1
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Ben Abdeljelil N, Ben Yaiche I, Ouerghi R, Torjemane L, Belloumi D, Turki I, Mekni S, Kanoun RY, Ben Othman T, Ladeb S. Cyclophosphamide and horse anti-thymocyte globulin versus fludarabine, reduced cyclophosphamide and rabbit anti-thymocyte globulin conditioning regimen for allogeneic hematopoietic stem cell transplantation from matched sibling donors in patients with acquired aplastic anemia. Expert Rev Hematol 2024; 17:527-538. [PMID: 39011776 DOI: 10.1080/17474086.2024.2381572] [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: 01/18/2024] [Accepted: 07/15/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is a potentially curative treatment for acquired aplastic anemia (acquired AA) in young patients. The objective of the study was to compare patient outcomes after Cyclophosphamide and horse antithymocyte globulin (Cy-hATG) versus Fludarabine-cyclophosphamide and rabbit ATG (Flu-Cy-rATG) as part of conditioning regimen in allo-HSCT for acquired AA. RESEARCH DESIGN AND METHODS Descriptive retrospective study conducted on patients with acquired AA who received allo-HSCT from HLA-matched sibling donors between January 2008 and August 2022 after conditioning regimen with Cy-hATG or Flu-Cy-rATG. RESULTS A total of 121 patients were enrolled. Cumulative incidence of graft failure was 11.2% in Cy-hATG and 5.3% Flu-Cy-rATG group. There were no significant differences between the two groups in terms of acute GVHD, chronic GVHD, and transplant related mortality. Flu-Cy-rATG group was associated with significantly higher CMV and EBV reactivation(s) compared to Cy-hATG group (p = 0.008 and 0.035, respectively). After a median follow-up of 58 months, estimated overall survival, event-free survival, and graft rejection-free survival were not statistically different between the two groups. CONCLUSIONS In high-risk population, Flu-Cy-rATG is associated with comparable outcomes to Cy-hATG in allo-HSCT from MSD. However, it seems to be associated with significant risk of viral infections.
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Affiliation(s)
- Nour Ben Abdeljelil
- Centre National de Greffe de Moelle Osseuse, Université de Tunis El Manar Tunis, Tunis, Tunisia
| | - Insaf Ben Yaiche
- Centre National de Greffe de Moelle Osseuse, Université de Tunis El Manar Tunis, Tunis, Tunisia
| | - Rihab Ouerghi
- Centre National de Greffe de Moelle Osseuse, Université de Tunis El Manar Tunis, Tunis, Tunisia
| | - Lamia Torjemane
- Centre National de Greffe de Moelle Osseuse, Université de Tunis El Manar Tunis, Tunis, Tunisia
| | - Dorra Belloumi
- Centre National de Greffe de Moelle Osseuse, Université de Tunis El Manar Tunis, Tunis, Tunisia
| | - Ines Turki
- Centre National de Greffe de Moelle Osseuse, Université de Tunis El Manar Tunis, Tunis, Tunisia
| | - Sabrine Mekni
- Centre National de Greffe de Moelle Osseuse, Université de Tunis El Manar Tunis, Tunis, Tunisia
| | - Rimel Yousr Kanoun
- Centre National de Greffe de Moelle Osseuse, Université de Tunis El Manar Tunis, Tunis, Tunisia
| | - Tarek Ben Othman
- Centre National de Greffe de Moelle Osseuse, Université de Tunis El Manar Tunis, Tunis, Tunisia
| | - Saloua Ladeb
- Centre National de Greffe de Moelle Osseuse, Université de Tunis El Manar Tunis, Tunis, Tunisia
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2
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Iftikhar R, Chaudhry QUN, Anwer F, Neupane K, Rafae A, Mahmood SK, Ghafoor T, Shahbaz N, Khan MA, Khattak TA, Shamshad GU, Rehman J, Farhan M, Khan M, Ansar I, Ashraf R, Marsh J, Satti TM, Ahmed P. Allogeneic hematopoietic stem cell transplantation in aplastic anemia: current indications and transplant strategies. Blood Rev 2020; 47:100772. [PMID: 33187812 DOI: 10.1016/j.blre.2020.100772] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 09/12/2020] [Accepted: 10/15/2020] [Indexed: 12/18/2022]
Abstract
Treatment options for newly diagnosed aplastic anemia (AA) patient includes upfront allogeneic hematopoietic stem cell transplant (HSCT) or immunosuppressive therapy (IST). With recent advances in supportive care, conditioning regimens and post-transplant immunosuppression the overall survival for HSCT approaches 70-90%. Transplant eligibility needs to be assessed considering age, comorbidities, donor availability and probability of response to immunosuppressive therapy (IST). Upfront HSCT should be offered to children and young adults with matched related donor (MRD). Upfront HSCT may also be offered to children and young adults with rapidly available matched unrelated donor (MUD) who require urgent HSCT. Bone marrow (BM) graft source and cyclosporine (CsA) plus methotrexate (MTX) as graft versus host disease (GVHD) prophylaxis are preferable when using anti-thymocyte globulin (ATG) based conditioning regimens. Alemtuzumab is an acceptable alternative to ATG and is used with CsA alone and with either BM or peripheral blood stem cells (PBSC). Cyclophosphamide (CY) plus ATG conditioning is preferable for patients receiving MRD transplant, while Fludarabine (Flu) based conditioning is reserved for older adults, those with risk factors of graft failure and those receiving MUD HSCT. For haploidentical transplant, use of low dose radiotherapy and post-transplant cyclophosphamide has resulted in a marked reduction in graft failure and GVHD.
