Nonmalignant Late Effects in Survivors of Partially Matched Donor Hematopoietic Stem Cell Transplantation

Basiliximab Treatment for Patients With Steroid-Refractory Acute Graft-Versus-Host Disease Following Matched Sibling Donor Hematopoietic Stem Cell Transplantation

Basiliximab is an important treatment for steroid-refractory acute graft-versus-host disease (SR-aGVHD). We performed this retrospective study to evaluate the efficacy and safety of basiliximab treatment in SR-aGVHD patients following matched sibling donor hematopoietic stem cell transplantation (MSD-HSCT) (n = 63). Overall response rate (ORR) was 63.5% and 54% at any time and at day 28 after basiliximab treatment. Grade III-IV aGVHD before basiliximab treatment predicted a poor ORR after basiliximab treatment. The rates of virus, bacteria, and fungi infections were 54%, 23.8%, and 3.1%, respectively. With a median follow-up of 730 (range, 67-3,042) days, the 1-year probability of overall survival and disease-free survival after basiliximab treatment were 58.6% (95% confidence interval [CI] = 47.6%-72.2%) and 55.4% (95% CI = 44.3%-69.2%), respectively. The 3-year cumulative incidence of relapse and non-relapse mortality after basiliximab treatment were 18.9% (95% CI = 8.3%-29.5%) and 33.8% (95% CI = 21.8%-45.7%), respectively. Comorbidities burden before allo-HSCT, severity of aGVHD and liver aGVHD before basiliximab treatment showed negative influences on survival. Thus, basiliximab was safe and effective treatment for SR-aGVHD following MSD-HSCT.

Optimizing antithymocyte globulin dosing in haploidentical hematopoietic cell transplantation: long-term follow-up of a multicenter, randomized controlled trial

Given that randomized studies testing the long-term impact of antithymocyte globulin (ATG) dosing are scarce, we report the results of an extended follow-up from the original trial. In our prospective, multicenter, randomized trial, 408 leukemia patients 14-65 years of age who underwent haploidentical hematopoietic cell transplantation (haplo-HCT) under our original "Beijing Protocol" were randomly assigned one-to-one to ATG doses of 7.5 mg/kg (n = 203, ATG-7.5) or 10 mg/kg (n = 205, ATG-10.0) at four sites. Extended follow-up (median 1968 d (range: 1300-2710 d) indicated comparable 5-year probabilities of moderate-to-severe chronic graft-versus-host disease (GVHD) (hazard ratio (HR): 1.384, 95% confidence interval (CI): 0.876-2.189, P = 0.164), nonrelapse mortality (HR: 0.814, 95% CI: 0.526-1.261, P = 0.357), relapse (HR: 1.521, 95% CI: 0.919-2.518, P = 0.103), disease-free survival (HR: 1.074, 95% CI: 0.783-1.473, P = 0.658), and GVHD-free/relapse-free survival (HR: 1.186, 95% CI: 0.904-1.555, P = 0.219) between groups (ATG-7.5 vs. ATG-10.0). The 5-year rate of late effects did not differ significantly. However, the cytomegalovirus/Epstein-Barr virus-related death rate was much higher in the ATG-10.0 cohort than in the ATG-7.5 cohort (9.8% vs. 1.5%; P = 0.003). In summary, patients undergoing haplo-HCT benefit from 7.5 mg/kg ATG compared to 10.0 mg/kg ATG based on a balance between GVHD and infection control. ATG (7.5 mg/kg) is potentially regarded as the standard regimen in the platform. These results support the optimization of ATG use in the "Beijing Protocol", especially considering the potential economic advantage in developing countries.

Prognosis and risk factors for central nervous system relapse after allogeneic hematopoietic stem cell transplantation in acute myeloid leukemia

We performed a nested case-control study to investigate the incidence, treatment, and prognosis of central nervous system (CNS) relapse after allogenic hematopoietic stem cell transplantation (allo-HSCT) for acute myeloid leukemia (AML) and compared the outcomes of patients with CNS relapse following haploidentical donor (HID) HSCT versus identical sibling donor (ISD) HSCT. A total of 37 patients (HID-HSCT, 24; ISD-HSCT, 13) developed CNS relapse after transplantation between January 2009 and January 2019, with an incidence of 1.81%. The median time from transplantation to CNS relapse was 239 days. Pre-HSCT CNS involvement (HR 6.940, 95% CI 3.146-15.306, p < .001) was an independent risk factor for CNS relapse after allo-HSCT for AML. The 3-year overall survival (OS) for patients with CNS relapse was 60.3 ± 8.8%, which was significantly lower than that in the controls (81.5 ± 4.5%, p = .003). The incidence of CNS relapse was 1.64% for patients who received HID-HSCT and 2.55% for those who received ISD-HSCT (p = .193). There was no significant difference in OS between the HID-HSCT and ISD-HSCT subgroups among the patients with CNS relapse. In conclusion, CNS relapse is a rare but serious complication after allo-HSCT for AML, and the incidence and outcomes of patients with CNS relapse are comparable following HID-HSCT and ISD-HSCT.

