess Margaret Cancer Centre, University Health Network, Canada
| | - Igor Novitzky-Basso
- Hans Messner Allogeneic Transplant Program, Division of Medical Oncology and Haematology, Princess Margaret Cancer Centre, University Health Network, Canada
| | - Christopher Patriquin
- Apheresis Program, Division of Medical Oncology and Haematology, University Health Network, Canada; Faculty of Medicine, Department of Medicine, University of Toronto, Canada
| | - Ivan Pasic
- Hans Messner Allogeneic Transplant Program, Division of Medical Oncology and Haematology, Princess Margaret Cancer Centre, University Health Network, Canada; Faculty of Medicine, Department of Medicine, University of Toronto, Canada
| | - Wilson Lam
- Hans Messner Allogeneic Transplant Program, Division of Medical Oncology and Haematology, Princess Margaret Cancer Centre, University Health Network, Canada; Faculty of Medicine, Department of Medicine, University of Toronto, Canada
| | - Arjun Law
- Hans Messner Allogeneic Transplant Program, Division of Medical Oncology and Haematology, Princess Margaret Cancer Centre, University Health Network, Canada; Faculty of Medicine, Department of Medicine, University of Toronto, Canada
| | - Fotios V Michelis
- Hans Messner Allogeneic Transplant Program, Division of Medical Oncology and Haematology, Princess Margaret Cancer Centre, University Health Network, Canada; Faculty of Medicine, Department of Medicine, University of Toronto, Canada
| | - Armin Gerbitz
- Hans Messner Allogeneic Transplant Program, Division of Medical Oncology and Haematology, Princess Margaret Cancer Centre, University Health Network, Canada; Faculty of Medicine, Department of Medicine, University of Toronto, Canada
| | - Auro Viswabandya
- Hans Messner Allogeneic Transplant Program, Division of Medical Oncology and Haematology, Princess Margaret Cancer Centre, University Health Network, Canada; Faculty of Medicine, Department of Medicine, University of Toronto, Canada
| | - Jeffrey Lipton
- Hans Messner Allogeneic Transplant Program, Division of Medical Oncology and Haematology, Princess Margaret Cancer Centre, University Health Network, Canada; Faculty of Medicine, Department of Medicine, University of Toronto, Canada
| | - Rajat Kumar
- Hans Messner Allogeneic Transplant Program, Division of Medical Oncology and Haematology, Princess Margaret Cancer Centre, University Health Network, Canada; Faculty of Medicine, Department of Medicine, University of Toronto, Canada
| | - Jonas Mattsson
- Hans Messner Allogeneic Transplant Program, Division of Medical Oncology and Haematology, Princess Margaret Cancer Centre, University Health Network, Canada; Faculty of Medicine, Department of Medicine, University of Toronto, Canada
| | - David Barth
- Hans Messner Allogeneic Transplant Program, Division of Medical Oncology and Haematology, Princess Margaret Cancer Centre, University Health Network, Canada; Faculty of Medicine, Department of Medicine, University of Toronto, Canada
| | - Dennis Dong Hwan Kim
- Hans Messner Allogeneic Transplant Program, Division of Medical Oncology and Haematology, Princess Margaret Cancer Centre, University Health Network, Canada; Faculty of Medicine, Department of Medicine, University of Toronto, Canada.
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Malard F, Mohty M. Updates in chronic graft-versus-host disease management. Am J Hematol 2023; 98:1637-1644. [PMID: 37483142 DOI: 10.1002/ajh.27040] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 06/05/2023] [Accepted: 07/09/2023] [Indexed: 07/25/2023]
Abstract
Chronic graft-versus-host disease (cGvHD) remains the most important long-term complication of allogeneic hematopoietic cell transplantation (allo-HCT), but the field has seen significant changes in the last decade. Remarkable advances in the understanding of the biological pathways of cGvHD, lead to the development of targeted therapy with novel drugs thereby minimizing the exposure to harmful corticosteroids, preserving function and mobility, preventing disability, and improving quality of life (QoL) and overall survival (OS). Steroid-refractory cGvHD management has recently experienced significant improvement since ibrutinib and ruxolitinib were approved for patients that failed at least one line of treatment and belumosudil for patients that failed two lines. These recently approved drugs will be discussed in this review, along with perspectives regarding cGVHD management and additional promising drug in development.
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Affiliation(s)
- Florent Malard
- Sorbonne Université, Centre de Recherche Saint-Antoine INSERM UMRs938, Service d'Hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint-Antoine, AP-HP, Paris, France
| | - Mohamad Mohty
- Sorbonne Université, Centre de Recherche Saint-Antoine INSERM UMRs938, Service d'Hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint-Antoine, AP-HP, Paris, France
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9
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Gonzalez R, Gaskill E, Padilla M, Pidala J, Lazaryan A, Perez L, Khimani F, Faramand R. Belumosudil Impacts Immunosuppression Pharmacokinetics in Patients with Chronic Graft-versus-Host Disease. Transplant Cell Ther 2023; 29:577.e1-577.e9. [PMID: 37355201 DOI: 10.1016/j.jtct.2023.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 06/15/2023] [Accepted: 06/18/2023] [Indexed: 06/26/2023]
Abstract
Belumosudil (BEL) is a novel Rho-associated coiled-coil containing protein kinase 2 (ROCK2) inhibitor approved for the treatment of chronic graft-versus-host disease (cGVHD) in patients who have failed 2 or more prior lines of systemic therapy. Although the pharmacokinetic effects of BEL on other immunosuppressive (IS) agents have not been clinically evaluated, in vitro data indicate that BEL may have possible interactions with drugs with a narrow therapeutic index used to treat cGVHD, such as tacrolimus, sirolimus, and cyclosporine, through cytochrome P450 (CYP3A) and p-glycoprotein interactions. Further evaluation of these potential interactions is warranted to optimize the safety and effectiveness of these medications when combined with BEL. In this study, we investigated the potential effects of BEL on sirolimus and tacrolimus levels when used concurrently by assessing changes in IS levels after the addition of BEL. This retrospective single-center study of patients who started BEL while on tacrolimus and/or sirolimus between February 1, 2019, to February 1, 2023, included patients who had IS levels measured at baseline prior to starting BEL and at least 1 subsequent IS measurement to assess changes over time. The primary endpoint was the concentration-dose (C/D) ratio analyzed before and after the addition of BEL. Secondary endpoints included the incidence of IS levels outside of the therapeutic range (subtherapeutic or supratherapeutic) and mean dosage changes over time. Thirty-seven patients met our eligibility criteria and were included in this analysis. Patients taking sirolimus (n = 30) or tacrolimus (n = 16) concurrently with BEL had a statistically significant increase in the C/D ratio (sirolimus recipients, 160% [P < .001]; tacrolimus recipients, 113% [P = .013]) between the pre-BEL and final post-BEL assessments. The C/D ratios for both tacrolimus and sirolimus recipients continued to increase at several time points after initiation of BEL, indicating that multiple drug dosage adjustments may be required. After BEL initiation, 19% of tacrolimus levels and 57% of sirolimus levels were supratherapeutic. Despite dosage adjustments, 27% of tacrolimus levels were supratherapeutic at both the second and third assessments after starting BEL, and 28% and 30% of sirolimus levels were supratherapeutic at these 2 time points, respectively. All 12 of the patients who discontinued BEL during the study period (100%) showed a return to their baseline C/D ratio, confirming that the C/D ratio change can be attributed to BEL. The impact of BEL on IS levels is clinically significant, warranting dosage adjustments of concurrent medications. A significant number of patients taking sirolimus with BEL had levels >15 ng/mL during the study period, indicating a potential risk for toxicity if this interaction is unmonitored. We recommend empiric dose reductions of 25% for tacrolimus and 25% to 50% for sirolimus when adding BEL, as well as close monitoring of IS levels during the initial weeks of BEL therapy. Future studies are warranted to better describe the impact of BEL on patients taking CYP3A inhibitors.
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Affiliation(s)
- Rebecca Gonzalez
- Blood and Marrow Transplantation and Cellular Immunotherapy, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida; Department of Pharmacy, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida.
| | - Eric Gaskill
- Blood and Marrow Transplantation and Cellular Immunotherapy, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida; Department of Pharmacy, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida.
| | - Maya Padilla
- Blood and Marrow Transplantation and Cellular Immunotherapy, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Joseph Pidala
- Blood and Marrow Transplantation and Cellular Immunotherapy, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Aleksandr Lazaryan
- Blood and Marrow Transplantation and Cellular Immunotherapy, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Lia Perez
- Blood and Marrow Transplantation and Cellular Immunotherapy, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Farhad Khimani
- Blood and Marrow Transplantation and Cellular Immunotherapy, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Rawan Faramand
- Blood and Marrow Transplantation and Cellular Immunotherapy, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
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10
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Soleimani M, Mahdavi Sharif P, Cheraqpour K, Koganti R, Masoumi A, Baharnoori SM, Salabati M, Djalilian AR. Ocular graft-versus-host disease (oGVHD): From A to Z. Surv Ophthalmol 2023; 68:697-712. [PMID: 36870423 PMCID: PMC10293080 DOI: 10.1016/j.survophthal.2023.02.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 02/24/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023]
Abstract
Allogeneic hematopoietic stem cell transplantation is a definitive therapy for a variety of disorders. One of the complications is acute graft-versus-host disease (aGVHD), which has a high mortality rate. Patients can also develop chronic graft-versus-host disease (cGVHD), a more indolent yet afflicting condition that affects up to 70% of patients. Ocular involvement (oGVHD) is one of the most prevalent presentations of cGVHD and can manifest as dry eye disease, meibomian gland dysfunction, keratitis, and conjunctivitis. Early recognition of ocular involvement using regular clinical assessments as well as robust biomarkers can aid in better management and prevention. Currently, the therapeutic strategies for the management of cGVHD, and oGVHD in particular, have mainly focused on the control of symptoms. There is an unmet need for translating the preclinical and molecular understandings of oGVHD into clinical practice. Herein, we have comprehensively reviewed the pathophysiology, pathologic features, and clinical characteristics of oGVHD and summarized the therapeutic landscape available to combat it. We also discuss the direction of future research regarding a more directed delineation of pathophysiologic underpinnings of oGVHD and the development of preventive interventions.
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Affiliation(s)
- Mohammad Soleimani
- Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran; Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL, USA
| | - Pouya Mahdavi Sharif
- Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Kasra Cheraqpour
- Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Raghuram Koganti
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL, USA
| | - Ahmad Masoumi
- Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Mahbod Baharnoori
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL, USA
| | - Mirataollah Salabati
- Department of Ophthalmology, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Ali R Djalilian
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL, USA.
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11
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Haroun E, Agrawal K, Leibovitch J, Kassab J, Zoghbi M, Dutta D, Lim SH. Chronic graft-versus-host disease in pediatric patients: Differences and challenges. Blood Rev 2023; 60:101054. [PMID: 36805299 DOI: 10.1016/j.blre.2023.101054] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/31/2023] [Accepted: 02/02/2023] [Indexed: 02/10/2023]
Abstract
Despite the use of high-resolution molecular techniques for tissue typing, chronic graft-versus-host disease (cGVHD) remains a major complication following allogeneic hematopoietic stem cell transplant. cGVHD adversely affects the life-expectancy and quality of life. The latter is particularly important and functionally relevant in pediatric patients who have a longer life-expectancy than adults. Current laboratory evidence suggests that there is not any difference in the pathophysiology of cGVHD between adults and pediatric patients. However, there are some clinical features and complications of the disease that are different in pediatric patients. There are also challenges in the development of new therapeutics for this group of patients. In this review, we will discuss the epidemiology, pathophysiology, clinical features and consequences of the disease, and highlight the differences between pediatric and adult patients. We will examine the current treatment options for pediatric patients with moderate to severe cGVHD and discuss the challenges facing therapeutic development for cGVHD in the pediatric population.
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Affiliation(s)
- Elio Haroun
- Division of Hematology and Oncology, State University of New York Upstate Medical University, Syracuse, NY, United States of America
| | - Kavita Agrawal
- Division of Hematology and Oncology, State University of New York Upstate Medical University, Syracuse, NY, United States of America
| | - Jennifer Leibovitch
- Division of Hematology and Oncology, State University of New York Upstate Medical University, Syracuse, NY, United States of America
| | - Joseph Kassab
- Department of Medicine, Saint-Joseph University of Beirut, Beirut, Lebanon
| | - Marianne Zoghbi
- Department of Medicine, Saint-Joseph University of Beirut, Beirut, Lebanon
| | - Dibyendu Dutta
- Division of Hematology and Oncology, State University of New York Upstate Medical University, Syracuse, NY, United States of America
| | - Seah H Lim
- Division of Hematology and Oncology, State University of New York Upstate Medical University, Syracuse, NY, United States of America,; Sanofi Oncology, Cambridge, MA, United States of America.
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12
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Hidalgo Calleja C, Sánchez González MD, Medina Luezas J, López Corral L. Chronic graft-versus-recipient disease: Systematic review of joint and fascial involvement. REUMATOLOGIA CLINICA 2023; 19:235-243. [PMID: 37087381 DOI: 10.1016/j.reumae.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 12/15/2022] [Indexed: 04/24/2023]
Abstract
BACKGROUND AND OBJECTIVE Chronic graft-versus-host disease (cGVRD) is a systemic immune-mediated complication that occurs in approximately half of the patients undergoing allogeneic haematopoietic stem cell transplantation (allo-HCT) and, although it is associated with beneficial graft versus tumour effects and lower relapse rates, it remains the leading cause of late morbidity and mortality in these patients. The aim of this systematic review of the literature is to provide a current overview on the diagnostic musculoskeletal manifestations of cGVRD, its clinical evaluation, and therapeutic possibilities. METHODS We ran a systematic search in PubMed, Embase, and Cochrane Library. Studies from the last 20 years were included. Priority was given to cross-sectional studies to evaluate diagnostic methods and to clinical trials in the case of articles referring to treatment. The search was limited to humans and articles published in English or Spanish. RESULTS We identified 6423 studies, of which we selected 86 (37 on clinical and diagnostic evaluation and 49 on treatments). Specific studies on fascial and joint complications are scarce and of low quality, including only isolated clinical cases or case series. Fasciitis is the most relevant musculoskeletal manifestation, and isolated joint involvement is low, sometimes unnoticed and underdiagnosed, if a thorough exploration of joint motion is not performed. Early detection of cGVRD with fascial and/or joint involvement requires careful and repeated evaluation. CONCLUSIONS The search for new biomarkers or advanced imaging techniques that allow early diagnosis is necessary. Physiotherapy is essential to improve functionality and prevent disease progression. Controlled studies are needed to establish recommendations on second lines of treatment. Because of its multisystemic nature, cGVRD requires a multidisciplinary approach.