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Affiliation(s)
- Raheel Iftikhar
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan.
| | - Qamar Un Nisa Chaudhry
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Faiz Anwer
- Department of Hematology, Medical Oncology, Tausig Cancer Center, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Karun Neupane
- Department of Internal Medicine, Manipal College of Medical Sciences, Pokhara 33700, Nepal
| | - Abdul Rafae
- Department of Internal Medicine, McLaren Flint Michigan State University, United States
| | - Syed Kamran Mahmood
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Tariq Ghafoor
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Nighat Shahbaz
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Mehreen Ali Khan
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Tariq Azam Khattak
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Ghassan Umair Shamshad
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Jahanzeb Rehman
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Muhammad Farhan
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Maryam Khan
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Iqraa Ansar
- Shifa College of Medicine, Islamabad 44000, Pakistan
| | - Rabia Ashraf
- King Edward Medical University, Lahore 54000, Pakistan
| | - Judith Marsh
- Department of Hematological Medicine, King's College Hospital, Denmark Hill, London SE59RS, UK
| | | | - Parvez Ahmed
- Department of Hematology Oncology and Stem Cell Transplant, Quaid-e-Azam International Hospital, Islamabad 44000, Pakistan
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3
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Iftikhar R, Chaudhry QUN, Mahmood SK, Ghafoor T, Satti HS, Shahbaz N, Khan MA, Khattak TA, Shamshad GU, Rehman J, Farhan M, Humayun S, Risalat A, Wahab A, Satti TM, Anwer F, Ahmed P. Single-Agent Cyclosporine for Graft-versus-Host Disease Prophylaxis in Patients with Acquired Aplastic Anemia Receiving Fludarabine-Based Conditioning. Biol Blood Marrow Transplant 2020; 26:2245-2251. [PMID: 32717437 DOI: 10.1016/j.bbmt.2020.07.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 07/16/2020] [Accepted: 07/20/2020] [Indexed: 11/20/2022]
Abstract
Cyclosporine (CsA) combined with short-course methotrexate is considered standard-of-care graft-versus-host disease (GVHD) prophylaxis for patients with severe aplastic anemia (AA) who undergo transplantation using cyclophosphamide (Cy) plus anti-thymocyte globulin (ATG) conditioning. However, there is no consensus on optimal post-transplant GVHD prophylaxis for patients undergoing matched related donor (MRD) transplantation using fludarabine (Flu)-based conditioning. We conducted a single-center retrospective analysis of patients with acquired AA (n = 106) undergoing MRD transplantation from July 2007 through January 2019. All patients received Flu-Cy-ATG conditioning and single-agent CsA as GVHD prophylaxis. Median age of the study cohort was 20 years (range, 3 to 52) and male to female ratio was 3.8:1. Median time from diagnosis to transplant was 11.5 months (range, 2.8 to 62). Graft source was bone marrow harvest in 71 (68%), combined bone marrow and peripheral blood stem cells in 34 (31%), and peripheral blood alone in 1 (1%) patient. Cumulative incidence of neutrophil engraftment at day 28 was 93.4% (95% confidence interval [CI], 87.3% to 97.1%) while that of platelet engraftment at day 100 was 90.5% (95% CI, 84% to 96%). Cumulative incidence of primary graft failure at day 28 was 6.6% (95% CI, 4% to 8%) while secondary graft failure occurred at a median of 190 days (range, 90 to 415) at a cumulative incidence of 3.7% (95% CI, 2% to 5%). Cumulative incidence of grade II to IV acute GVHD at day 100 was 3.8% (95% CI, 1.4% to 9.9%), while a 1-year probability of chronic GVHD was calculated as 7.5% (95% CI, 2.6% to 15%). Median follow-up post-transplant was 61 months (range, 6 to 144). Overall survival was 84.9%, disease-free survival was 80.2%, and GVHD-free relapse-free survival was 76.3%. This study indicates that single-agent cyclosporine is a feasible option for GVHD prophylaxis in MRD hematopoietic stem cell transplantation using Flu-Cy-ATG conditioning and is associated with very low rates of acute and chronic GVHD.
