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Dogliotti I, Levis M, Martin A, Bartoncini S, Felicetti F, Cavallin C, Maffini E, Cerrano M, Bruno B, Ricardi U, Giaccone L. Maintain Efficacy and Spare Toxicity: Traditional and New Radiation-Based Conditioning Regimens in Hematopoietic Stem Cell Transplantation. Cancers (Basel) 2024; 16:865. [PMID: 38473227 DOI: 10.3390/cancers16050865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 02/14/2024] [Accepted: 02/19/2024] [Indexed: 03/14/2024] Open
Abstract
Novelty in total body irradiation (TBI) as part of pre-transplant conditioning regimens lacked until recently, despite the developments in the field of allogeneic stem cell transplants. Long-term toxicities have been one of the major concerns associated with TBI in this setting, although the impact of TBI is not so easy to discriminate from that of chemotherapy, especially in the adult population. More recently, lower-intensity TBI and different approaches to irradiation (namely, total marrow irradiation, TMI, and total marrow and lymphoid irradiation, TMLI) were implemented to keep the benefits of irradiation and limit potential harm. TMI/TMLI is an alternative to TBI that delivers more selective irradiation, with healthy tissues being better spared and the control of the radiation dose delivery. In this review, we discussed the potential radiation-associated long-term toxicities and their management, summarized the evidence regarding the current indications of traditional TBI, and focused on the technological advances in radiotherapy that have resulted in the development of TMLI. Finally, considering the most recent published trials, we postulate how the role of radiotherapy in the setting of allografting might change in the future.
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Affiliation(s)
- Irene Dogliotti
- Allogeneic Transplant and Cellular Therapy Unit, Division of Hematology, Department of Oncology, University Hospital A.O.U. "Città della Salute e della Scienza di Torino", University of Torino, 10126 Torino, Italy
- Department of Molecular Biotechnology and Health Sciences, University of Turin, 10126 Torino, Italy
| | - Mario Levis
- Department of Oncology, University of Turin, 10126 Torino, Italy
| | - Aurora Martin
- Allogeneic Transplant and Cellular Therapy Unit, Division of Hematology, Department of Oncology, University Hospital A.O.U. "Città della Salute e della Scienza di Torino", University of Torino, 10126 Torino, Italy
- Department of Molecular Biotechnology and Health Sciences, University of Turin, 10126 Torino, Italy
| | - Sara Bartoncini
- Department of Oncology, University of Turin, 10126 Torino, Italy
| | - Francesco Felicetti
- Division of Oncological Endocrinology, Department of Oncology, University Hospital A.O.U. "Città della Salute e della Scienza di Torino", 10126 Torino, Italy
| | - Chiara Cavallin
- Department of Oncology, University of Turin, 10126 Torino, Italy
| | - Enrico Maffini
- Hematology Institute "Seràgnoli", IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Marco Cerrano
- Division of Hematology, University Hospital A.O.U. "Città della Salute e della Scienza di Torino", 10126 Torino, Italy
| | - Benedetto Bruno
- Allogeneic Transplant and Cellular Therapy Unit, Division of Hematology, Department of Oncology, University Hospital A.O.U. "Città della Salute e della Scienza di Torino", University of Torino, 10126 Torino, Italy
- Department of Molecular Biotechnology and Health Sciences, University of Turin, 10126 Torino, Italy
| | - Umberto Ricardi
- Department of Oncology, University of Turin, 10126 Torino, Italy
| | - Luisa Giaccone
- Allogeneic Transplant and Cellular Therapy Unit, Division of Hematology, Department of Oncology, University Hospital A.O.U. "Città della Salute e della Scienza di Torino", University of Torino, 10126 Torino, Italy
- Department of Molecular Biotechnology and Health Sciences, University of Turin, 10126 Torino, Italy
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2
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El Cheikh J, Bidaoui G, Atoui A, Terro K, Sharrouf L, Zahreddine A, Moukalled N, Abou Dalle I, Bazarbachi A, Mohty M, Dulery R. Clofarabine and total body irradiation (TBI) as conditioning regimen for allogeneic stem cell transplantation in high-risk acute leukemia patients: a two-center retrospective cohort study. Bone Marrow Transplant 2023:10.1038/s41409-023-01947-z. [PMID: 36914730 DOI: 10.1038/s41409-023-01947-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 02/14/2023] [Accepted: 02/20/2023] [Indexed: 03/16/2023]
Abstract
Clofarabine (Clo) is an immunosuppressive purine analog that may have better anti-leukemic activity than fludarabine (Flu). The addition of total body irradiation (TBI) to conditioning regimens has been widely investigated. However, the use of single agent Clo in combination with intermediate doses of TBI ranging from 4 to 8 Gy has not been studied yet. This study is a double center, observational, retrospective study of patients with high-risk hematological malignancies diagnosed from 2012 to 2021, treated at the American University of Beirut Medical Center in Beirut (AUBMC), Lebanon, and Saint-Antoine Hospital (SAH) in Paris, France. It aims to identify the outcome of patients with high-risk hematological malignancies who underwent allogeneic stem cell transplant (allo-SCT) and received Clo and TBI (4-8 Gy) before transplant. Data regarding patient baseline characteristics, disease-related factors, and transplant outcomes including graft-versus-host disease (GVHD), Non-relapse mortality (NRM), progression-free survival (PFS), and overall survival (OS), were collected. We identified 24 high-risk patients diagnosed with a hematological malignancy. The median age at transplant was 37 years (range 22-78). At the time of the transplant, only 15 patients (63%) were in complete remission (CR). All patients received Clo/TBI (4-8 Gy). After a median follow-up of 40 months, the cumulative incidences of grade II-III acute GVHD, grade IV acute GVHD, and chronic GVHD were 50%, 4%, and 8%, respectively. NRM at 100 days, and 1 year after transplant was 4% and 25%, respectively. 17% of the patients had a relapse or progression of the disease by the end of the study. The 2-year PFS and OS were 50% and 56%, respectively. The median PFS and OS were 66 and 68 months respectively. As a conclusion, Clo/TBI (4-8 Gy) as a conditioning regimen for allo-SCT in high-risk patients confers disease control with an acceptable toxicity profile.