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Affiliation(s)
- Cristina Hidalgo Calleja
- Servicio de Reumatología, Complejo Asistencial Universitario de Salamanca-IBSAL, Salamanca, Spain.
| | | | - Julio Medina Luezas
- Servicio de Reumatología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Lucía López Corral
- Servicio de Hematología, Complejo Asistencial Universitario de Salamanca-IBSAL. Centro de Investigación del Cáncer-IBMCC, Salamanca, Spain
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13
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Schain F, Boissin C, Laczik T, Fedeli S, Remberger M, Blennow O, Dykes J, Eich T, Jones C, Mattsson J, Berlin G. Real-world clinical characterization, healthcare resource utilization and productivity loss in chronic graft versus host patients exposed to extracorporeal photopheresis in Sweden. Transfus Apher Sci 2023:103705. [DOI: 10.1016/j.transci.2023.103705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 03/09/2023] [Accepted: 03/19/2023] [Indexed: 04/05/2023]
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14
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Zeiser R. Novel Approaches to the Treatment of Chronic Graft-Versus-Host Disease. J Clin Oncol 2023; 41:1820-1824. [PMID: 36800551 DOI: 10.1200/jco.22.02256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Abstract
The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice.Chronic graft-versus-host disease (cGVHD) is an immune-mediated disease that ensues after allogeneic hematopoietic cell transplantation often affecting multiple organs, decreases quality of life, and necessitates immunosuppressive therapy. The current standard first-line cGVHD therapy is glucocorticoids (GCs) which have major side effects. So far, all attempts to improve response to first-line GC therapy of cGVHD by adding other agents, such as mycophenolate mofetil, or cyclosporine A have not improved response. The data reported in the trial by Miklos et al indicate that ibrutinib should not be added to GC in first-line cGVHD therapy. The findings instruct future studies that aim at the identification of patients with cGVHD who may benefit from a GC-ibrutinib combination using biomarkers or clinical parameters. Currently, ibrutinib, ruxolitinib, and belumosudil are the only drugs that are approved by the Food and Drug Administration for steroid-refractory cGVHD. In light of the current standard management of cGVHD, the trial results indicate that ibrutinib will remain reserved for second-line therapy, which may be due to its mechanisms of action. The recommendation on the basis of this trial is that GC monotherapy remains the standard therapy for cGVHD.
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Affiliation(s)
- Robert Zeiser
- Department of Medicine I, Faculty of Medicine, Medical Center, University of Freiburg, Freiburg, Germany
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15
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Incidence of graft-versus-host-disease in Germany: evidence from health care claims data. J Public Health (Oxf) 2022. [DOI: 10.1007/s10389-022-01736-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
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16
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[Chinese consensus on diagnosis and treatment of bronchiolitis obliterans syndrome after hematopoietic stem cell transplantation (2022)]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2022; 43:441-447. [PMID: 35968585 PMCID: PMC9800223 DOI: 10.3760/cma.j.issn.0253-2727.2022.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Indexed: 12/24/2022]
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17
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Dean D, Sroussi H. Oral Chronic Graft-Versus-Host Disease. FRONTIERS IN ORAL HEALTH 2022; 3:903154. [PMID: 35719318 PMCID: PMC9205403 DOI: 10.3389/froh.2022.903154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 04/18/2022] [Indexed: 11/30/2022] Open
Abstract
Chronic oral graft-versus-host disease (cGVHD) is a complex, frequent, and highly impactful complication of allogeneic hematopoietic cell transplantation (alloHCT). It represents the leading cause of morbidity and mortality in long-term alloHCT survivors. cGVHD can affect almost any visceral organ system and commonly affects the skin, eyes and mouth, manifesting with signs and symptoms similar to other known immune-mediated and autoimmune diseases. Oral manifestations of GVHD include inflammation, thinning, and ulceration of oral mucosal tissues (similar to lichen planus), lymphocyte-mediated salivary gland dysfunction (similar to Sjögren/Sicca Syndrome), and decreased oral opening (trismus) secondary to sclerosis of oral and perioral tissues (analogous to limitation in scleroderma). Potential sequelae include severe mucosal pain, compromised nutrition, weight loss, limitation in opening, and sometimes irreversible fibrosis of the salivary glands. While some cases can be managed with topical therapies, management may also require long-term targeted immunosuppressive and/or corticosteroid therapy with associated risk of local and systemic infection, hyperglycemia, kidney dysfunction, osteopenia/osteoporosis, and possibly secondary malignancies. The aim of this mini-review is to provide an up-to-date review of literature related to the diagnosis and management of oral cGVHD to aid dental and medical clinicians in optimizing oral cGVHD therapy while minimizing potential adverse effects.
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Affiliation(s)
- David Dean
- Department of Oral Medicine, University of Washington/Seattle Cancer Care Alliance, Seattle, WA, United States
- *Correspondence: David Dean
| | - Herve Sroussi
- Division of Oral Medicine and Dentistry, Brigham and Women's Hospital and Dana Farber Cancer Institute Department of Oral Medicine, Infection and Immunity, Harvard School of Dental Medicine, Boston, MA, United States
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18
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Zaiken MC, Flynn R, Paz KG, Rhee SY, Jin S, Mohamed FA, Saha A, Thangavelu G, Park PMC, Hemming ML, Sage PT, Sharpe AH, DuPage M, Bluestone JA, Panoskaltsis-Mortari A, Cutler CS, Koreth J, Antin JH, Soiffer RJ, Ritz J, Luznik L, Maillard I, Hill GR, MacDonald KPA, Munn DH, Serody JS, Murphy WJ, Kean LS, Zhang Y, Bradner JE, Qi J, Blazar BR. BET-bromodomain and EZH2 inhibitor-treated chronic GVHD mice have blunted germinal centers with distinct transcriptomes. Blood 2022; 139:2983-2997. [PMID: 35226736 PMCID: PMC9101246 DOI: 10.1182/blood.2021014557] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 02/09/2022] [Indexed: 01/26/2023] Open
Abstract
Despite advances in the field, chronic graft-versus-host-disease (cGVHD) remains a leading cause of morbidity and mortality following allogenic hematopoietic stem cell transplant. Because treatment options remain limited, we tested efficacy of anticancer, chromatin-modifying enzyme inhibitors in a clinically relevant murine model of cGVHD with bronchiolitis obliterans (BO). We observed that the novel enhancer of zeste homolog 2 (EZH2) inhibitor JQ5 and the BET-bromodomain inhibitor JQ1 each improved pulmonary function; impaired the germinal center (GC) reaction, a prerequisite in cGVHD/BO pathogenesis; and JQ5 reduced EZH2-mediated H3K27me3 in donor T cells. Using conditional EZH2 knockout donor cells, we demonstrated that EZH2 is obligatory for the initiation of cGVHD/BO. In a sclerodermatous cGVHD model, JQ5 reduced the severity of cutaneous lesions. To determine how the 2 drugs could lead to the same physiological improvements while targeting unique epigenetic processes, we analyzed the transcriptomes of splenic GCB cells (GCBs) from transplanted mice treated with either drug. Multiple inflammatory and signaling pathways enriched in cGVHD/BO GCBs were reduced by each drug. GCBs from JQ5- but not JQ1-treated mice were enriched for proproliferative pathways also seen in GCBs from bone marrow-only transplanted mice, likely reflecting their underlying biology in the unperturbed state. In conjunction with in vivo data, these insights led us to conclude that epigenetic targeting of the GC is a viable clinical approach for the treatment of cGVHD, and that the EZH2 inhibitor JQ5 and the BET-bromodomain inhibitor JQ1 demonstrated clinical potential for EZH2i and BETi in patients with cGVHD/BO.
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Affiliation(s)
- Michael C Zaiken
- Division of Blood & Marrow Transplant & Cellular Therapy, Department of Pediatrics, Masonic Cancer Center, University of Minnesota, Minneapolis, MN
| | - Ryan Flynn
- Division of Blood & Marrow Transplant & Cellular Therapy, Department of Pediatrics, Masonic Cancer Center, University of Minnesota, Minneapolis, MN
| | - Katelyn G Paz
- Division of Blood & Marrow Transplant & Cellular Therapy, Department of Pediatrics, Masonic Cancer Center, University of Minnesota, Minneapolis, MN
| | - Stephanie Y Rhee
- Division of Blood & Marrow Transplant & Cellular Therapy, Department of Pediatrics, Masonic Cancer Center, University of Minnesota, Minneapolis, MN
| | - Sujeong Jin
- Division of Blood & Marrow Transplant & Cellular Therapy, Department of Pediatrics, Masonic Cancer Center, University of Minnesota, Minneapolis, MN
| | - Fathima A Mohamed
- Division of Blood & Marrow Transplant & Cellular Therapy, Department of Pediatrics, Masonic Cancer Center, University of Minnesota, Minneapolis, MN
| | - Asim Saha
- Division of Blood & Marrow Transplant & Cellular Therapy, Department of Pediatrics, Masonic Cancer Center, University of Minnesota, Minneapolis, MN
| | - Govindarajan Thangavelu
- Division of Blood & Marrow Transplant & Cellular Therapy, Department of Pediatrics, Masonic Cancer Center, University of Minnesota, Minneapolis, MN
| | - Paul M C Park
- Department of Cancer Biology, Dana-Farber Cancer Institute, Boston, MA
| | - Matthew L Hemming
- Department of Cancer Biology, Dana-Farber Cancer Institute, Boston, MA
| | - Peter T Sage
- Department of Immunology, Blavatnik Institute, Harvard Medical School, Boston, MA
- Evergrande Center for Immunologic Diseases, Harvard Medical School-Brigham and Women's Hospital, Boston, MA
| | - Arlene H Sharpe
- Department of Immunology, Blavatnik Institute, Harvard Medical School, Boston, MA
- Evergrande Center for Immunologic Diseases, Harvard Medical School-Brigham and Women's Hospital, Boston, MA
| | - Michel DuPage
- Division of Immunology and Pathogenesis, Department of Molecular and Cell Biology, University of California Berkeley, Berkeley, CA
| | | | - Angela Panoskaltsis-Mortari
- Division of Blood & Marrow Transplant & Cellular Therapy, Department of Pediatrics, Masonic Cancer Center, University of Minnesota, Minneapolis, MN
| | | | | | | | - Robert J Soiffer
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | | | - Leo Luznik
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, MD
| | - Ivan Maillard
- Division of Hematology-Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Geoffrey R Hill
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
- Division of Medical Oncology, University of Washington, Seattle, WA
| | - Kelli P A MacDonald
- Department of Immunology, Queensland Institute of Medical Research (QIMR), University of Queensland, Brisbane, QLD, Australia
| | - David H Munn
- Georgia Cancer Center, Augusta University, Augusta, GA
| | - Jonathan S Serody
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | - William J Murphy
- Department of Dermatology, School of Medicine, University of California, Davis, Sacramento, CA
| | - Leslie S Kean
- Department of Cancer Biology, Dana-Farber Cancer Institute, Boston, MA
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, MA
| | - Yi Zhang
- Fels Institute for Cancer Research and Molecular Biology, Department of Microbiology and Immunology, Temple University, Philadelphia, PA
| | - James E Bradner
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA; and
| | - Jun Qi
- Department of Cancer Biology, Dana-Farber Cancer Institute, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Bruce R Blazar
- Division of Blood & Marrow Transplant & Cellular Therapy, Department of Pediatrics, Masonic Cancer Center, University of Minnesota, Minneapolis, MN
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19
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Kaurinovic M, Delli K, Jonk AME, Biswana A, Hazenberg CLE, Choi G, de Groot MR, Morsink LM, Vissink A, Bellido M. Effect of ruxolitinib on the oral mucosa of patients with steroid-refractory chronic Graft-versus-Host disease and oral involvement. Clin Oral Investig 2022; 26:4209-4216. [PMID: 35169886 PMCID: PMC9072523 DOI: 10.1007/s00784-022-04393-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 01/11/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND Chronic Graft-versus-Host Disease (cGVHD) can impact quality of life, especially in patients with oral involvement. Half of the patients with cGVHD do not respond to first-line therapy with corticosteroids and calcineurin inhibitors. Ruxolitinib is effective in steroid-refractory (SR)-cGVHD cases, but the long-term effects of ruxolitinib on the oral mucosa are unknown. OBJECTIVE(S) This study aims to assess the effect of ruxolitinib on the oral mucosa of SR-cGVHD patients with oral involvement. MATERIALS AND METHODS An observational longitudinal patient study was conducted in 53 patients with SR-cGVHD and oral involvement who were treated with ruxolitinib. The baseline condition of the oral mucosa was compared to its condition at 4 and 12 weeks after starting ruxolitinib. RESULTS The overall response was 81% (43/53), with a complete response in 53% (28/53) and partial response in 28% (15/53) after 12 weeks (p < 0.001). Men and patients concurrently using immunosuppressive therapy responded better than women (p = 0.005) and patients with ruxolitinib monotherapy (p = 0.02), respectively. At a longer follow-up (median 20 months), oral symptoms were comparable to the 12-week symptoms (p = 0.78), regardless of ruxolitinib use (p = 0.83). CONCLUSION Ruxolitinib treatment of SR-cGVHD patients with oral involvement was associated with a significant response of the oral manifestations at 12 weeks. CLINICAL RELEVANCE The oral mucosa of SR-cGVHD patients is likely to improve after 4 and 12 weeks of ruxolitinib treatment. Symptom severity at baseline does not affect the response of the oral mucosa.