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Affiliation(s)
- Raheel Iftikhar
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi, Pakistan.
| | - Qamar Un Nisa Chaudhry
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi, Pakistan
| | - Syed Kamran Mahmood
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi, Pakistan
| | - Tariq Ghafoor
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi, Pakistan
| | - Humayun Shafique Satti
- Department of Molecular Hematology, National University of Medical Sciences, Rawalpindi, Pakistan
| | - Nighat Shahbaz
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi, Pakistan
| | - Mehreen Ali Khan
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi, Pakistan
| | - Tariq Azam Khattak
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi, Pakistan
| | - Ghassan Umair Shamshad
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi, Pakistan
| | - Jahanzeb Rehman
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi, Pakistan
| | - Muhammad Farhan
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi, Pakistan
| | - Saima Humayun
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi, Pakistan
| | - Amina Risalat
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi, Pakistan
| | - Ahsan Wahab
- Baptist Medical Center South, Montgomery, Alabama
| | | | - Faiz Anwer
- Department of Hematology, Medical Oncology, Tausig Cancer Center, Cleveland Clinic, Cleveland, Ohio
| | - Parvez Ahmed
- Department of Hematology Oncology and Stem Cell Transplant, Quaid-e-Azam International Hospital, Islamabad, Pakistan
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Iftikhar R, Chaudhry QUN, Satti TM, Mahmood SK, Ghafoor T, Shamshad GU, Shahbaz N, Khan MA, Khattak TA, Rehman J, Farhan M, Humayun S, Haq H, Naqvi SAA, Anwer F, Satti HS, Ahmed P. Comparison of Conventional Cyclophosphamide versus Fludarabine-Based Conditioning in High-Risk Aplastic Anemia Patients Undergoing Matched-Related Donor Transplantation. Clin Hematol Int 2020; 2:82-91. [PMID: 34595447 PMCID: PMC8432348 DOI: 10.2991/chi.d.200426.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 04/24/2020] [Indexed: 11/30/2022] Open
Abstract
Allogeneic stem cell transplant for high-risk aplastic anemia (AA) yields inferior results using conventional cyclophosphamide (CY)-based conditioning. The use of fludarabine (Flu)-based regimens has resulted in improved outcomes in high-risk patients. Limited data are available comparing these two conditioning regimens in such patients. We retrospectively analyzed 192 high-risk patients undergoing matched-related donor transplantation from July 2001 to December 2018. The median age was 19.5 (2–52) years. Patients were divided into 2 groups, Cy200 anti-thymocyte globulin (ATG)20 (Gp1 n = 79) or Flu120–150 Cy120–160 ATG20 (Gp2 n = 113). The risk of graft failure was significantly higher in Gp1, and the majority occurred in patients with >2 risk factors (p = 0.02). The incidence of grade II-IV acute graft versus host disease (GVHD) and chronic GVHD was not significantly different between the two groups. The overall survival (OS) of the study cohort was 81.3 %, disease-free survival (DFS) 76.6 % and GVHD-free relapse-free survival (GRFS) was 64.1%. DFS and GRFS were significantly higher in Gp2 as compared to Gp1: DFS 84.1% versus 68.4 % (p = 0.02), GRFS 77.9% versus 54.4% (p = 0.01), respectively. We conclude that Flu-based conditioning is associated with superior OS, DFS and GRFS as compared to the conventional Cy-based regimen in high-risk AA.