Ruxolitinib is an effective salvage treatment for multidrug-resistant graft-versus-host disease after haploidentical allogeneic hematopoietic stem cell transplantation without posttransplant cyclophosphamide

The purpose of our study is to identify the efficacy of ruxolitinib in human leukocyte antigen (HLA) haploidentical hematopoietic stem cell transplantation (haplo-HSCT) recipients with multidrug-resistant (MDR)-graft-versus-host disease (GVHD, n = 34). MDR-GVHD was defined as GVHD showing no improvement after at least 3 types of treatments. The median number of previous GVHD-therapies was 4 for both MDR-acute GVHD (aGVHD) and MDR-chronic GVHD (cGVHD). For MDR-aGVHD (n = 15), the median time to response was 10 days (range 2 to 65), and the overall response rate (ORR) was 60.0% (9/15), including 40.0% (6/15) complete response (CR) and 20.0% (3/15) partial response (PR). The 1-year probability of overall survival after ruxolitinib was 66.7%. The rates of hematologic and infectious toxicities were 73.3% and 46.7% after ruxolitinib treatment. For MDR-cGVHD (n = 19), the median time to response was 29 days (range 6 to 175), and the ORR was 89.5% (17/19), including 26.3% (5/19) CR and 63.2% (12/19) PR. All patients remained alive until our last follow-up. The rates of hematologic and infectious toxicities were 36.8% and 47.4% after ruxolitinib treatment. Ruxolitinib is an effective salvage treatment for MDR-GVHD in haplo-HSCT recipients.

Optimal dose of rabbit thymoglobulin in conditioning regimens for unmanipulated, haploidentical, hematopoietic stem cell transplantation: Long-term outcomes of a prospective randomized trial

BACKGROUND

Antithymocyte globulin (ATG) is an important component of conditioning regimens to prevent severe graft-versus-host disease (GVHD) in patients undergoing unmanipulated, haploidentical stem cell transplantation (haplo-SCT). However, to the authors' knowledge, the optimal dose of ATG is unknown.

METHODS

In this prospective, randomized trial, the authors compared the long-term outcomes of 2 ATG doses (rabbit thymoglobulin) used in myeloablative conditioning before unmanipulated haplo-HSCT. Patients were randomly assigned (1:1) to received 10 mg/kg (ATG-10) or 6 mg/kg (ATG-6) of ATG. Analysis of disease-free survival, GVHD-free/recurrence-free survival (GRFS), disease recurrence, nonrecurrence mortality, and chronic GVHD (cGVHD) included the entire population. Late effects were assessed in disease-free patients who had survived for at least 6 months and had received regular follow-up evaluations.

RESULTS

A total of 224 patients were recruited. The median follow-up period was 1614 days (range, 28-1929 days). The rate of infection-related deaths in ATG-10 arm was double that of the ATG-6 arm (14.3% vs 7.1%; P = .084). The 5-year cumulative incidence was comparable between the ATG-6 and ATG-10 groups for disease recurrence (12.8% vs 13.4%; P = .832) and nonrecurrence mortality (11.6% vs 17.0%; P = .263). The 5-year probability of disease-free survival was comparable between the groups (75.6% vs 69.6%; P = .283). The 5-year cumulative incidence of cGVHD was found to be higher with ATG-6 (75.0% vs 56.3% [P = .007] and moderate-to-severe cGVHD: 56.3% vs 30.4% [P<.0001]) as well as that for late effects (71.2% vs 56.9%; P = .043). The 5-year probability of GRFS was higher in the ATG-10 group (41.0% vs 26.8%; P = .008). In the multivariate analysis, ATG-10 was found to be associated with a lower risk of cGVHD and improved GRFS.

CONCLUSIONS

ATG-10 was found to be associated with better GVHD prevention and superior GRFS, but an increase in infection-related deaths. Cancer 2017;123:2881-92. © 2017 American Cancer Society.