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Affiliation(s)
- Martina Kaurinovic
- Department of Oral and Maxillofacial Surgery, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands.
| | - Konstantina Delli
- Department of Oral and Maxillofacial Surgery, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
| | - Ana-Mae E Jonk
- Department of Oral and Maxillofacial Surgery, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
| | - Anouschka Biswana
- Department of Hematology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
| | - Carin L E Hazenberg
- Department of Hematology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
| | - Goda Choi
- Department of Hematology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
| | - Marco R de Groot
- Department of Hematology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
| | - Linde M Morsink
- Department of Hematology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
| | - Arjan Vissink
- Department of Oral and Maxillofacial Surgery, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
| | - Mar Bellido
- Department of Hematology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
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20
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Bujan Rivera J, Kühl R, Zech U, Hendricks A, Luft T, Dreger P, Friedmann-Bette B, Betz TM, Wiskemann J. Impact of Resistance Exercise and Nutritional Endorsement on physical performance in patients with GvHD (IRENE-G study) - design and rational of a randomized controlled trial. BMC Cancer 2022; 22:440. [PMID: 35459108 PMCID: PMC9024288 DOI: 10.1186/s12885-022-09497-1] [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: 03/15/2022] [Accepted: 04/06/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Graft-versus-host disease (GvHD) remains a major complication and limitation to successful allogeneic hematopoietic stem cell transplantation. Treatment of GvHD is challenging due to its heterogeneous nature of presentation, with steroids remaining the established first-line treatment. Long-term doses of systemic corticosteroids have many well-known side-effects including muscle atrophy. Despite the fact that reports in non-cancer clinical populations treated with glucocorticoids demonstrated that resistance training can reverse atrophy and weakness, no RCT has evaluated the potential of resistance training on preventing the disease- and treatment-induced loss of skeletal muscle mass and function in GvHD patients yet. In this context, ensuring adequate nutrition is important as protein deprivation may accelerate the wasting process. As GvHD patients are commonly found to be malnourished, nutritional medical care should be considered when investigating the effect of exercise in GvHD patients. Therefore, the aim of the present "Impact of Resistance Exercise and Nutritional Endorsement on physical performance in patients with GvHD" - Study (IRENE-G) is to evaluate the effects of resistance exercise in combination with nutritional endorsement on physical, nutritional and patient-reported outcomes in GvHD patients. METHODS IRENE-G is a 24-week prospective interventional RCT. One hundred twelve participants will be randomly allocated (1:1) to one of two arms: resistance exercise and nutritional optimization (experimental) vs. nutritional optimization only (control). Participants in the experimental group will engage in a supervised, progressive moderate-to-high intensity resistance training that is consistent with exercise guidelines for cancer patients, while additionally receiving nutritional support/therapy. Subjects of the control group solely receive nutritional support/therapy based on individual needs. Participants will be assessed at baseline, at 8, 16, 24 weeks for physical performance and various physiological, nutritional and patient-reported outcomes. Follow-up will be 6 months after intervention completion. DISCUSSION To our knowledge, this will be the first RCT to assess and compare the effects of a resistance intervention supplemented by nutritional support/therapy against nutritional support only on various health-related outcomes in GvHD patients. The study will contribute to our understanding of the value of exercise and nutritional endorsement in counteracting the negative consequences of GvHD and its treatment. TRIAL REGISTRATION ClinicalTrials.gov : NCT05111834 . Registered 8 November 2021 - Retrospectively registered.
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Affiliation(s)
- Janina Bujan Rivera
- Division of Medical Oncology, National Center for Tumor Diseases (NCT), University Hospital Heidelberg, Im Neuenheimer Feld 460, 69120, Heidelberg, Germany
| | - Rea Kühl
- Division of Medical Oncology, National Center for Tumor Diseases (NCT), University Hospital Heidelberg, Im Neuenheimer Feld 460, 69120, Heidelberg, Germany
| | - Ulrike Zech
- Department of Internal Medicine I, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Anne Hendricks
- Department of Internal Medicine I, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Thomas Luft
- Department of Internal Medicine V, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Peter Dreger
- Department of Internal Medicine V, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Birgit Friedmann-Bette
- Department of Internal Medicine VII, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Theresa-Maria Betz
- Department of Internal Medicine III, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Joachim Wiskemann
- Division of Medical Oncology, National Center for Tumor Diseases (NCT), University Hospital Heidelberg, Im Neuenheimer Feld 460, 69120, Heidelberg, Germany.
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21
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Link-Rachner CS, Sockel K, Schuetz C. Established and Emerging Treatments of Skin GvHD. Front Immunol 2022; 13:838494. [PMID: 35185931 PMCID: PMC8847139 DOI: 10.3389/fimmu.2022.838494] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 01/11/2022] [Indexed: 01/14/2023] Open
Abstract
Graft-versus-host disease (GvHD) of the skin is a severe allo-immune reaction and complication following allogeneic stem cell transplantation. Over the past years, intensive pre-clinical research has led to an improved understanding of the pathophysiology of acute and to a lesser extend chronic GvHD. This has translated into the approval of several new agents for the treatment of both forms of GvHD. This review summarizes the most recent advances in underlying pathomechanisms, clinical trials and newly approved agents for GvHD, with a special focus on skin involvement.
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Affiliation(s)
- Cornelia S Link-Rachner
- Medizinische Klinik und Poliklinik I, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Center for Regenerative Therapies Dresden, Technische Universität Dresden, Dresden, Germany
| | - Katja Sockel
- Medizinische Klinik und Poliklinik I, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Catharina Schuetz
- Klinik und Poliklinik für Kinder- und Jugendmedizin, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
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22
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Thangavelu G, Zaiken MC, Mohamed FA, Flynn R, Du J, Rhee SY, Riddle MJ, Aguilar EG, Panoskaltsis-Mortari A, Sanders ME, Blazar BR. Targeting the Retinoid X Receptor Pathway Prevents and Ameliorates Murine Chronic Graft-Versus-Host Disease. Front Immunol 2022; 13:765319. [PMID: 35359939 PMCID: PMC8963714 DOI: 10.3389/fimmu.2022.765319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 01/26/2022] [Indexed: 02/03/2023] Open
Abstract
Most allogeneic hematopoietic stem cell transplant (allo-HSCT) recipients receive peripheral blood stem cell grafts resulting in a 30%-70% incidence of chronic graft-versus-host disease (cGVHD), a major cause of mortality and morbidity in long-term survivors. While systemic steroids remain the standard of care for first-line therapy, patients may require long-term administration, and those with steroid-resistant or refractory cGVHD have a worse prognosis. Although durable and deep responses with second-line therapies can be achieved in some patients, there remains an urgent need for new therapies. In this study, we evaluated the efficacy of IRX4204, a novel agonist that activates RXRs and is in clinical trials for cancer treatment to prevent and treat cGVHD in two complementary murine models. In a major histocompatibility complex mismatched, non-sclerodermatous multiorgan system model with bronchiolitis obliterans, IRX4204 prevented and reversed cGVHD including associated pulmonary dysfunction with restoration of germinal center T-follicular helper: T-follicular regulatory cell balance. In a minor histocompatibility antigen disparate sclerodermatous model, IRX4204 treatment significantly prevented and ameliorated skin cGVHD by reducing Th1 and Th17 differentiation due to anti-inflammatory properties. Together, these results indicate that IRX4204 is a promising therapeutic option to treat cGVHD with bronchiolitis obliterans or sclerodermatous manifestations.
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Affiliation(s)
- Govindarajan Thangavelu
- Department of Pediatrics, Division of Blood & Marrow Transplantation & Cellular Therapy, University of Minnesota, Minneapolis, MN, United States
| | - Michael C. Zaiken
- Department of Pediatrics, Division of Blood & Marrow Transplantation & Cellular Therapy, University of Minnesota, Minneapolis, MN, United States
| | - Fathima A. Mohamed
- Department of Pediatrics, Division of Blood & Marrow Transplantation & Cellular Therapy, University of Minnesota, Minneapolis, MN, United States
| | - Ryan Flynn
- Department of Pediatrics, Division of Blood & Marrow Transplantation & Cellular Therapy, University of Minnesota, Minneapolis, MN, United States
| | - Jing Du
- Department of Pediatrics, Division of Blood & Marrow Transplantation & Cellular Therapy, University of Minnesota, Minneapolis, MN, United States
| | - Stephanie Y. Rhee
- Department of Pediatrics, Division of Blood & Marrow Transplantation & Cellular Therapy, University of Minnesota, Minneapolis, MN, United States
| | - Megan J. Riddle
- Department of Pediatrics, Division of Blood & Marrow Transplantation & Cellular Therapy, University of Minnesota, Minneapolis, MN, United States
| | - Ethan G. Aguilar
- Department of Pediatrics, Division of Blood & Marrow Transplantation & Cellular Therapy, University of Minnesota, Minneapolis, MN, United States
| | - Angela Panoskaltsis-Mortari
- Department of Pediatrics, Division of Blood & Marrow Transplantation & Cellular Therapy, University of Minnesota, Minneapolis, MN, United States
| | | | - Bruce R. Blazar
- Department of Pediatrics, Division of Blood & Marrow Transplantation & Cellular Therapy, University of Minnesota, Minneapolis, MN, United States
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23
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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: 8] [Impact Index Per Article: 4.0] [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.
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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
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24
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Thevenet U, Daguenet E, Beszera SM, Cornillon J, Tavernier E, Schein F, Honeyman F, Guyotat D. Infectious risks in patients treated with extracorporeal photopheresis for graft-versus-host disease: A retrospective cohort study. J Clin Apher 2021; 37:106-116. [PMID: 34967023 DOI: 10.1002/jca.21957] [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: 09/27/2021] [Revised: 12/08/2021] [Accepted: 12/10/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Infections are common with significant mortality and morbidity in patients with graft-versus-host disease (GvHD). Extracorporeal photopheresis (ECP) is an advantageous treatment option for patients with GvHD because it is not immunosuppressive. The objective of this study was to assess the rate of infections and to determine risk factors in patients with GvHD. MATERIALS AND METHODS In a single-center cohort, we retrospectively collected data on infectious episodes by evaluating the clinical records of patients with GvHD treated by ECP since 2011. RESULTS A total of 47 patients were included in this study. At ECP initiation, there were 10 patients with acute GvHD and 37 with chronic GvHD. At the final follow-up, 200 infectious episodes were diagnosed in 91.5% of patients with an average follow-up of 25.9 months (ie, 1.97 infections per patient per year). Most episodes had positive outcomes as there was no death related to infections, and only six infections required long-term treatment. Higher dose of corticosteroids at the initiation of ECP was significantly associated with a shorter onset of the first infection (hazard ratio [HR] = 2.05; 95% confidence interval [CI] [1.17, 3.57]; P = .013). Unrelated donor transplants were significantly associated with a lower rate of infection (HR = 0.61; 95% CI [0.39, 0.95]; P = .028). CONCLUSION The results of our study suggest that ECP is associated with a low infection rate and an optimal clinical efficacy. Thus, ECP is still a suitable treatment for GvHD. Yet, a future study with a larger cohort will be necessary to deepen the identification of risk factors for infection.
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Affiliation(s)
- Ugo Thevenet
- Department of Clinical Hematology and Cellular Therapy, Institut de Cancérologie Lucien Neuwirth, Saint-Priest-en-Jarez, France
| | - Elisabeth Daguenet
- Department of Clinical Hematology and Cellular Therapy, Institut de Cancérologie Lucien Neuwirth, Saint-Priest-en-Jarez, France
| | - Silvia-Maria Beszera
- Department of Clinical Hematology and Cellular Therapy, Institut de Cancérologie Lucien Neuwirth, Saint-Priest-en-Jarez, France
| | - Jérôme Cornillon
- Department of Clinical Hematology and Cellular Therapy, Institut de Cancérologie Lucien Neuwirth, Saint-Priest-en-Jarez, France
| | - Emmanuelle Tavernier
- Department of Clinical Hematology and Cellular Therapy, Institut de Cancérologie Lucien Neuwirth, Saint-Priest-en-Jarez, France
| | - Flora Schein
- Department of Internal Medicine, CHU de Saint-Étienne, Saint-Étienne, France
| | - Fressia Honeyman
- Department of Clinical Hematology and Cellular Therapy, Institut de Cancérologie Lucien Neuwirth, Saint-Priest-en-Jarez, France
| | - Denis Guyotat
- Department of Clinical Hematology and Cellular Therapy, Institut de Cancérologie Lucien Neuwirth, Saint-Priest-en-Jarez, France
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25
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Smith Knutsson E, Nicklasson M, Björk Y, Stenberg K, Sundfeldt K, Brune M. Late follow-up of genital and ophthalmologic chronic graft-versus-host disease in females after allogeneic stem cell transplantation. Acta Obstet Gynecol Scand 2021; 101:364-373. [PMID: 34962288 DOI: 10.1111/aogs.14308] [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: 05/28/2021] [Revised: 10/30/2021] [Accepted: 12/06/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Genital chronic graft-versus-host disease (cGvHD) is a common late effect after allogeneic stem cell transplantation. In a previous cross-sectional study, prevalence, signs and symptoms of genital and extra-genital cGvHD were accounted for in a cohort of 42 women. Classifications of cGvHD were performed as per the National Institutes of Health (NIH) 2005 criteria. In this follow-up study on surviving women, the aim was to assess genital and extra-genital cGvHD status after long period of time. Our hypothesis was that signs and symptoms of cGvHD alleviate over time. MATERIAL AND METHODS All surviving women (n = 38) were re-examined by an ophthalmologist, a gynecologist and a hematologist. Signs and symptoms were classified according to the NIH 2014 criteria. Clinical scorings of affected organs were combined for estimating global score of cGvHD. To make possible comparisons between the two studies, data from the original study were re-classified as per the NIH 2014 criteria, and the four dead women were excluded. The same questionnaires were completed. Cervical smear, human papilloma virus test and vulvar photo-documentation were performed. RESULTS Median time after original study was 8.4 (5.8-12) years and after transplant 14.5 (10-19.3) years. The prevalence of genital cGvHD was similar in the original (50%) and follow-up (58%) studies (p = 0.646) as well as extra-genital cGvHD. Systemic corticosteroid treatment of cGvHD was ongoing in 34% and 29%, respectively (p = 0.805). Ocular cGvHD was found in 24 of 37 examined women (65%) in the follow-up study. Genital cGvHD had disappeared in three women and developed in two women 5-12 and 9-17 years, respectively, after transplantation. The severity of global cGvHD changed over time in 14 women, but was the same on group level (p = 0.345). Atrophic mucous membranes as in estrogen deficiency were seen in 66%. Three women had human papilloma virus genotypes associated with the risk of developing cervical cancer. CONCLUSIONS Chronic GvHD did not alleviate over time. Allotransplanted women require early and continuous life-long contact with a gynecologist and an ophthalmologist for the detection of cGvHD. Specific attention should be given to the need for local estrogen and the risk of genital epithelial malignancies.