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Affiliation(s)
- Raheel Iftikhar
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Qamar Un Nisa Chaudhry
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Tariq Mehmood Satti
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Syed Kamran Mahmood
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Tariq Ghafoor
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Ghassan Umair Shamshad
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Nighat Shahbaz
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Mehreen Ali Khan
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Tariq Azam Khattak
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Jahanzeb Rehman
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Muhammad Farhan
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Saima Humayun
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Humera Haq
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Syeda Ammaara Anwaar Naqvi
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Faiz Anwer
- Department of Hematology, Medical Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH 44195, USA
| | | | - Parvez Ahmed
- Department of Hematology-Oncology and Stem Cell Transplant, Quaid-e-Azam International Hospital, Islamabad 44000, Pakistan
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5
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Chaudhry QUN, Iftikhar R, Satti TM, Mahmood SK, Ghafoor T, Shamshad GU, Farhan M, Shahbaz N, Khan MA, Khattak TA, Rehman J, Humayun S, Satti HS, Anwer F, Ahmed P. Outcome of Fludarabine-Based Conditioning in High-Risk Aplastic Anemia Patients Undergoing Matched Related Donor Transplantation: A Single-Center Study from Pakistan. Biol Blood Marrow Transplant 2019; 25:2375-2382. [DOI: 10.1016/j.bbmt.2019.07.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 07/08/2019] [Accepted: 07/23/2019] [Indexed: 10/26/2022]
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6
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Ren J, Lin Q, Chen W, Lin C, Zhang Y, Chen C, Chen S, Yuan X, Chen P, Luo X, Lin Y, Shen L, Guo M, Chen Q, Xiao M, Chen Y, Wu X, Zeng Y, Chen Z, Ma X, Hu J, Yang T. G-CSF-primed haplo-identical HSCT with intensive immunosuppressive and myelosuppressive treatments does not increase the risk of pre-engraftment bloodstream infection: a multicenter case-control study. Eur J Clin Microbiol Infect Dis 2019; 38:865-876. [PMID: 30685808 DOI: 10.1007/s10096-019-03482-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 01/03/2019] [Indexed: 01/26/2023]
Abstract
A multicenter retrospective study in 131 patients (44 females/87 males) with hematological disorders who underwent G-CSF-primed/haplo-identical (Haplo-ID) (n = 76) or HLA-identical (HLA-ID) HSCT (n = 55) from February 2013 to February 2016 was conducted to compare the incidence and risk factors for pre-engraftment bloodstream infection (PE-BSI). In the Haplo-ID group, 71/76 patients with high-risk (n = 28) or relapsed/refractory hematological malignancies (n = 43) received FA5-BUCY conditioning (NCT02328950). All received trimethoprim-sulfamethoxazole (TMP-SMX) prophylaxis. Blood cultures and catheter tip cultures were obtained to confirm the BSI. PE-BSI was detected in 24/131 HSCT patients (18/76 in Haplo-ID and 6/55 in HLA-ID) after 28 febrile neutropenic episodes. Among 28 isolates for the 24 patients, 21 (75%) were Gneg bacteria, 6 (21.4%) Gpos and 1 (3.6%) fungi. Bacteria sources were central venous line infection (7/29.2%), gastroenteritis (6/25%), lower respiratory tract infection (LRTI; 5/20.8%), perianal skin infection (4/16.7%), and unknown (2/8.3%). The duration of neutropenia (P = 0.046) and previous Gneg bacteremia (P = 0.037) were important risk factors by univariate analysis, while the type of HSCT was not. A trend of TMP-SMX-resistant BSI in both groups may be due to routine antibacterial prophylaxis strategies. Our data show that G-CSF-primed Haplo-ID HSCT did not increase the risk of PE-BSI, even with intensive immunosuppressive treatments.
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Affiliation(s)
- Jinhua Ren
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Medical University Union Hospital, No. 29 Xinquan Rd, 350001, Fuzhou, Fujian, People's Republic of China
| | - Qiaoxian Lin
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Medical University Union Hospital, No. 29 Xinquan Rd, 350001, Fuzhou, Fujian, People's Republic of China.,Department of Hematology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350001, Fujian, People's Republic of China
| | - Weimin Chen
- Department of Hematology, Fujian Provincial Hospital, Fuzhou, 350001, Fujian, People's Republic of China
| | - Congmeng Lin
- Department of Hematology, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, 363000, Fujian, People's Republic of China
| | - Yuxin Zhang
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Medical University Union Hospital, No. 29 Xinquan Rd, 350001, Fuzhou, Fujian, People's Republic of China
| | - Cunrong Chen
- Department of Intensive Care Unit, Fujian Medical University Union Hospital, Fuzhou, 350001, Fujian, People's Republic of China
| | - Shaozhen Chen
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Medical University Union Hospital, No. 29 Xinquan Rd, 350001, Fuzhou, Fujian, People's Republic of China
| | - Xiaohong Yuan
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Medical University Union Hospital, No. 29 Xinquan Rd, 350001, Fuzhou, Fujian, People's Republic of China
| | - Ping Chen
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Medical University Union Hospital, No. 29 Xinquan Rd, 350001, Fuzhou, Fujian, People's Republic of China
| | - Xiaofeng Luo
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Medical University Union Hospital, No. 29 Xinquan Rd, 350001, Fuzhou, Fujian, People's Republic of China
| | - Yun Lin
- Department of Hematology, Fujian Provincial Hospital, Fuzhou, 350001, Fujian, People's Republic of China
| | - Lvying Shen
- Department of Hematology, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, 363000, Fujian, People's Republic of China
| | - Mengxian Guo
- Department of Hematology, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, 363000, Fujian, People's Republic of China
| | - Qiuru Chen
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Medical University Union Hospital, No. 29 Xinquan Rd, 350001, Fuzhou, Fujian, People's Republic of China
| | - Min Xiao
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Medical University Union Hospital, No. 29 Xinquan Rd, 350001, Fuzhou, Fujian, People's Republic of China
| | - Yongquan Chen
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Medical University Union Hospital, No. 29 Xinquan Rd, 350001, Fuzhou, Fujian, People's Republic of China
| | - Xueqiong Wu
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Medical University Union Hospital, No. 29 Xinquan Rd, 350001, Fuzhou, Fujian, People's Republic of China
| | - Yanling Zeng
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Medical University Union Hospital, No. 29 Xinquan Rd, 350001, Fuzhou, Fujian, People's Republic of China.,Department of Hematology, Affiliated Nanping First Hospital of Fujian Medical University, Nanping, 353000, Fujian, People's Republic of China
| | - Zhizhe Chen
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Medical University Union Hospital, No. 29 Xinquan Rd, 350001, Fuzhou, Fujian, People's Republic of China
| | - Xudong Ma
- Department of Hematology, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, 363000, Fujian, People's Republic of China
| | - Jianda Hu
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Medical University Union Hospital, No. 29 Xinquan Rd, 350001, Fuzhou, Fujian, People's Republic of China
| | - Ting Yang
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Medical University Union Hospital, No. 29 Xinquan Rd, 350001, Fuzhou, Fujian, People's Republic of China.