Improved clinical outcomes of rhG-CSF-mobilized blood and marrow haploidentical transplantation compared to propensity score-matched rhG-CSF-primed peripheral blood stem cell haploidentical transplantation: a multicenter study

The effects of haploidentical rhG-CSF-mobilized blood and marrow transplantation (HBMT) on hematological malignances are well established. Previous prospective single-center studies have demonstrated better survival after HBMT versus haploidentical rhG-CSF-mobilized peripheral blood stem cell transplantation (HPBSCT) for acute leukemia (AL) not in remission (NR) or in more than the second complete remission (>CR2). To test the hypothesis that HBMT is still superior to HPBSCT for patients with AL, multiple myeloma (MM), or non-Hodgkin lymphoma (NHL) in CR1/CR2 and for patients with chronic myeloid leukemia in the first and second chronic phase lacking a matched donor, we designed a propensity score method-based multicenter study. Hematopoietic recovery, acute graft-versus-host disease (aGVHD), and chronic GVHD were comparable between the HBMT group (n=168) and the HPBSCT group (n=42). No significant differences were found in non-relapse mortality rate (20.17%±3.58% and 27.24%±7.16%, P=0.18) or relapse rate (19.96%±3.72% and 28.49%±8.25%, P=0.32) between the HBMT group and the HPBSCT group. HBMT recipients had better overall survival (65.0%±4.2% and 54.2%±8.3%, P=0.037) and disease-free survival (59.9%±4.6% and 44.3%±8.7%, P=0.051). Multivariate analysis showed that HPBSCT was associated with poorer DFS (HR (95%CI), 1.639 (0.995-2.699), P=0.052). Our comparisons showed that HBMT was superior to HPBSCT as a post-remission treatment for patients lacking an identical donor.

Late-onset severe pneumonia after allogeneic hematopoietic stem cell transplantation: prognostic factors and treatments

Background

In this study, we aimed to evaluate the prognostic factors associated with and treatments for late‐onset severe pneumonia (LOSP) in patients who underwent allogeneic hematopoietic stem cell transplantation (allo‐HSCT).

Methods

Fifty consecutive patients who underwent non‐T‐cell‐depleted allo‐HSCT at the Peking University Institute of Hematology and met the criterion of LOSP after allo‐HSCT were enrolled.

Results

The median time from allo‐HSCT to the occurrence of LOSP was 231 (90–1487) days. Twenty‐eight patients harbored 1 or more pathogens (infectious LOSP, I‐LOSP), whereas 22 did not harbor any pathogens (non‐infectious LOSP, NI‐LOSP). The 100‐day survival rate of LOSP patients was 31.1%. Patients smoking before allo‐HSCT (0% vs. 35.4%, P = 0.002) and male gender (20.0% vs. 61.9%, P = 0.026) had lower 100‐day survival rate. Patients with a lower bronchoalveolar lavage fluid (BALF) neutrophil percentage had higher 100‐day survival rate relative to those with higher BALF neutrophil percentage (45.5% vs. 16.7%, P = 0.012). The 100‐day survival rate of patients with I‐LOSP was lower than that of patients with NI‐LOSP (19.1% vs. 46.9%, P = 0.043). Patients given late (≥1 week after LOSP diagnosis) and low‐dose methylprednisolone (MP) therapy (≤2 mg/kg/day) had the best 100‐day survival rate. In the multivariate analysis, nonsmoking before allo‐HSCT and late and low‐dose MP therapy were significantly associated with a better survival after LOSP.

Conclusion

LOSP is a severe complication after allo‐HSCT. The correct timing and corticosteroid dosage in the context of broad‐spectrum antimicrobial therapy might further improve the outcomes of patients with LOSP.

Improving the clinical outcome of unmanipulated haploidentical blood and marrow transplantation

Unmanipulated haploidentical blood and marrow transplantation (HBMT) has been one of the most applied haploidentical transplant protocol, which offers rapid immune recovery, desirable health-related quality of life and comparable survival rate with those who received HLA-identical sibling transplantation or HLA-matched unrelated donor transplantation. Compared with HLA-identical sibling recipients, HBMT recipients experienced a lower risk of late effects. The HBMT protocol also shows superior in treating pediatric hematological malignancies compared with umbilical cord blood transplantation and could be successfully used as a post-remission treatment algorithm for adults acute myeloid leukemia with unfavorable cytogenetics. Several approaches, including optimal dose investigation of anti-thymocyte globulin, selecting the best donor, and modified donor lymphocyte infusion, have been designed to improve transplant outcomes.

Fighting against hematological malignancy in China: from unique system to global impact

During recent decades, substantial progress has been made in clinical strategies for treating hematological malignancies. Not only did China benefit from the global progression in the management of acute promyelocytic leukemia, risk-stratification-directed strategies for acute or chronic leukemia and haploidentical hematopoietic stem cell transplantation, the unique system developed by Chinese doctors has also become inspiration for refining global clinical practice. The multicenter trials and collaborations adhering to international standards might further strengthen the global impact and lead the way in specific fields of research worldwide.