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Affiliation(s)
- Eva Smith Knutsson
- Department of Obstetrics and Gynecology, NU Hospital Group, Trollhättan, Sweden.,Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
| | - Malin Nicklasson
- Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden.,Section of Hematology and Coagulation, Department of Medicine, Sahlgrenska University Hospital, Sahlgrenska, Gothenburg, Sweden
| | - Yvonne Björk
- Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden.,Section of Hematology and Coagulation, Department of Medicine, Sahlgrenska University Hospital, Sahlgrenska, Gothenburg, Sweden
| | - Kristina Stenberg
- Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden.,Department of Ophthalmology, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Karin Sundfeldt
- Department Obstetrics and Gynecology, Institution for Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
| | - Mats Brune
- Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden.,Section of Hematology and Coagulation, Department of Medicine, Sahlgrenska University Hospital, Sahlgrenska, Gothenburg, Sweden
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26
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Ramos GDA, Leite TDB, Lobo CB, Santos PSDS, Moreira MCR, Antunes HS. Treatment of oral chronic graft-versus-host disease: a retrospective cohort study. EINSTEIN-SAO PAULO 2021; 19:eAO6177. [PMID: 34730704 PMCID: PMC8528385 DOI: 10.31744/einstein_journal/2021ao6177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 05/10/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE The aim of this study was to evaluate patients with complete response of oral chronic graft-versus-host disease to immunosuppressive treatment. METHODS A total of 29 patients submitted to allogeneic hematopoietic stem cell transplantation, with oral chronic graft-versus-host disease, were enrolled in this retrospective study, from September 2012 to February 2018. Patients were treated with combined topical dexamethasone solution and topical tacrolimus ointment, combined topical dexamethasone and topical tacrolimus, systemic immunosuppressive medication, and topical dexamethasone only. RESULTS The mean time of complete response of lichenoid lesions, erythema, and ulcers using dexamethasone and systemic immunosuppressive medication was of 105, 42 and 42 days, respectively (p=0.013).When we associated dexamethasone, tacrolimus and systemic immunosuppressive medication, the mean time of complete response of lichenoid lesions, erythema and ulcers was of 91,84 and 77 days (p=0.011). When dexamethasone was used alone, the mean time of complete response of lichenoid lesions, erythema and ulcers was 182, 140, 21 days, respectively (p=0.042). CONCLUSION Our study shows that lichenoid lesions require more time to heal. Notably, lichenoid lesions tend to respond better to dexamethasone combined with tacrolimus and systemic immunosuppressive medication, whereas erythema and ulcers respond better to dexamethasone combined with systemic immunosuppressive medication and dexamethasone only, respectively.
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Affiliation(s)
- Gabriela de Assis Ramos
- Divisão de Pesquisa ClínicaInstituto Nacional de CâncerRio de JaneiroRJBrazilDivisão de Pesquisa Clínica, Instituto Nacional de Câncer - INCA, Rio de Janeiro, RJ, Brazil.
| | - Taísa Domingues Boehmer Leite
- Divisão de Pesquisa ClínicaInstituto Nacional de CâncerRio de JaneiroRJBrazilDivisão de Pesquisa Clínica, Instituto Nacional de Câncer - INCA, Rio de Janeiro, RJ, Brazil.
| | - Camila Brandão Lobo
- Divisão de Pesquisa ClínicaInstituto Nacional de CâncerRio de JaneiroRJBrazilDivisão de Pesquisa Clínica, Instituto Nacional de Câncer - INCA, Rio de Janeiro, RJ, Brazil.
| | - Paulo Sérgio da Silva Santos
- Faculdade de Odontologia de BauruUniversidade de São PauloBauruSPBrazilFaculdade de Odontologia de Bauru, Universidade de São Paulo, Bauru, SP, Brazil.
| | - Maria Claudia Rodrigues Moreira
- Centro de Transplante de Medula ÓsseaInstituto Nacional de CâncerRio de JaneiroRJBrazilCentro de Transplante de Medula Óssea, Instituto Nacional de Câncer - INCA, Rio de Janeiro, RJ, Brazil.
| | - Héliton Spindola Antunes
- Divisão de Pesquisa ClínicaInstituto Nacional de CâncerRio de JaneiroRJBrazilDivisão de Pesquisa Clínica, Instituto Nacional de Câncer - INCA, Rio de Janeiro, RJ, Brazil.
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27
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Wang D, Liu Y, Lai X, Chen J, Cheng Q, Ma X, Lin Z, Wu D, Xu Y. Efficiency and Toxicity of Ruxolitinib as a Salvage Treatment for Steroid-Refractory Chronic Graft-Versus-Host Disease. Front Immunol 2021; 12:673636. [PMID: 34276662 PMCID: PMC8278571 DOI: 10.3389/fimmu.2021.673636] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 06/21/2021] [Indexed: 11/13/2022] Open
Abstract
Graft-versus-host disease (GVHD), especially steroid-refractory GVHD, remains a life-threatening complication after hematopoietic stem cell transplantation (HSCT). The effect of the JAK1/2 kinase inhibitor ruxolitinib on treating steroid-refractory acute GVHD has been verified by the REACH1/2 study; however, its safety and efficacy in patients with steroid-refractory chronic GVHD (SR-cGVHD) remain unclear. In this retrospective study, 70 patients received ruxolitinib as a salvage therapy for SR-cGVHD. Twenty-four weeks after ruxolitinib treatment, the overall response rate (ORR) was 74.3% (52/70), including 34 patients who achieved complete remission (CR) and 18 who achieved partial remission (PR). The main adverse event was cytopenia, which occurred in 51.4% (36/70) of patients. After ruxolitinib treatment, the percentage of CD4 cells increased from 18.20% to 23.22% (P<0.001), while the percentages of NK (CD16+CD56+) cells and regulatory T cells (CD4+CD127 ± CD25+) decreased (P<0.001, P<0.001). Among the B cell subsets, the proportion of total B cells approximately tripled from 3.69% to 11.16% (P<0.001). Moreover, we observed a significant increase in IL-10 levels after ruxolitinib treatment (P=0.025) and a remarkable decrease in levels of suppression of tumorigenicity 2 (ST2) from 229.90 ng/ml to 72.65 ng/ml. The median follow-up after the initiation of ruxolitinib treatment was 401 (6-1076) days. The estimated one-year overall survival rate of the whole group was 66.0% (54.4-77.6%, 95% CI), and the one-year overall survival rate of patients with mild and moderate cGVHD was 69.6% (57.4-81.8%, 95% CI), which was better than that of patients with severe cGVHD (31.3%, 0.0-66.2%, 95% CI) (P=0.002). Patients who achieved a CR and PR achieved better survival outcomes (84.5%, 73.9-95.1%, 95% CI) than those who showed NR to ruxolitinib treatments (16.7%, 0-34.3%, 95% CI) (P<0.001). At the final follow-up, cGVHD relapse occurred in six patients after they reduced or continued their ruxolitinib doses. Collectively, our results suggest that ruxolitinib is potentially a safe and effective treatment for SR-cGVHD.
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Affiliation(s)
- Dong Wang
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Yin Liu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Xiaoxuan Lai
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Jia Chen
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Qiao Cheng
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Xiao Ma
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, The First Affiliated Hospital of Soochow University, Suzhou, China.,Department of Hematology, Soochow Hopes Hematonosis Hospital, Suzhou, China
| | - Zhihong Lin
- Soochow Yongding Hospital, Department of Affiliated Renji Hospital of Shanghai Jiao Tong University of Medicine, Suzhou, China
| | - Depei Wu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Yang Xu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
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28
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Boluda B, Solana-Altabella A, Cano I, Acuña-Cruz E, Rodríguez-Veiga R, Ballesta-López O, Megías-Vericat JE, Martínez-Cuadrón D, Gómez I, Solves P, Lorenzo I, Piñana JL, Sanz J, Guerreiro M, Montoro Gómez J, Díaz-González A, Marco J, Blanco A, Sanz MÁ, Montesinos P. Extracorporeal photopheresis vs standard therapies for steroid-refractory chronic graft-vs-host disease: Pharmacoeconomic assessment of hospital resource use in Spain. J Clin Apher 2021; 36:612-620. [PMID: 33964038 PMCID: PMC8453768 DOI: 10.1002/jca.21901] [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: 12/21/2020] [Revised: 02/24/2021] [Accepted: 04/09/2021] [Indexed: 11/11/2022]
Abstract
Background This study assessed pharmacoeconomic costs associated with extracorporeal photopheresis (ECP) compared with other available second‐line therapies for chronic graft‐vs‐host disease (cGvHD) in a tertiary Spanish institution. Methods Patients (≥18 years) diagnosed with steroid‐refractory cGvHD were eligible. Data were collected retrospectively from index date until 1 year or relapse. Patients were distributed in two cohorts (ECP vs non‐ECP), matched by age (≤ or > 40), hematopoietic stem cell transplant (HLA‐identical sibling donor or other) and number of previous immunosuppressive lines (1, 2, or ≥ 3). Costs were assigned using the 2016 diagnosis‐related group (DRG) system: DRG 579 (€22 383) overnight stay due to major complication (ie, sepsis, pneumonia, parenteral nutrition, or respiratory failure), and DRG 875 (€5154) if no major complication. The primary endpoint was healthcare resource utilization per patient. Results Forty patients (n = 20 per cohort) were included. Median age was 49, and 37.5% were female. Mean total cost per patient was €25 319 (95% CI: €17 049–€33 590) across the two cohorts, with a slightly lower mean cost per ECP‐treated patient (€23 120) compared with the non‐ECP cohort (€27 519; P = .597). Twenty‐seven inpatient hospitalizations occurred among ECP‐treated patients, vs 33 in the non‐ECP cohort. Day hospital and external consultations were more frequent in the ECP cohort. However, fewer inpatient admissions included DRG 579 compared with the non‐ECP cohort (44% vs 58%). Inpatient length of stay was slightly shorter in the ECP cohort (30 vs 49 days; P = .298). Conclusions ECP treatment may yield economic savings in Spain through resource savings and moving costs toward outpatient care.
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Affiliation(s)
- Blanca Boluda
- Haematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Antonio Solana-Altabella
- Pharmacy Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain.,Hematology Research Group, Instituto de Investigación Sanitaria La Fe, Valencia, Spain
| | - Isabel Cano
- Haematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain.,Hematology Research Group, Instituto de Investigación Sanitaria La Fe, Valencia, Spain
| | - Evelyn Acuña-Cruz
- Haematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Rebeca Rodríguez-Veiga
- Haematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain.,Hematology Research Group, Instituto de Investigación Sanitaria La Fe, Valencia, Spain
| | - Octavio Ballesta-López
- Pharmacy Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain.,Hematology Research Group, Instituto de Investigación Sanitaria La Fe, Valencia, Spain
| | | | - David Martínez-Cuadrón
- Haematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain.,Hematology Research Group, Instituto de Investigación Sanitaria La Fe, Valencia, Spain.,CIBERONC, Instituto Carlos III, Madrid, Spain
| | - Ines Gómez
- Haematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Pilar Solves
- Haematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Ignacio Lorenzo
- Haematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Jose Luis Piñana
- Haematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain.,Hematology Research Group, Instituto de Investigación Sanitaria La Fe, Valencia, Spain.,CIBERONC, Instituto Carlos III, Madrid, Spain
| | - Jaime Sanz
- Haematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain.,Hematology Research Group, Instituto de Investigación Sanitaria La Fe, Valencia, Spain.,CIBERONC, Instituto Carlos III, Madrid, Spain
| | - Manuel Guerreiro
- Haematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Juan Montoro Gómez
- Haematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Alvaro Díaz-González
- Haematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Javier Marco
- Haematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Albert Blanco
- Haematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Miguel Á Sanz
- Haematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain.,Hematology Research Group, Instituto de Investigación Sanitaria La Fe, Valencia, Spain.,CIBERONC, Instituto Carlos III, Madrid, Spain
| | - Pau Montesinos
- Haematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain.,Hematology Research Group, Instituto de Investigación Sanitaria La Fe, Valencia, Spain.,CIBERONC, Instituto Carlos III, Madrid, Spain
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Wertheimer T, Dohse M, Afram G, Weber D, Heidenreich M, Holler B, Kattner AS, Neubauer A, Mielke S, Ljungman P, Holler E, Herr W, Edinger M, Martínez AP, Fante M, Wolff D. Abatacept as salvage therapy in chronic graft-versus-host disease-a retrospective analysis. Ann Hematol 2021; 100:779-787. [PMID: 33515310 PMCID: PMC7914235 DOI: 10.1007/s00277-021-04434-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 01/18/2021] [Indexed: 01/08/2023]
Abstract
The immunomodulatory fusion protein abatacept has recently been investigated for the treatment of steroid-refractory chronic graft-versus-host disease (cGvHD) in a phase 1 clinical trial. We analyzed the safety and efficacy of abatacept for cGvHD therapy in a retrospective study with 15 patients who underwent allogeneic hematopoietic stem cell transplantation (allo-HSCT) and received abatacept for cGvHD with a median age of 49 years. Grading was performed as part of the clinical routine according to the National Institute of Health’s (NIH) consensus criteria at initiation of abatacept and 1, 3, 6, 9 and 12 months thereafter. The median time of follow-up was 191 days (range 55–393 days). Best overall response rate (ORR) was 40%. In particular, patients with bronchiolitis obliterans syndrome showed significant clinical improvement and durable responses following abatacept treatment with a response rate of 89% based on improvement in lung severity score (n = 6) or stabilized lung function (n = 4) or both (n = 3). Infectious complications CTCAE °III or higher were observed in 3/15 patients. None of the patients relapsed from the underlying malignancy. Thus, abatacept appears to be a promising treatment option for cGvHD, in particular for patients with lung involvement. However, further evaluation within a phase 2 clinical trial is required.