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7
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Ghanem KM, Kharfan-Dabaja MA, El-Solh H, Harris N, Kreidieh N, Nehme R, Muwakkit SA, Saab R, Bazarbachi A, Abboud MR. Fludarabine-based reduced intensity regimen for matched related donor hematopoietic stem cell transplantation in acquired severe aplastic anemia. Curr Res Transl Med 2017; 65:115-119. [PMID: 28988743 DOI: 10.1016/j.retram.2017.09.001] [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: 08/08/2017] [Revised: 09/05/2017] [Accepted: 09/06/2017] [Indexed: 10/18/2022]
Abstract
Different conditioning regimens have been evaluated in matched-related donor allogeneic hematopoietic stem cell transplantation (allo-HSCT) for acquired severe aplastic anemia (SAA) with varying results. In this manuscript, we report our experience with fludarabine (120mg/m2), very low dose cyclophosphamide (1200mg/m2) and antithymocyte globulin (7.5mg/kg). Low dose total body irradiation (2Gy) was added to the conditioning regimen for patients older than 15 years. Nineteen patients (median age 23years) underwent transplant between 2008 and 2015. The majority (89%) were younger than 40 years. Stem cell source was BM (n=11) or PBSC (n=8). GvHD prophylaxis consisted of cyclosporine and either a short course of methotrexate (n=9) or mycophenolate mofetil (n=10). Eighteen (94.7%) patients achieved sustained engraftment. The median times to neutrophil and platelet engraftments were 19 (range: 14-34) and 17.1 (range: 12-25) days, respectively. The day-30 cumulative incidence of neutrophil and platelet engraftment was 89.4% and 94.7%, respectively. No secondary graft rejection was observed. The 1-year cumulative incidence of aGvHD (grade II-IV) and cGvHD was 11.7% and 0%, respectively. The 2-year GvHD-free survival rate was 78.6% (95% CI: 52.5-91.4%). Fludarabine-based reduced intensity regimen for MRD allo-HSCT in SAA compares favorably to other available regimens. This regimen deserves further investigations with larger cohort of patients.
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Affiliation(s)
- K M Ghanem
- Department of Pediatrics and Adolescent Medicine, American University of Beirut, Beirut, Lebanon; Bone Marrow Transplantation Program, American University of Beirut, Beirut, Lebanon
| | - M A Kharfan-Dabaja
- Bone Marrow Transplantation Program, American University of Beirut, Beirut, Lebanon; Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - H El-Solh
- Department of Pediatrics and Adolescent Medicine, American University of Beirut, Beirut, Lebanon; Bone Marrow Transplantation Program, American University of Beirut, Beirut, Lebanon
| | - N Harris
- Department of Pediatrics and Adolescent Medicine, American University of Beirut, Beirut, Lebanon; Bone Marrow Transplantation Program, American University of Beirut, Beirut, Lebanon
| | - N Kreidieh
- Bone Marrow Transplantation Program, American University of Beirut, Beirut, Lebanon; Department of Pathology and Laboratory Medicine, American University of Beirut, Beirut, Lebanon
| | - R Nehme
- Bone Marrow Transplantation Program, American University of Beirut, Beirut, Lebanon; Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - S A Muwakkit
- Department of Pediatrics and Adolescent Medicine, American University of Beirut, Beirut, Lebanon; Bone Marrow Transplantation Program, American University of Beirut, Beirut, Lebanon
| | - R Saab
- Department of Pediatrics and Adolescent Medicine, American University of Beirut, Beirut, Lebanon; Bone Marrow Transplantation Program, American University of Beirut, Beirut, Lebanon
| | - A Bazarbachi
- Bone Marrow Transplantation Program, American University of Beirut, Beirut, Lebanon; Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - M R Abboud
- Department of Pediatrics and Adolescent Medicine, American University of Beirut, Beirut, Lebanon; Bone Marrow Transplantation Program, American University of Beirut, Beirut, Lebanon.