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Affiliation(s)
- Tobias Wertheimer
- Department of Internal Medicine III, Hematology and Oncology, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany.
| | - Marius Dohse
- Department of Hematology, Oncology and Immunology, University Hospital Giessen and Marburg, Marburg, Germany
| | - Gabriel Afram
- Department of Cellular Therapy and Allogeneic Stem Cell Transplantation, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Daniela Weber
- Department of Internal Medicine III, Hematology and Oncology, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Martin Heidenreich
- Department of Internal Medicine III, Hematology and Oncology, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Barbara Holler
- Department of Internal Medicine III, Hematology and Oncology, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Anna-Sophia Kattner
- Department of Internal Medicine III, Hematology and Oncology, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Andreas Neubauer
- Department of Hematology, Oncology and Immunology, University Hospital Giessen and Marburg, Marburg, Germany
| | - Stephan Mielke
- Department of Cellular Therapy and Allogeneic Stem Cell Transplantation, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Per Ljungman
- Department of Cellular Therapy and Allogeneic Stem Cell Transplantation, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Ernst Holler
- Department of Internal Medicine III, Hematology and Oncology, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany.,Regensburg Center for Interventional Immunology, Regensburg, Germany
| | - Wolfgang Herr
- Department of Internal Medicine III, Hematology and Oncology, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany.,Regensburg Center for Interventional Immunology, Regensburg, Germany
| | - Matthias Edinger
- Department of Internal Medicine III, Hematology and Oncology, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany.,Regensburg Center for Interventional Immunology, Regensburg, Germany
| | - Antonio Pérez Martínez
- Pediatric Hematology, Oncology and Stem Cell Transplantation, Hospital Universitario La Paz, Universidad Autonóma de Madrid, Madrid, Spain
| | - Matthias Fante
- Department of Internal Medicine III, Hematology and Oncology, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Daniel Wolff
- Department of Internal Medicine III, Hematology and Oncology, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany.,Regensburg Center for Interventional Immunology, Regensburg, Germany
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30
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Wu H, Shi J, Luo Y, Tan Y, Zhang M, Lai X, Yu J, Liu L, Fu H, Huang H, Zhao Y. Evaluation of Ruxolitinib for Steroid-Refractory Chronic Graft-vs-Host Disease After Allogeneic Hematopoietic Stem Cell Transplantation. JAMA Netw Open 2021; 4:e2034750. [PMID: 33502484 PMCID: PMC7841467 DOI: 10.1001/jamanetworkopen.2020.34750] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
IMPORTANCE Ruxolitinib, a selective inhibitor of the Janus kinases 1/2 signaling pathway, has shown a significant response in steroid-refractory chronic graft-vs-host disease (SR-cGVHD), a major cause of morbidity and mortality in individuals who have undergone allogeneic hematopoietic stem cell transplantation (HSCT). OBJECTIVES To investigate the clinical response to ruxolitinib in patients with SR-cGVHD after allogeneic HSCT and to evaluate its safety profile during the treatment course. DESIGN, SETTING, AND PARTICIPANTS This single-center case series included 41 consecutive patients who were treated with ruxolitinib for SR-cGVHD after allogeneic HSCT between August 2017 and December 2019. Data were collected from each patient's medical record at the First Affiliated Hospital of Zhejiang University School of Medicine. Data analysis was conducted from March to May 2020. EXPOSURE Ruxolitinib. MAIN OUTCOMES AND MEASURES Treatment responses, factors associated with response, and adverse effects during ruxolitinib administration. FINDINGS Overall, 41 patients (median [range] age, 31 [17-56] years; 14 [34.1%] women) were treated with ruxolitinib and included in this study. A total of 15 patients (36.6%) had a complete remission, and 14 (34.1%) had a partial remission, with an overall response rate of 70.7% (29 patients; 95% CI, 56.2%-85.3%). Lung involvement (odds ratio, 0.112; 95% CI, 0.020-0.639; P = .01) and matched related donors (odds ratio, 0.149; 95% CI, 0.022-0.981; P = .048) were associated with less favorable treatment response. Major adverse events associated with ruxolitinib were cytopenias and infectious complications. The median (range) follow-up for this cohort was 14.9 (1.4-32.5) months. Prolonged survival was observed in patients with a male donor (P = .006), complete remission before transplantation (P = .02), baseline moderate cGVHD (P = .02), and skin cGVHD (P = .001). CONCLUSIONS AND RELEVANCE In this small, single-site case series, ruxolitinib demonstrated a significant response in heavily pretreated patients with SR-cGVHD and a reasonably well-tolerated safety profile. The results add to the body of literature suggesting ruxolitinib as a promising treatment option in SR-cGVHD.
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Affiliation(s)
- Hengwei Wu
- Bone Marrow Transplantation Center, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People’s Republic of China
- Institute of Hematology, Zhejiang University, Hangzhou, Zhejiang, People’s Republic of China
| | - Jimin Shi
- Bone Marrow Transplantation Center, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People’s Republic of China
- Institute of Hematology, Zhejiang University, Hangzhou, Zhejiang, People’s Republic of China
| | - Yi Luo
- Bone Marrow Transplantation Center, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People’s Republic of China
- Institute of Hematology, Zhejiang University, Hangzhou, Zhejiang, People’s Republic of China
| | - Yamin Tan
- Bone Marrow Transplantation Center, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People’s Republic of China
- Institute of Hematology, Zhejiang University, Hangzhou, Zhejiang, People’s Republic of China
| | - Mingming Zhang
- Bone Marrow Transplantation Center, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People’s Republic of China
- Institute of Hematology, Zhejiang University, Hangzhou, Zhejiang, People’s Republic of China
| | - Xiaoyu Lai
- Bone Marrow Transplantation Center, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People’s Republic of China
- Institute of Hematology, Zhejiang University, Hangzhou, Zhejiang, People’s Republic of China
| | - Jian Yu
- Bone Marrow Transplantation Center, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People’s Republic of China
- Institute of Hematology, Zhejiang University, Hangzhou, Zhejiang, People’s Republic of China
| | - Lizhen Liu
- Bone Marrow Transplantation Center, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People’s Republic of China
- Institute of Hematology, Zhejiang University, Hangzhou, Zhejiang, People’s Republic of China
| | - Huarui Fu
- Bone Marrow Transplantation Center, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People’s Republic of China
- Institute of Hematology, Zhejiang University, Hangzhou, Zhejiang, People’s Republic of China
| | - He Huang
- Bone Marrow Transplantation Center, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People’s Republic of China
- Institute of Hematology, Zhejiang University, Hangzhou, Zhejiang, People’s Republic of China
| | - Yanmin Zhao
- Bone Marrow Transplantation Center, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People’s Republic of China
- Institute of Hematology, Zhejiang University, Hangzhou, Zhejiang, People’s Republic of China
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31
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McBride DA, Kerr MD, Dorn NC, Ogbonna DA, Santos EC, Shah NJ. Triggers, Timescales, and Treatments for Cytokine-Mediated Tissue Damage. ACTA ACUST UNITED AC 2020; 5:52-62. [PMID: 34013158 DOI: 10.33590/emjinnov/20-00203] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Inflammation is an essential cytokine-mediated process for generating a neutralizing immune response against pathogens and is generally protective. However, aberrant or excessive production of pro-inflammatory cytokines is associated with uncontrolled local and systemic inflammation, resulting in cell death and often irreversible tissue damage. Uncontrolled inflammation can manifest over timescales spanning hours to years and is primarily dependent on the triggering event. Rapid and potentially lethal increase in cytokine production, or a 'cytokine storm,' develops in hours to days and is associated with cancer cell-based immunotherapies, such as CAR-T cell therapy. On the other hand, some bacterial and viral infections with high microbial replication or highly potent antigens elicit immune responses that result in supraphysiological systemic cytokine concentrations which manifest over days to weeks. Immune dysregulation in autoimmune diseases can lead to chronic cytokine-mediated tissue damage spanning months to years, which often occurs episodically. While the initiating events and cellular participants may differ in these disease processes, many of the cytokines that drive disease progression are shared. For example, upregulation of IL-1, IL-6, IFN-γ, TNF, and GM-CSF frequently coincides with cytokine storm, sepsis, and autoimmune disease. Targeted inhibition of these pro-inflammatory molecules via antagonist monoclonal antibodies has improved clinical outcomes, but the complexity of the underlying immune dysregulation results in high variability. Rather than a "one size fits all" treatment approach, an identification of disease endotypes may permit the development of effective therapeutic strategies that address the contributors of disease progression. Here, we present a literature review of the cytokine-associated etiology of acute and chronic cytokine-mediated tissue damage, describe successes and challenges in developing clinical treatments, and highlight advancements in preclinical therapeutic strategies for mitigating pathological cytokine production.
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Affiliation(s)
- David A McBride
- Department of NanoEngineering, University of California, San Diego, La Jolla, CA 92093, USA.,Chemical Engineering Program, University of California, San Diego, La Jolla, CA 92093, USA.,Center for Nano-Immuno Engineering, University of California, San Diego, La Jolla, CA 92093, USA
| | - Matthew D Kerr
- Department of NanoEngineering, University of California, San Diego, La Jolla, CA 92093, USA.,Chemical Engineering Program, University of California, San Diego, La Jolla, CA 92093, USA.,Center for Nano-Immuno Engineering, University of California, San Diego, La Jolla, CA 92093, USA
| | - Nicholas C Dorn
- Department of NanoEngineering, University of California, San Diego, La Jolla, CA 92093, USA.,Chemical Engineering Program, University of California, San Diego, La Jolla, CA 92093, USA
| | - Dora A Ogbonna
- Department of NanoEngineering, University of California, San Diego, La Jolla, CA 92093, USA.,Chemical Engineering Program, University of California, San Diego, La Jolla, CA 92093, USA
| | - Evan C Santos
- Department of NanoEngineering, University of California, San Diego, La Jolla, CA 92093, USA.,Chemical Engineering Program, University of California, San Diego, La Jolla, CA 92093, USA
| | - Nisarg J Shah
- Department of NanoEngineering, University of California, San Diego, La Jolla, CA 92093, USA.,Chemical Engineering Program, University of California, San Diego, La Jolla, CA 92093, USA.,Center for Nano-Immuno Engineering, University of California, San Diego, La Jolla, CA 92093, USA.,Program in Immunology, University of California, San Diego, La Jolla, CA 92093, USA.,San Diego Center for Precision Immunotherapy, Moores Cancer Center, University of California, San Diego, La Jolla, CA 92093, USA
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32
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Cho A, Paulitschke V, Just U, Knobler R. Cutaneous manifestations of acute and chronic graft-versus-host disease. GIORN ITAL DERMAT V 2020; 155:76-87. [PMID: 32100975 DOI: 10.23736/s0392-0488.19.06535-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Graft-versus-host disease (GvHD) is a commonly occurring immunological reaction and frequent complication following allogeneic hematopoietic stem cell transplantation. Its highly diverse manifestations including skin involvement as the most common appearance of GvHD, can dramatically influence patient's quality of life, in particular in the chronic stage, in addition to patient's decreased survival outcome. Hence, the role of the dermatologist has become very crucial in an interdisciplinary setting, particularly since appearances of GvHD in the skin can be multifaceted and challenging. Clinical manifestation of the acute GvHD (aGvHD) is limited to erythematous maculopapular rash and oral mucosal lesions while the chronic form manifests in a wider range in a localized area or disseminated including involvement of nail, scalp and genital area. This article aims to provide a comprehensive overview on the variable cutaneous presentations of acute and chronic GvHD for a proper and early diagnosis on the one hand, and to discuss updated therapeutic options for both acute and chronic GvHD on the other hand, to initiate an adequate treatment to obtain the most beneficial clinical outcome.
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Affiliation(s)
- Ara Cho
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - Verena Paulitschke
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - Ulrike Just
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - Robert Knobler
- Department of Dermatology, Medical University of Vienna, Vienna, Austria -
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33
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Treister N, Li S, Soiffer R, Cutler C. Topical sirolimus for management of refractory oral chronic graft-versus-host disease. Oral Dis 2020; 27:1451-1454. [PMID: 33037754 DOI: 10.1111/odi.13676] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 09/18/2020] [Accepted: 09/23/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Nathaniel Treister
- Division of Oral Medicine and Dentistry, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, USA.,Department of Oral Medicine, Infection and Immunity, Harvard School of Dental Medicine, Boston, USA
| | - Shuli Li
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, USA
| | - Robert Soiffer
- Department of Hematologic Malignancies, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Corey Cutler
- Department of Hematologic Malignancies, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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34
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Knobler R, Arenberger P, Arun A, Assaf C, Bagot M, Berlin G, Bohbot A, Calzavara-Pinton P, Child F, Cho A, French LE, Gennery AR, Gniadecki R, Gollnick HPM, Guenova E, Jaksch P, Jantschitsch C, Klemke C, Ludvigsson J, Papadavid E, Scarisbrick J, Schwarz T, Stadler R, Wolf P, Zic J, Zouboulis C, Zuckermann A, Greinix H. European dermatology forum - updated guidelines on the use of extracorporeal photopheresis 2020 - part 1. J Eur Acad Dermatol Venereol 2020; 34:2693-2716. [PMID: 33025659 PMCID: PMC7820969 DOI: 10.1111/jdv.16890] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 08/06/2020] [Indexed: 01/01/2023]
Abstract
Background Following the first investigational study on the use of extracorporeal photopheresis for the treatment of cutaneous T‐cell lymphoma published in 1983, this technology has received continued use and further recognition for additional earlier as well as refractory forms. After the publication of the first guidelines for this technology in the JEADV in 2014, this technology has maintained additional promise in the treatment of other severe and refractory conditions in a multi‐disciplinary setting. It has confirmed recognition in well‐known documented conditions such as graft‐versus‐host disease after allogeneic bone marrow transplantation, systemic sclerosis, solid organ transplant rejection including lung, heart and liver and to a lesser extent inflammatory bowel disease. Materials and methods In order to further provide recognized expert practical guidelines for the use of this technology for all indications, the European Dermatology Forum (EDF) again proceeded to address these questions in the hands of the recognized experts within and outside the field of dermatology. This was done using the recognized and approved guidelines of EDF for this task. All authors had the opportunity to review each contribution as it was added. Results and conclusion These updated 2020 guidelines provide at present the most comprehensive available expert recommendations for the use of extracorporeal photopheresis based on the available published literature and expert consensus opinion. The guidelines are divided in two parts: PART I covers cutaneous T‐cell lymphoma, chronic graft‐versus‐host disease and acute graft‐versus‐host disease while PART II will cover scleroderma, solid organ transplantation, Crohn's disease, use of ECP in paediatrics practice, atopic dermatitis, type 1 diabetes, pemphigus, epidermolysis bullosa acquisita and erosive oral lichen planus.
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Affiliation(s)
- R Knobler
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - P Arenberger
- Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - A Arun
- FRCPath, The Rotherham NHA Foundation Trust, Rotherham, UK
| | - C Assaf
- Department of Dermatology and Venerology, Helios Klinikum Krefeld, Krefeld, Germany
| | - M Bagot
- Hospital Saint Louis, Université de Paris, Paris, France
| | - G Berlin
- Department of Clinical Immunology and Transfusion Medicine, Linköping University, Linköping, Sweden.,Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - A Bohbot
- Onco-Hematology Department, Hautepierre Hospital, Strasbourg, France
| | | | - F Child
- FRCP, St John's Institution of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - A Cho
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - L E French
- Department of Dermatology, University Hospital, München, Germany
| | - A R Gennery
- Translational and Clinical Research Institute, Newcastle University Great North Children's Hospital Newcastle upon Tyne, Newcastle University, Newcastle upon Tyne, UK
| | - R Gniadecki
- Division of Dermatology, University of Alberta, Edmonton, AB, Canada
| | - H P M Gollnick
- Dept. Dermatology & Venereology, Otto-von-Guericke University, Magdeburg, Germany
| | - E Guenova
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.,Department of Dermatology, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - P Jaksch
- Department of Thoracic Surgery, Medical University Vienna, Vienna, Austria
| | - C Jantschitsch
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - C Klemke
- Hautklinik Städtisches Klinikum Karlsruhe, Karlsruhe, Germany
| | - J Ludvigsson
- Crown Princess Victoria Children's Hospital and Division of Pediatrics, Department of Biomedical and Clinical Sciences, University Hospital, Linköping University, Linköping, Sweden
| | - E Papadavid
- National and Kapodistrian University of Athens, Athens, Greece
| | | | - T Schwarz
- Department of Dermatology, University Clinics Schleswig-Holstein, Kiel, Germany
| | - R Stadler
- University Clinic for Dermatology Johannes Wesling Medical Centre, UKRUB, University of Bochum, Minden, Germany
| | - P Wolf
- Department of Dermatology, Medical University of Graz, Graz, Austria
| | - J Zic
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - C Zouboulis
- Departments of Dermatology, Venereology, Allergology and Immunology, Dessau Medical Center, Brandenburg Medical School Theodor Fontane, Dessau, Germany
| | - A Zuckermann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - H Greinix
- Division of Haematology, LKH-Univ. Klinikum Graz, Medical University of Graz, Graz, Austria
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35
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Soder RP, Dawn B, Weiss ML, Dunavin N, Weir S, Mitchell J, Li M, Shune L, Singh AK, Ganguly S, Morrison M, Abdelhakim H, Godwin AK, Abhyankar S, McGuirk J. A Phase I Study to Evaluate Two Doses of Wharton's Jelly-Derived Mesenchymal Stromal Cells for the Treatment of De Novo High-Risk or Steroid-Refractory Acute Graft Versus Host Disease. Stem Cell Rev Rep 2020; 16:979-991. [PMID: 32740891 PMCID: PMC9289888 DOI: 10.1007/s12015-020-10015-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Because of their well-described immunosuppressive properties, allogeneic adult human mesenchymal stromal cells (MSC) derived from bone marrow have demonstrated safety and efficacy in steroid refractory acute graft versus host disease (SR aGVHD). Clinical trials have resulted in variable success and an optimal source of MSC has yet to be defined. Based on the importance of maternal-fetal interface immune tolerance, extraembryonic fetal tissues, such as the umbilical cord, may provide an superior tissue source of MSC to mediate immunomodulation in aGVHD. METHODS A two-dose cohort trial allogeneic Wharton's Jelly-derived mesenchymal stromal cells (WJMSC, referred to as MSCTC-0010, here) were tested in 10 patients with de novo high risk (HR) or SR aGVHD post allogeneic hematopoietic stem cell transplantation (allo-HCT). Following Good Manufacturing Practices isolation, expansion and cryostorage, WJMSC were thawed and administered via intravenous infusions on days 0 and 7 at one of two doses (low dose cohort, 2 × 106/kg, n = 5; high dose cohort, 10 × 106/kg, n = 5). To evaluate safety, patients were monitored for infusion related toxicity, Treatment Related Adverse Events (TRAE) til day 42, or ectopic tissue formation at day 90. Clinical responses were monitored at time points up to 180 days post infusion. Serum biomarkers ST2 and REG3α were acquired 1 day prior to first MSCTC-0010 infusion and on day 14. RESULTS Safety was indicated, e.g., no infusion-related toxicity, no development of TRAE, nor ectopic tissue formation in either low or high dose cohort was observed. Clinical response was suggested at day 28: the overall response rate (ORR) was 70%, 4 of 10 patients had a complete response (CR) and 3 had a partial response (PR). By study day 90, the addition of escalated immunosuppressive therapy was necessary in 2 of 9 surviving patients. Day 100 and 180 post infusion survival was 90% and 60%, respectively. Serum biomarker REG3α decreased, particularly in the high dose cohort, and with REG3α decrease correlated with clinical response. CONCLUSIONS Treatment of patients with de novo HR or SR aGVHD with low or high dose MSCTC-0010 was safe: the infusion was well-tolerated, and no TRAEs or ectopic tissue formation was observed. A clinical improvement was seen in about 70% patients, with 4 of 10 showing a complete response that may have been attributable to MSCTC-0010 infusions. These observations indicate safety of two different doses of MSCTC-0010, and suggest that the 10 × 106 cells/ kg dose be tested in an expanded randomized, controlled Phase 2 trial. Graphical abstract.
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Affiliation(s)
- Rupal P Soder
- Midwest Stem Cell Therapy Center, University of Kansas Medical Center, Kansas City, KS, USA
| | - Buddhadeb Dawn
- University of Nevada, Las Vegas School of Medicine, Las Vegas, NV, USA
| | - Mark L Weiss
- Midwest Institute of Comparative Stem Cell Biotechnology and Department of Anatomy and Physiology, Kansas State University, Manhattan, KS, USA
| | - Neil Dunavin
- University of California, San Francisco, CA, USA
| | - Scott Weir
- Institute for Advancing Medical Innovation Medical Center, University of Kansas, Kansas City, USA
| | - James Mitchell
- Midwest Stem Cell Therapy Center, University of Kansas Medical Center, Kansas City, KS, USA
| | - Meizhang Li
- Pathology & Laboratory Medicine, Univeristy of Kansas Medical Center, Kansas City, USA
| | - Leyla Shune
- Blood and Marrow Transplant Program, Division of Hematologic Malignancies and Cellular Therapeutics, University of Kansas Medical Center, 2330 Shawnee Mission Parkway, Suite 210, Westwood, KS, 66205, USA
| | - Anurag K Singh
- Blood and Marrow Transplant Program, Division of Hematologic Malignancies and Cellular Therapeutics, University of Kansas Medical Center, 2330 Shawnee Mission Parkway, Suite 210, Westwood, KS, 66205, USA
| | - Siddhartha Ganguly
- Blood and Marrow Transplant Program, Division of Hematologic Malignancies and Cellular Therapeutics, University of Kansas Medical Center, 2330 Shawnee Mission Parkway, Suite 210, Westwood, KS, 66205, USA
| | - Marc Morrison
- Blood and Marrow Transplant Program, Division of Hematologic Malignancies and Cellular Therapeutics, University of Kansas Medical Center, 2330 Shawnee Mission Parkway, Suite 210, Westwood, KS, 66205, USA
| | - Haitham Abdelhakim
- Blood and Marrow Transplant Program, Division of Hematologic Malignancies and Cellular Therapeutics, University of Kansas Medical Center, 2330 Shawnee Mission Parkway, Suite 210, Westwood, KS, 66205, USA
| | - Andrew K Godwin
- Pathology & Laboratory Medicine, Univeristy of Kansas Medical Center, Kansas City, USA
| | - Sunil Abhyankar
- Midwest Stem Cell Therapy Center, University of Kansas Medical Center, Kansas City, KS, USA
- Blood and Marrow Transplant Program, Division of Hematologic Malignancies and Cellular Therapeutics, University of Kansas Medical Center, 2330 Shawnee Mission Parkway, Suite 210, Westwood, KS, 66205, USA
| | - Joseph McGuirk
- Blood and Marrow Transplant Program, Division of Hematologic Malignancies and Cellular Therapeutics, University of Kansas Medical Center, 2330 Shawnee Mission Parkway, Suite 210, Westwood, KS, 66205, USA.
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Bondeelle L, Chevret S, Hurabielle C, Samy L, Goletto T, Costantini A, Sicre de Fontbrune F, Michonneau D, Socié G, Tazi A, Bouaziz JD, Bergeron A. Effect of Ruxolitinib on Lung Function after Allogeneic Stem Cell Transplantation. Biol Blood Marrow Transplant 2020; 26:2115-2120. [PMID: 32738501 DOI: 10.1016/j.bbmt.2020.07.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 06/23/2020] [Accepted: 07/26/2020] [Indexed: 12/11/2022]
Abstract
Ruxolitinib, a selective Janus kinase (JAK)1/2 inhibitor, has recently been proposed for steroid-refractory chronic graft-versus host disease (cGVHD) after allogeneic hematopoietic stem cell transplantation (HSCT), particularly in severe skin cGVHD. Lung function impairment is common in severe skin cGVHD through concomitant bronchiolitis obliterans syndrome (BOS) or restrictive lung disease (RLD) from skin sclerosis. To date, no treatment has shown a benefit on lung function in this context. We retrospectively assessed the effect of ruxolitinib on lung function in a cohort of 70 patients diagnosed with sclerotic-type skin cGVHD between March 2015 and April 2018. Among these patients, 36 received ruxolitinib. To handle confounding by indication bias, exposure groups were matched on the propensity score to receive ruxolitinib, incorporating age, myeloablative conditioning, total body irradiation, BOS, forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), and tobacco use at the time of cohort entry, as well as the time from transplantation. The 1:1 matching used a greedy-matching algorithm with replacement, with a caliper of 0.10. FVC and FEV1 trajectories during follow-up were compared in the matched samples, using linear mixed-effects models. The median duration of follow-up of the 46 matched patients was 58 months (interquartile range, 32 to 84 months). Ten patients had an RLD (6 exposed, 4 unexposed), and 13 patients were diagnosed with BOS (8 exposed, 5 unexposed). FEV1 decreased significantly over time independent of exposure to ruxolitinib (P < .0001). The FEV1 trajectory was similar in the exposed patients and the unexposed patients (P = .11). In conclusion, ruxolitinib administration did not demonstrate any improvement in the course of respiratory function in allogeneic HSCT recipients with sclerotic-type skin cGVHD.
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Affiliation(s)
- Louise Bondeelle
- Pneumology Department, Service de Pneumologie, Université de Paris, Hôpital Saint-Louis, AP-HP, Paris, France
| | - Sylvie Chevret
- ECSTRRA Team, Université de Paris, INSERM, UMR 1153 CRESS, Paris, France; Biostatistics and Medical data Department, Service de Biostatistique et Information Médicale, Hôpital Saint-Louis, AP-HP, Paris, France
| | - Charlotte Hurabielle
- Dermatology Department, Service de Dermatologie, Hôpital Saint-Louis, AP-HP, Paris, France
| | - Laila Samy
- Pneumology Department, Service de Pneumologie, Université de Paris, Hôpital Saint-Louis, AP-HP, Paris, France
| | - Tiphaine Goletto
- Pneumology Department, Service de Pneumologie, Université de Paris, Hôpital Saint-Louis, AP-HP, Paris, France
| | - Adrien Costantini
- Pneumology Department, Service de Pneumologie, Université de Paris, Hôpital Saint-Louis, AP-HP, Paris, France
| | - Flore Sicre de Fontbrune
- Hematology-Bone marrow transplant Unit, Hématologie-Greffe, Hôpital St Louis, APHP, Paris, France
| | - David Michonneau
- Hematology-Bone marrow transplant Unit, Hématologie-Greffe, Hôpital St Louis, APHP, Paris, France
| | - Gérard Socié
- Hematology-Bone marrow transplant Unit, Hématologie-Greffe, Hôpital St Louis, APHP, Paris, France
| | - Abdellatif Tazi
- Pneumology Department, Service de Pneumologie, Université de Paris, Hôpital Saint-Louis, AP-HP, Paris, France; INSERM U976, Institut de Recherche Saint-Louis, Paris, France
| | - Jean-David Bouaziz
- Dermatology Department, Service de Dermatologie, Hôpital Saint-Louis, AP-HP, Paris, France
| | - Anne Bergeron
- Pneumology Department, Service de Pneumologie, Université de Paris, Hôpital Saint-Louis, AP-HP, Paris, France; ECSTRRA Team, Université de Paris, INSERM, UMR 1153 CRESS, Paris, France.