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Yamei W, Rongmu L, Yongbin C, Yingjian S, Xiaohong L, Xiaomei Z, Pei Y, Zhenlan D, Haitao W, Jing W, Bojing W, Xiaoxiong W, Wanming D. Improved outcome of haploidentical transplantation in severe aplastic anemia using reduced-intensity fludarabine-based conditioning. Oncotarget 2017; 8:83817-83830. [PMID: 29137385 PMCID: PMC5663557 DOI: 10.18632/oncotarget.19745] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 06/19/2017] [Indexed: 12/18/2022] Open
Abstract
Significant improvements in hematopoietic stem cell transplantation (HSCT) with haploidentical family donors (HFD) have confirmed its therapeutic role in severe aplastic anemia (SAA) and led to the evolution of treatment algorithms. However, the optimal conditioning regimen for HFD-HSCT remains undefined, especially the dosage of cyclophosphamide (Cy). A total of 77 patients with SAA from two research centers, who received HFD-HSCT with reduced-intensity fludarabine + cyclophosphamide + thymoglobulin ± busulfan conditioning regimen plus third-party cells infusion were included in this study, of which 67 pairs had 4-5 loci mismatched. We were particularly interested in whether the dosage of Cy significantly impacted graft failure (GF) and overall survival (OS). All patients showed sustained hematopoietic engraftment without any increase in severe aGVHD and transplantation-related mortality (TRM). The incidences of grade II-IV aGVHD, grade III-IV aGVHD and extensive cGVHD were 18%, 10% and 7%, respectively. The probabilities of 1-year and 5-year OS were 93.1% and 87.9%, respectively. Furthermore, patient age <15 years, MNC cells >8×108/kg and donor age <45 years were associated with better survival (P=0.043, P=0.023, and P=0.037, respectively) and engraftment (P=0.019, P=0.008, and P=0.001, respectively). Our findings indicated that SAA patients lack MSD benefited the most if HFD-HSCT was performed with reduced-intensity fludarabine-based conditioning regimen. Improved outcomes with HFD-HSCT may lead to a salvaged therapy and an expanded direct role for SAA in the future.
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Affiliation(s)
- Wu Yamei
- Department of Hematology, The First Affiliated Hospital, Chinese PLA General Hospital, Beijing 100048, China
| | - Luo Rongmu
- Department of Hematology, Affiliated BaYi Children's Hospital, PLA Army General Hospital, Beijing 100700, China
| | - Cao Yongbin
- Department of Hematology, The First Affiliated Hospital, Chinese PLA General Hospital, Beijing 100048, China
| | - Si Yingjian
- Department of Hematology, Affiliated BaYi Children's Hospital, PLA Army General Hospital, Beijing 100700, China
| | - Li Xiaohong
- Department of Hematology, The First Affiliated Hospital, Chinese PLA General Hospital, Beijing 100048, China
| | - Zhang Xiaomei
- Department of Hematology, Affiliated BaYi Children's Hospital, PLA Army General Hospital, Beijing 100700, China
| | - Yan Pei
- Department of Hematology, The First Affiliated Hospital, Chinese PLA General Hospital, Beijing 100048, China
| | - Du Zhenlan
- Department of Hematology, Affiliated BaYi Children's Hospital, PLA Army General Hospital, Beijing 100700, China
| | - Wang Haitao
- Department of Hematology, The First Affiliated Hospital, Chinese PLA General Hospital, Beijing 100048, China
| | - Wang Jing
- Department of Hematology, The First Affiliated Hospital, Chinese PLA General Hospital, Beijing 100048, China
| | - Wang Bojing
- Department of Hematology, The First Affiliated Hospital, Chinese PLA General Hospital, Beijing 100048, China
| | - Wu Xiaoxiong
- Department of Hematology, The First Affiliated Hospital, Chinese PLA General Hospital, Beijing 100048, China
| | - Da Wanming
- Department of Hematology, The First Affiliated Hospital, Chinese PLA General Hospital, Beijing 100048, China.,Department of Hematology, Affiliated BaYi Children's Hospital, PLA Army General Hospital, Beijing 100700, China.,Department of Hematology, Chinese PLA General Hospital, Beijing 100853, China
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9
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Population pharmacokinetics of fludarabine in patients with aplastic anemia and Fanconi anemia undergoing allogeneic hematopoietic stem cell transplantation. Bone Marrow Transplant 2017; 52:977-983. [PMID: 28481355 PMCID: PMC5584518 DOI: 10.1038/bmt.2017.79] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 03/09/2017] [Accepted: 03/17/2017] [Indexed: 01/05/2023]
Abstract
Although hematopoietic stem cell transplantation (HSCT) with a conditioning regimen consisting of fludarabine (F-araA) and cyclophosphamide (Cy) is associated with improved outcome in young patients with aplastic anemia (AA) and Fanconi anemia (FA), several factors limit the success of the procedure. We evaluated the population pharmacokinetics (POPPK) of F-araA and its influence on HSCT outcome in patients (n=53) with AA and FA undergoing HSCT. Patients carrying a 5′-UTR polymorphism in NT5E gene (rs2295890 G>C) exhibited significantly lower plasma F-araA clearance compared to those with wild-type genotype (7.12 vs 5.03 L/h/m2 (29%) P<0.05). F-araA clearance was significantly higher in patients with AA compared to FA (2.46 ×, P<1e−6). Of all the outcome parameters evaluated (engraftment, rejection/graft failure, GvHD, TRM, OS), high F-araA AUC (>29.4 μm*h) was the only significant factor associated with the development of aGvHD by both univariate and multivariate analysis (P=0.02). The influence of plasma F-araA levels need to be evaluated in a larger cohort of patients to propose the need for therapeutic drug monitoring.
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10
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Bacigalupo A. Bone Marrow Transplantation for Acquired Severe Aplastic Anemia. Hematol Oncol Clin North Am 2014; 28:1145-55. [DOI: 10.1016/j.hoc.2014.08.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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11
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Reduced intensity conditioning, combined transplantation of haploidentical hematopoietic stem cells and mesenchymal stem cells in patients with severe aplastic anemia. PLoS One 2014; 9:e89666. [PMID: 24594618 PMCID: PMC3940616 DOI: 10.1371/journal.pone.0089666] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Accepted: 01/22/2014] [Indexed: 01/22/2023] Open
Abstract
We examined if transplantation of combined haploidentical hematopoietic stem cells (HSC) and mesenchymal stem cells (MSC) affected graft failure and graft-versus-host disease (GVHD) in patients with severe aplastic anemia (SAA). Patients with SAA-I (N = 17) received haploidentical HSCT plus MSC infusion. Stem cell grafts used a combination of granulocyte colony-stimulating factor (G-CSF)-primed bone marrow and G-CSF-mobilized peripheral blood stem cells of haploidentical donors and the culture-expanded third-party donor-derived umbilical cord MSCs (UC-MSCs), respectively. Reduced intensity conditioning consisted of fludarabine (30 mg/m2·d)+cyclosphamide (500 mg/m2·d)+anti-human thymocyte IgG. Transplant recipients also received cyclosporin A, mycophenolatemofetil, and CD25 monoclonal antibody. A total of 16 patients achieved hematopoietic reconstitution. The median mononuclear cell and CD34 count was 9.3×108/kg and 4.5×106/kg. Median time to ANC was >0.5×109/L and PLT count >20×109/L were 12 and 14 days, respectively. Grade III-IV acute GVHD was seen in 23.5% of the cases, while moderate and severe chronic GVHD were seen in 14.2% of the cases. The 3-month and 6-month survival rates for all patients were 88.2% and 76.5%, respectively; mean survival time was 56.5 months. Combined transplantation of haploidentical HSCs and MSCs on SAA without an HLA-identical sibling donor was safe, effectively reduced the incidence of severe GVHD, and improved patient survival.
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12
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Ashizawa M, Akahoshi Y, Nakano H, Ugai T, Wada H, Yamasaki R, Ishihara Y, Kawamura K, Sakamoto K, Sato M, Terasako K, Kimura SI, Kikuchi M, Nakasone H, Kako S, Kanda J, Yamazaki R, Tanihara A, Nishida J, Kanda Y. A combination of fludarabine, half-dose cyclophosphamide, and anti-thymocyte globulin is an effective conditioning regimen before allogeneic stem cell transplantation for aplastic anemia. Int J Hematol 2014; 99:311-7. [PMID: 24488782 DOI: 10.1007/s12185-014-1501-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Revised: 01/07/2014] [Accepted: 01/14/2014] [Indexed: 11/26/2022]
Abstract
Conditioning regimens consisting of reduced-dose cyclophosphamide (CY) and fludarabine (FDR) have been investigated for use in allogeneic hematopoietic stem cell transplantation (allo-HSCT) in patients with aplastic anemia to reduce the toxicities associated with CY. However, the ideal dose of CY has not been identified. In addition, little information is available regarding donor cell chimerism after allo-HSCT with these regimens. Therefore, we retrospectively analyzed 13 patients who underwent allo-HSCT with half-dose CY (100 mg/kg in total), FDR, and anti-thymocyte globulin at total doses of 2.5-10 mg/kg at our center. All the patients except one, who died due to encephalopathy on day 20, achieved neutrophil engraftment a median of 18.5 days after HSCT with complete donor-type chimerism. Two patients who received a graft from an HLA-matched donor subsequently developed mixed chimerism (MC) associated with transfusion-dependent cytopenia. One became transfusion-independent after donor lymphocyte infusion, but continues to exhibit MC. The other regained complete donor-type chimerism after the cessation of cyclosporine, but remains transfusion-dependent. These findings suggest that a conditioning regimen with half-dose CY and FDR is effective for achieving neutrophil engraftment and complete donor-type chimerism. However, subsequent MC may be observed, especially after HLA-matched HSCT.