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Fante MA, Holler B, Weber D, Angstwurm K, Bergler T, Holler E, Edinger M, Herr W, Wertheimer T, Wolff D. Cyclophosphamide for salvage therapy of chronic graft-versus-host disease: a retrospective analysis. Ann Hematol 2020; 99:2181-2190. [PMID: 32715339 PMCID: PMC7419371 DOI: 10.1007/s00277-020-04193-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 07/20/2020] [Indexed: 12/16/2022]
Abstract
We retrospectively analyzed the safety and efficacy of cyclophosphamide (cyclo) for salvage treatment of chronic graft-versus-host disease (cGvHD) and cGvHD-associated (glomerulo-)nephritis at our center between 01/2010 and 11/2019. We identified 13 patients (pts) receiving cyclo for treatment of moderate (3/13) and severe (6/13) steroid-refractory cGvHD, cGvHD-associated (glomerulo-)nephritis (3/13), or vasculitis-like CNS manifestation of cGvHD (1/13). Cyclo was started on median day 509 (range 42-8193) after cGvHD onset; the median duration of application was 153 days (range 14-486) with 2/13 currently continuing treatment. The National Institute of Health organ grading and the intensity of immunosuppression (IS) were assessed at cyclo start and repeated after 3, 6, and 12 months. Response assessment was stopped at the start of any additional new IS. The median time of follow up was 407 days (range 86-1534). Best response was 1/13 CR, 6/13 PR, 4/13 SD, 1/13 MR, and 1/13 PD (ORR 54%). Significant and durable response was observed especially in cGvHD-associated (glomerulo-)nephritis (3/3). Infectious complications > CTCAE grade III were observed in 3/12 pts. During cyclo therapy, none of the pts suffered from recurrence of underlying malignancy. Overall, cyclo was relatively well tolerated and showed responses in heavily pretreated patients but requires further evaluation within clinical trials.
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Affiliation(s)
- Matthias A Fante
- Department of Hematology and Oncology, Internal Medicine III, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany.
| | - Barbara Holler
- Department of Hematology and Oncology, Internal Medicine III, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Daniela Weber
- Department of Hematology and Oncology, Internal Medicine III, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Klemens Angstwurm
- Department of Neurology, University Hospital Regensburg, Regensburg, Germany
| | - Tobias Bergler
- Department of Nephrology, University Hospital Regensburg, Regensburg, Germany
| | - Ernst Holler
- Department of Hematology and Oncology, Internal Medicine III, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Matthias Edinger
- Department of Hematology and Oncology, Internal Medicine III, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Wolfgang Herr
- Department of Hematology and Oncology, Internal Medicine III, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Tobias Wertheimer
- Department of Hematology and Oncology, Internal Medicine III, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Daniel Wolff
- Department of Hematology and Oncology, Internal Medicine III, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
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Efficacy and immunologic effects of extracorporeal photopheresis plus interleukin-2 in chronic graft-versus-host disease. Blood Adv 2020; 3:969-979. [PMID: 30936057 DOI: 10.1182/bloodadvances.2018029124] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 02/23/2019] [Indexed: 01/15/2023] Open
Abstract
Chronic graft-versus-host disease (cGVHD) affects >50% of hematopoietic stem cell transplant patients. Extracorporeal photopheresis (ECP), an immunomodulatory therapy, provides clinical benefit in steroid-refractory (SR) cGVHD, possibly via regulatory T (Treg) and natural killer (NK) cell expansion. We demonstrated that low-dose interleukin-2 (IL2) led to clinical improvement in SR-cGVHD and stimulated preferential Treg and NK-cell expansion with minimal effect on conventional T (Tcon) cells. We evaluated the effect of ECP (weeks 1-16) plus IL2 (1 × 106 IU/m2, weeks 9-16) in 25 adult patients with SR-cGVHD in a prospective phase 2 trial. Objective responses occurred in 29% and 62% of evaluable patients at weeks 8 (ECP alone) and 16 (ECP plus IL2), respectively. Eight weeks of ECP alone was associated with a marked decline in CD4+ Tcon (P = .03) and CD8+ T cells (P = .0002), with minimal change in Treg cells, Treg:Tcon cell ratio, or NK cells. Adding IL2 induced an increase in Treg cells (P < .05 at weeks 9-16 vs week 8), Treg:Tcon cell ratio (P < .0001 at weeks 9-16 vs week 8), and NK cells (P < .05 at weeks 9-16 vs week 8). Patients responding to ECP alone had significantly fewer CD4+ Tcon and CD8+ T cells at baseline compared with patients who responded after IL2 addition and patients who did not respond; neither Treg nor NK cells were associated with response to ECP alone. Altogether, ECP plus IL2 is safe and effective in patients with SR-cGVHD. ECP and IL2 have distinct immunologic effects, suggesting different therapeutic mechanisms of action. This trial was registered at www.clinicaltrials.gov as #NCT02340676.
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Fall-Dickson JM, Pavletic SZ, Mays JW, Schubert MM. Oral Complications of Chronic Graft-Versus-Host Disease. J Natl Cancer Inst Monogr 2020; 2019:5551350. [PMID: 31425593 DOI: 10.1093/jncimonographs/lgz007] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 03/15/2019] [Accepted: 04/01/2019] [Indexed: 02/07/2023] Open
Abstract
The increasing clinical indications for hematopoietic stem cell transplantation (HSCT) and improved clinical care throughout and following HSCT have led to not only long-term survival but also to an increasing incidence and prevalence of graft-versus-host disease (GVHD). Chronic GVHD (cGVHD) affects almost 50% of adult patients post-HSCT, with increasing incidence in pediatric patients as well. Oral cGVHD specifically has a reported prevalence ranging from 45% to 83% in patients who develop cGVHD and is more extensive in adult patients than in children. Oral cGVHD affects patients through clinically significant oral symptoms that may lead to significantly decreased caloric intake, oral infections, and increased health service utilization, and may thus affect overall health and survival. The most commonly used therapy for mucosal involvement of oral cGVHD is topical high-dose and ultra-high potency corticosteroids, and calcineurin inhibitors. This review of oral complications of cGVHD presents the clinical significance of oral cGVHD to HSCT survivors, our current understanding of the pathobiology of oral cGVHD and gaps in this evidence, and the global targeted interdisciplinary clinical research efforts, including the National Institutes of Health Consensus Development Project on Criteria for Clinical Trials in Chronic Graft-versus-Host Disease. Current challenges regarding the management of oral cGVHD and strategies to advance our scientific understanding of this clinically significant chronic oral disease are presented.
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Affiliation(s)
- Jane M Fall-Dickson
- Department of Professional Nursing Practice, Georgetown University School of Nursing & Health Studies, Washington, DC
| | - Steven Z Pavletic
- Experimental Transplantation and Immunology Branch, National Cancer Institute, Division of Intramural Research, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD
| | - Jacqueline W Mays
- Experimental Transplantation and Immunology Branch, National Cancer Institute, Division of Intramural Research, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD
| | - Mark M Schubert
- Department of Oral Medicine, University of Washington, School of Dentistry and Seattle Cancer Care Alliance and Oral Medicine, Fred Hutchinson Cancer Research Center, Seattle, WA
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Randomized controlled study of ECP with methoxsalen as first-line treatment of patients with moderate to severe cGVHD. Blood Adv 2020; 3:2218-2229. [PMID: 31332045 DOI: 10.1182/bloodadvances.2019000145] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 05/31/2019] [Indexed: 11/20/2022] Open
Abstract
The investigation of extracorporeal photopheresis (ECP) plus standard of care (SoC) (SoC+ECP) in chronic graft-versus-host disease (cGVHD) within prospective, randomized clinical studies is limited, despite its frequent clinical use. This phase 1/pilot study was the first randomized, prospective study to investigate ECP use as first-line therapy in cGVHD, based on the 2015 National Institutes of Health (NIH) consensus criteria for diagnosis and response assessment. Adult patients with new-onset (≤3 years of hematopoietic stem cell transplantation) moderate or severe cGVHD were randomized 1:1 to 26 weeks of SoC+ECP vs SoC (corticosteroids and cyclosporine A/tacrolimus) between 2011 and 2015. The primary endpoint was overall response rate (ORR), defined as complete or partial response, at week 28 in the intention-to-treat population (ITT). Other outcomes included quality of life (QoL) measures and safety. Sixty patients were randomized; ITT included 53 patients (SoC+ECP: 29; SoC: 24). Week 28 ORR was 74.1% (SoC+ECP) and 60.9% (SoC). Investigator-assessed ORR was 56.0% (SoC+ECP) and 66.7% (SoC). Patients treated with SoC experienced a decline in QoL over the 28-week study period; QoL remained unchanged in SoC+ECP patients. Most frequent treatment-emergent adverse events (TEAEs) in SoC+ECP patients were hypertension (31.0%), cough (20.7%), dyspnea (17.2%), and fatigue (17.2%). Seventeen patients (SoC+ECP: 8; SoC: 9) experienced 35 serious adverse events (SAEs). No TEAEs or SAEs were considered related to the ECP instrument or methoxsalen. The encouraging short-term results of this study could inform the design of subsequent studies. This trial was registered at www.clinicaltrials.gov as #NCT01380535.
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Helmberg W, Sipurzynski S, Groselje-Strehle A, Greinix H, Schlenke P. Does Offline Beat Inline Treatment: Investigation into Extracorporeal Photopheresis. Transfus Med Hemother 2020; 47:198-204. [PMID: 32595424 DOI: 10.1159/000506750] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 02/24/2020] [Indexed: 12/17/2022] Open
Abstract
Background Extracorporeal photopheresis is a therapy based on the induction of apoptosis to cells harvested from peripheral blood, followed by direct retransfusion. Currently, there are two approaches: inline procedures, where cell harvesting, 8-methoxypsoralen (8-MOP) incubation, and UV irradiation is performed with a single device, and offline procedures, with collection in one device, followed by 8-MOP incubation/UV irradiation using a second device. Study Design and Methods In a prospective crossover study, we compared an inline (Cellex, Therakos) with an established offline procedure (Optia, Terumo, and MacoGenic G2, Macopharma) in 6 patients, focusing on cell composition and apoptosis induction after 24 h. In total, 32 photopheresis treatments per device were performed. Results We observed an overall 2-fold higher number of apoptotic "target" cells for each patient with offline treatment. All yields were stratified per patient. Yields were compared as ratio offline/inline for CD3+ (2.5-fold), CD4+ (2-fold), CD8+ (2.8-fold), CD56+ (2.8-fold), CD19+ (1.8-fold), CD15+ (0.5-fold), and CD14+ (2.2-fold) cells. Apoptosis induction was measured after 24 h with Annexin V/7-AAD for early and late apoptosis rates of CD3+ (CD4+, CD8+) and CD56+ cells. CD3+ cells of the inline treatment had an average of 88% (26% early, 62% late) of apoptotic cells compared to 75% (34% early, 41% late) in the offline treatment. Procedure duration ranged from 80 to 100 min inline, with a maximum of 1,500 mL processed blood, and 125-140 min offline, with at least 3,000 mL processed blood, depending on blood flow. Average hematocrit levels of the products were 2.7% inline versus 1.7% offline. Conclusions The offline procedure, as established in our department, provides more apoptotic cells for treatment. The increased number of mononuclear cells collected outweighs a slightly reduced apoptosis rate after 24 h in comparison to the inline procedure. Besides this, the final decision for one or the other procedure has to take into account additional aspects, such as peripheral white blood cell count, hematocrit, and weight of the patient, required before apheresis, extracorporeal volume, and, last but not least, overall costs. The final criterion, however, has to be the reported clinical efficacy of the system applied.
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Affiliation(s)
- Wolfgang Helmberg
- Blood Group Serology and Transfusion Medicine, Medical University Graz, Graz, Austria
| | - Sabine Sipurzynski
- Blood Group Serology and Transfusion Medicine, Medical University Graz, Graz, Austria
| | - Andrea Groselje-Strehle
- Core Facility Computational Bioanalytics, Center for Medical Research, Medical University Graz, Graz, Austria
| | | | - Peter Schlenke
- Blood Group Serology and Transfusion Medicine, Medical University Graz, Graz, Austria
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Gonzalez RM, Pidala J. Evolving Therapeutic Options for Chronic Graft‐versus‐Host Disease. Pharmacotherapy 2020; 40:756-772. [DOI: 10.1002/phar.2427] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 04/04/2020] [Accepted: 04/13/2020] [Indexed: 12/17/2022]
Affiliation(s)
- Rebecca M. Gonzalez
- Department of Blood & Marrow Transplant and Cellular Immunotherapy (BMT CI) Moffitt Cancer Center Tampa Florida USA
- Department of Pharmacy Moffitt Cancer Center Tampa Florida USA
| | - Joseph Pidala
- Department of Blood & Marrow Transplant and Cellular Immunotherapy (BMT CI) Moffitt Cancer Center Tampa Florida USA
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Wang X, Billick M, Monsour D, Liu J. Central nervous system graft-versus-host disease in a 68-year-old man presenting with myoclonus. CMAJ 2020; 191:E1078-E1081. [PMID: 31570546 DOI: 10.1503/cmaj.190216] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Xin Wang
- Divisions of General Internal Medicine (Wang, Billick, Liu) and Neurology (Monsour), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.
| | - Maxime Billick
- Divisions of General Internal Medicine (Wang, Billick, Liu) and Neurology (Monsour), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont
| | - Danny Monsour
- Divisions of General Internal Medicine (Wang, Billick, Liu) and Neurology (Monsour), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont
| | - Jessica Liu
- Divisions of General Internal Medicine (Wang, Billick, Liu) and Neurology (Monsour), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.
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Bactericidal activity and recovery effect of hydroxyl radicals generated by ultraviolet irradiation and silver ion application on an infected titanium surface. Sci Rep 2020; 10:8553. [PMID: 32444858 PMCID: PMC7244495 DOI: 10.1038/s41598-020-65411-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 04/05/2020] [Indexed: 12/03/2022] Open
Abstract
This study investigated the bactericidal effect, the underlying mechanisms of treatment, and recovery of biocompatibility of the infected titanium surface using a combination treatment of silver ion application and ultraviolet-A (UV-A) light irradiation. Streptococcus mutans and Aggregatibacter actinomycetemcomitans were used in suspension and as a biofilm on a titanium surface to test for the bactericidal effect. The bactericidal effect of the combination treatment was significantly higher than that of silver ion application or UV-A light irradiation alone. The bactericidal effect of the combination treatment was attributable to hydroxyl radicals, which generated from the bacterial cell wall and whose yield increased with the silver concentration. To assess the biocompatibility, proliferation and calcification of MC3T3E1 cells were evaluated on the treated titanium surface. The treated titanium screws were implanted into rat tibias and the removal torques were measured 28 days post-surgery. The titanium surface that underwent the combination treatment exhibited recovery of biocompatibility by allowing cellular proliferation or calcification at levels observed in the non-infected titanium surfaces. The removal torque 28 days after surgery was also comparable to the control values. This approach is a novel treatment option for peri-implantitis.
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45
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Hui L, Qi L, Guoyu H, Xuliang S, Meiao T. Ruxolitinib for treatment of steroid-refractory graft-versus-host disease in adults: a systematic review and meta-analysis. Expert Rev Hematol 2020; 13:565-575. [PMID: 32178541 DOI: 10.1080/17474086.2020.1738214] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Objectives: Authors assessed the impact of ruxolitinib (RUX) on steroid-refractory graft-versus-host disease (SR-GVHD) patients.Methods: Studies published before January 2019 were identified by electronic search of MEDLINE, EMBASE, Cochrane Library, Clinical Trials.Gov and Web of Science databases.Results: Sixteen cohort studies (414 adults) were included whose methodological quality ranged from poor to good. Pooled outcomes such as the response rates, steroid dose reduction, 1-year overall survival, overall infection, and grade 3 to 4 cytopenia were calculated separately for adults with steroid-refractory acute GVHD (aGVHD) and chronic GVHD (cGVHD). Further, the overall response rates were analyzed according to the affected organ. Adults with aGVHD as well as cGVHD showed high response with RUX, and steroid dose reduction was observed in both cases. Infection rates and cytopenia were important safety concerns for both aGVHD and cGVHD.Conclusion: Notwithstanding the need of randomized controlled trials to confirm the effect of RUX on SR-GVHD, response rates among adults with aGVHD and cGVHD seem to be high with the use of RUX as a salvage treatment, particularly in cases with gastrointestinal and cutaneous involvement. However, high rates of myelosuppression and infection remain a cause for concern regardless of aGVHD or cGVHD.
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Affiliation(s)
- Li Hui
- Department of Hematology, Zhuzhou Central Hospital, The Affiliated Zhuzhou Hospital of Xiangya Medical College of Central South University, Zhuzhou, Hunan, China
| | - Li Qi
- Department of Gastroenterology, Shaoyang Hospital of TCM, Shaoyang, Hunan, China
| | - Hu Guoyu
- Department of Hematology, Zhuzhou Central Hospital, The Affiliated Zhuzhou Hospital of Xiangya Medical College of Central South University, Zhuzhou, Hunan, China
| | - Shen Xuliang
- Graduate School, Changzhi Medical College, Changzhi, Shanxi, China.,Department of Hematology, Heping Hospital of Changzhi Medical College, Changzhi, Shanxi, China
| | - Tan Meiao
- Graduate School, First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
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Kattner AS, Holler E, Holler B, Klobuch S, Weber D, Martinovic D, Edinger M, Herr W, Wolff D. IL6-receptor antibody tocilizumab as salvage therapy in severe chronic graft-versus-host disease after allogeneic hematopoietic stem cell transplantation: a retrospective analysis. Ann Hematol 2020; 99:847-853. [PMID: 32086584 PMCID: PMC7069928 DOI: 10.1007/s00277-020-03968-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 02/15/2020] [Indexed: 12/20/2022]
Abstract
Chronic graft-versus-host disease (cGvHD) remains the most relevant factor affecting survival after allogeneic hematopoietic stem cell transplantation (alloHSCT). Besides corticosteroids (and ibrutinib in the USA), there is no established therapy for cGvHD. Tocilizumab, a humanized IgG1 IL6-receptor antibody, has shown efficacy in acute GvHD and cGvHD. We retrospectively analyzed the efficacy and safety of tocilizumab for the treatment of advanced cGvHD. Eleven patients with severe steroid refractory cGvHD (median age 49; range 21–62 years) that received at least two prior lines of therapy for cGvHD (range 2–8 regimens) were treated with tocilizumab (q4w, dosage 8 mg/kg IV) with a median number of 15 cycles (range 2–31). NIH consensus criteria grading for cGvHD were recorded prior to tocilizumab administration and after 3, 6, and 12 months of therapy. All patients received additional concomitant immunosuppression (IS) but no new IS within the last 4 weeks before start of tocilizumab and response assessment was terminated before start of any new IS. The median number of days between alloHSCT and initiation of tocilizumab therapy was 1033 days. Organs involved at initiation of tocilizumab therapy were skin (100%, all grade 3), eyes (82%), fascia (82%), mouth (64%), lungs (55%), and genitals (18%). Overall, 7/10 patients (70%) showed partial remission, 2/10 patients (20%) showed progressive cGvHD, 1/10 patient (10%) showed mixed response, and 1 patient died due to sepsis before first response assessment 1.5 months after initiation of treatment. Four patients required subsequent new immunosuppressive treatment. Two patients developed bacterial sepsis, one of whom died. The overall survival and relapse-free survival were 82% with an average follow-up of 22 months (range 1.5–52 months). Tocilizumab seems a promising treatment option in advanced cGvHD but further evaluation within a phase II trial is required.
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Affiliation(s)
- Anna-Sophia Kattner
- Department of Internal Medicine III, Hematology & Internal Oncology, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Ernst Holler
- Department of Internal Medicine III, Hematology & Internal Oncology, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Barbara Holler
- Department of Internal Medicine III, Hematology & Internal Oncology, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Sebastian Klobuch
- Department of Internal Medicine III, Hematology & Internal Oncology, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Daniela Weber
- Department of Internal Medicine III, Hematology & Internal Oncology, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Danilo Martinovic
- Department of Internal Medicine III, Hematology & Internal Oncology, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Matthias Edinger
- Department of Internal Medicine III, Hematology & Internal Oncology, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Wolfgang Herr
- Department of Internal Medicine III, Hematology & Internal Oncology, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Daniel Wolff
- Department of Internal Medicine III, Hematology & Internal Oncology, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany.
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47
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Mankarious M, Matthews NC, Snowden JA, Alfred A. Extracorporeal Photopheresis (ECP) and the Potential of Novel Biomarkers in Optimizing Management of Acute and Chronic Graft vs. Host Disease (GvHD). Front Immunol 2020; 11:81. [PMID: 32082329 PMCID: PMC7005102 DOI: 10.3389/fimmu.2020.00081] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 01/13/2020] [Indexed: 12/14/2022] Open
Abstract
As the use of hematopoietic stem cell transplantation (HSCT) has become a more widespread and effective treatment for hematological malignant and non-malignant conditions, the need to minimize the harmful effects of graft- vs.-host disease (GvHD) has become more important in achieving good outcomes. With diagnosis of GvHD reliant on its clinical manifestations, research into biomarkers for the diagnosis, progression, and even for the prediction of disease, is imperative to combating the high levels of morbidity and mortality post-HSCT. Despite the development of novel treatment approaches to GvHD, corticosteroids remain the standard first-line treatment, with immunosuppressant therapies as second-line options. These strategies however have significant limitations and associated complications. Extracorporeal Photopheresis (ECP) has shown to be effective and safe in treating patients with symptomatic GvHD. ECP has been shown to have varied effects on multiple parts of the immune system and does not appear to increase the risk of relapse or infection in the post HSCT setting. Even so, ECP can be logistically more complex to organize and requires patients to be sufficiently stable. This review aims to summarize the potential role of biomarkers to help guide individualized treatment decisions in patients with acute and chronic GvHD. In relation to ECP, robust biomarkers of GvHD will be highly useful in informing patient selection, intensity and duration of the ECP schedule, monitoring of response and other treatment decisions alongside the concurrent administration of other GvHD therapies. Further research is warranted to establish how GvHD biomarkers are best incorporated into ECP treatment pathways with the goal of tailoring ECP to the needs of individual patients and maximizing benefit.
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Affiliation(s)
- Matthew Mankarious
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Nick C Matthews
- Department of Photopheresis, The Rotherham NHS Foundation Trust, Rotherham, United Kingdom
| | - John A Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Arun Alfred
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, United Kingdom.,Department of Photopheresis, The Rotherham NHS Foundation Trust, Rotherham, United Kingdom
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48
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Kim YJ, Lee GH, Kwong BY, Martires KJ. Evidence-based, Skin-directed Treatments for Cutaneous Chronic Graft-versus-host Disease. Cureus 2019; 11:e6462. [PMID: 32025391 PMCID: PMC6977575 DOI: 10.7759/cureus.6462] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Chronic graft-versus host disease (cGVHD) occurs in 30% to 70% of patients undergoing allogeneic hematopoietic cell transplantation (HCT). Cutaneous cGVHD affects 75% of cGVHD patients, causing discomfort, limiting the range of movement, and increasing the risk of wound infections. Furthermore, systemic immunosuppression is often needed to treat cGVHD and long-term use can lead to adverse events. Optimal use of skin-directed therapies is integral to the management of cutaneous cGVHD and may decrease the amount of systemic immunosuppression required. This study reviewed English-language articles published from 1990 to 2017 that evaluated the effect of skin-directed treatments for cutaneous cGVHD. A total of 201 papers were identified, 164 articles were screened, 46 were read, and 18 publications were utilized in the review. Skin-directed treatments for cGVHD included topical steroids, topical calcineurin inhibitors, psoralen with ultraviolet A (PUVA) irradiation, ultraviolet A1 (UVA1) irradiation, and ultraviolet B (UVB) irradiation. We report the number of complete remissions, partial remissions, and systemic immunosuppression reduction in each study, as available. Twenty-two out of 30 (73.3%) patients experienced overall improvement with topical calcineurin inhibitors. At least 26 out of 76 patients (34.2%) receiving PUVA experienced complete remission, and 30 out of 76 patients (39.5%) experienced partial remission. In UVA1 studies, 44 out of 52 (84.6%) patients experienced overall improvement. In UVB studies, nine out of 14 patients (64.3%) experienced complete remission and four out of 14 patients (28.6%) experienced partial remission. As more HCTs are performed, more individuals will develop cGVHD. Awareness and optimal use of skin-directed therapies for cutaneous cGVHD may help improve patient outcomes and quality of life.
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Affiliation(s)
- Yoo Jung Kim
- Department of Dermatology, Stanford University School of Medicine, Stanford, USA
| | - Gun Ho Lee
- Department of Dermatology, Stanford University School of Medicine, Stanford, USA
| | - Bernice Y Kwong
- Department of Dermatology, Stanford University School of Medicine, Stanford, USA
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Lv M, Zhang X, Xu L, Wang Y, Yan C, Chen H, Chen Y, Han W, Wang F, Wang J, Liu K, Huang X, Mo X. Risk factors for chronic graft-versus-host disease after anti-thymocyte globulin-based haploidentical hematopoietic stem cell transplantation in acute myeloid leukemia. Front Med 2019; 13:667-679. [PMID: 31512033 DOI: 10.1007/s11684-019-0702-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Accepted: 05/21/2019] [Indexed: 11/29/2022]
Abstract
Chronic graft-versus-host disease (cGVHD) is a major complication following unmanipulated haploidentical hematopoietic stem cell transplantation (haplo-HSCT). We aimed to identify the risk factors for cGVHD in patients who underwent anti-thymocyte globulin-based haplo-HSCT for acute myeloid leukemia (n = 280). The diagnosis of cGVHD was in accordance with the National Institutes of Health consensus criteria. A total of 169 patients suffered from cGVHD. The patients who had 3 loci mismatched had a higher 8-year incidence of cGVHD (total, 66.0% vs. 53.7%, P = 0.031; moderate to severe, 42.4% vs. 30.1%, P = 0.036) than the patients who had 1 to 2 loci mismatched. The patients who had maternal donors had a higher 8-year incidence of moderate to severe cGVHD (49.2% vs. 32.9%, P = 0.024) compared with the patients who had other donors. The patients who had grades III to IV acute GVHD (aGVHD) had higher 8-year incidence of cGVHD (total, 88.0% vs. 50.4%, P < 0.001; moderate to severe, 68.0% vs. 27.0%, P < 0.001) compared with the patients without aGVHD. In multivariate analysis, grades III to IV aGVHD was the only independent risk factor for cGVHD. Thus, further interventions should be considered in patients with severe aGVHD to prevent cGVHD.
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Affiliation(s)
- Meng Lv
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, 100044, China
| | - Xiaohui Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, 100044, China
| | - Lanping Xu
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, 100044, China
| | - Yu Wang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, 100044, China
| | - Chenhua Yan
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, 100044, China
| | - Huan Chen
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, 100044, China
| | - Yuhong Chen
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, 100044, China
| | - Wei Han
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, 100044, China
| | - Fengrong Wang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, 100044, China
| | - Jingzhi Wang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, 100044, China
| | - Kaiyan Liu
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, 100044, China
| | - Xiaojun Huang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, 100044, China.,Peking-Tsinghua Center for Life Sciences, Academy for Advanced Interdisciplinary Studies, Peking University, Beijing, 100044, China
| | - Xiaodong Mo
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, 100044, China.
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Anti-Tumor Potential of IMP Dehydrogenase Inhibitors: A Century-Long Story. Cancers (Basel) 2019; 11:cancers11091346. [PMID: 31514446 PMCID: PMC6770829 DOI: 10.3390/cancers11091346] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 09/01/2019] [Accepted: 09/02/2019] [Indexed: 01/15/2023] Open
Abstract
The purine nucleotides ATP and GTP are essential precursors to DNA and RNA synthesis and fundamental for energy metabolism. Although de novo purine nucleotide biosynthesis is increased in highly proliferating cells, such as malignant tumors, it is not clear if this is merely a secondary manifestation of increased cell proliferation. Suggestive of a direct causative effect includes evidence that, in some cancer types, the rate-limiting enzyme in de novo GTP biosynthesis, inosine monophosphate dehydrogenase (IMPDH), is upregulated and that the IMPDH inhibitor, mycophenolic acid (MPA), possesses anti-tumor activity. However, historically, enthusiasm for employing IMPDH inhibitors in cancer treatment has been mitigated by their adverse effects at high treatment doses and variable response. Recent advances in our understanding of the mechanistic role of IMPDH in tumorigenesis and cancer progression, as well as the development of IMPDH inhibitors with selective actions on GTP synthesis, have prompted a reappraisal of targeting this enzyme for anti-cancer treatment. In this review, we summarize the history of IMPDH inhibitors, the development of new inhibitors as anti-cancer drugs, and future directions and strategies to overcome existing challenges.
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