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Affiliation(s)
- Masahiro Ashizawa
- Division of Hematology, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma, Omiya-ku, Saitama, Saitama, 330-8503, Japan
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13
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George B, Mathews V, Lakshmi KM, Melinkeri S, Sharma A, Viswabandya A, Sharma S, Das S, Ahmed R, Abraham A, Nair V, Apte S, Chandy M, Srivastava A. The use of a fludarabine-based conditioning regimen in patients with severe aplastic anemia - a retrospective analysis from three Indian centers. Clin Transplant 2013; 27:923-9. [DOI: 10.1111/ctr.12263] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2013] [Indexed: 11/29/2022]
Affiliation(s)
- Biju George
- Department of Haematology; Christian Medical College Vellore; Vellore India
| | - Vikram Mathews
- Department of Haematology; Christian Medical College Vellore; Vellore India
| | - Kavitha M. Lakshmi
- Department of Haematology; Christian Medical College Vellore; Vellore India
| | | | - Ajay Sharma
- Department of Haematology; Army Hospital (Research and Referral); New Delhi India
| | - Auro Viswabandya
- Department of Haematology; Christian Medical College Vellore; Vellore India
| | - Sanjeevan Sharma
- Department of Haematology; Army Hospital (Research and Referral); New Delhi India
| | - Satyaranjan Das
- Department of Haematology; Army Hospital (Research and Referral); New Delhi India
| | - Rayaz Ahmed
- Department of Haematology; Christian Medical College Vellore; Vellore India
| | - Aby Abraham
- Department of Haematology; Christian Medical College Vellore; Vellore India
| | - Velu Nair
- Department of Haematology; Army Hospital (Research and Referral); New Delhi India
| | | | - Mammen Chandy
- Department of Haematology; Christian Medical College Vellore; Vellore India
| | - Alok Srivastava
- Department of Haematology; Christian Medical College Vellore; Vellore India
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14
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Hematopoietic stem cell transplantation with umbilical cord multipotent stromal cell infusion for the treatment of aplastic anemia—a single-center experience. Cytotherapy 2013; 15:1118-25. [DOI: 10.1016/j.jcyt.2013.04.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2012] [Revised: 04/21/2013] [Accepted: 04/23/2013] [Indexed: 10/26/2022]
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15
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Management of adult patients older than 40 years refractory to at least one immunosuppressive course: HLA-identical sibling HSCT using fludarabine-based conditioning. Bone Marrow Transplant 2012; 48:196-7. [PMID: 23222386 DOI: 10.1038/bmt.2012.251] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Allogeneic hematopoietic SCT (HSCT) from an HLA-identical sibling donor is the recommended upfront therapeutic option for young patients with SAA. The outcome of allogeneic sibling HSCT has remarkably improved during the last decade as a function of improvement in transplantation supportive care. However, there is still much debate concerning the upper age limit for sibling HSCT in SAA, particularly in patients who are refractory to at least one immunosuppressive course. Recent studies suggest that fludarabine-based conditioning may improve HSCT outcome in older patients with SAA. This review discusses available data about the use of fludarabine-based conditioning in transplantation of older patients with SAA. More definitive conclusions are needed from larger studies before the wide adoption of fludarabine-based conditioning as an alternative to the standard CY and ATG-based conditioning.
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16
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Standard treatment of acquired SAA in adult patients 18–40 years old with an HLA-identical sibling donor. Bone Marrow Transplant 2012; 48:178-9. [DOI: 10.1038/bmt.2012.223] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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17
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Abstract
Acquired aplastic anemia is a potentially fatal bone marrow failure disorder that is characterized by pancytopenia and a hypocellular bone marrow. Hematopoietic stem-cell transplantation or bone marrow transplantation (BMT) is the treatment of choice for young patients who have a matched sibling donor. Immunosuppression with either anti-thymocyte globulin and cyclosporine or high-dose cyclophosphamide is an effective therapy for patients who are not suitable BMT candidates owing to age or lack of a suitable donor. Results of BMT from unrelated and mismatched donors are improving, but presently this treatment option is best reserved for those patients who do not respond, relapse or develop secondary clonal disorders following immunosuppressive therapy. Efforts are currently underway to both improve immunosuppressive regimens and to expand the application of BMT.
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Affiliation(s)
- Amy E Dezern
- Division of Medical Oncology, Department of Medicine, The Johns Hopkins School of Medicine, 720 Rutland Avenue, Baltimore, MD 21205, USA
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