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Affiliation(s)
- Jean El Cheikh
- Division of Hematology/Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon. .,Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
| | - Ghassan Bidaoui
- Division of Hematology/Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ali Atoui
- Division of Hematology/Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Khodr Terro
- Division of Hematology/Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Layal Sharrouf
- Division of Hematology/Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ammar Zahreddine
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Nour Moukalled
- Division of Hematology/Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon.,Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Imane Abou Dalle
- Division of Hematology/Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon.,Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ali Bazarbachi
- Division of Hematology/Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon.,Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mohamad Mohty
- Department of Hematology, Saint Antoine Hospital, INSERM UMR 938, Sorbonne University, Paris, France
| | - Remy Dulery
- Department of Hematology, Saint Antoine Hospital, INSERM UMR 938, Sorbonne University, Paris, France
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3
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Lowsky R, Strober S. Establishment of Chimerism and Organ Transplant Tolerance in Laboratory Animals: Safety and Efficacy of Adaptation to Humans. Front Immunol 2022; 13:805177. [PMID: 35222384 PMCID: PMC8866443 DOI: 10.3389/fimmu.2022.805177] [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: 10/29/2021] [Accepted: 01/03/2022] [Indexed: 11/13/2022] Open
Abstract
The definition of immune tolerance to allogeneic tissue and organ transplants in laboratory animals and humans continues to be the acceptance of the donor graft, rejection of third-party grafts, and specific unresponsiveness of recipient immune cells to the donor alloantigens in the absence of immunosuppressive treatments. Actively acquired tolerance was achieved in mice more than 60 years ago by the establishment of mixed chimerism in neonatal mice. Once established, mixed chimerism was self-perpetuating and allowed for acceptance of tissue transplants in adults. Successful establishment of tolerance in humans has now been reported in several clinical trials based on the development of chimerism after combined transplantation of hematopoietic cells and an organ from the same donor. This review examines the mechanisms of organ graft acceptance after establishment of mixed chimerism (allo-tolerance) or complete chimerism (self-tolerance), and compares the development of graft versus host disease (GVHD) and graft versus tumor (GVT) activity in complete and mixed chimerism. GVHD, GVT activity, and complete chimerism are also discussed in the context of bone marrow transplantation to treat hematologic malignancies. The roles of transient versus persistent mixed chimerism in the induction and maintenance of tolerance and organ graft acceptance in animal models and clinical studies are compared. Key differences in the stability of mixed chimeras and tolerance induction in MHC matched and mismatched rodents, large laboratory animals, and humans are examined to provide insights into the safety and efficacy of translation of results of animal models to clinical trials.
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Affiliation(s)
- Robert Lowsky
- Division of Blood and Marrow Transplantation and Cancer Cellular Therapy, Stanford University School of Medicine, Stanford, CA, United States
| | - Samuel Strober
- Division of Immunology and Rheumatology, Stanford University School of Medicine, Stanford, CA, United States
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Franke GN, Dumann K, Jentzsch M, Monecke A, Doehring C, Nehring-Vucinic C, Schwind S, Niederwieser D, Platzbecker U, Ziemer M, Vucinic V. Case Report: Graft Versus Tumor Effect After Non-Myeloablative Allogeneic Stem-Cell Transplantation in a Patient With Brentuximab-Vedotin Refractory Sezary Syndrome. Front Oncol 2021; 11:749691. [PMID: 34956873 PMCID: PMC8695846 DOI: 10.3389/fonc.2021.749691] [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: 07/29/2021] [Accepted: 11/22/2021] [Indexed: 11/13/2022] Open
Abstract
Sezary Syndrome (SS) is a rare leukemic variant of primary cutaneous T-cell lymphoma. Relapsed or refractory disease is generally considered incurable by conventional therapeutic approaches, although durable responses can be achieved with novel monoclonal antibodies. Allogeneic hematopoietic stem cell transplantation (alloHSCT) may have potential value by inducing graft vs-lymphoma (GvL) effects, but there is currently no consensus regarding the timing of alloHSCT or type of conditioning regimen. Here we present the case of a male patient who achieved a complete remission (CR) of primary refractory SS after non-myeloablative alloHSCT. Patient: Two years prior to HSCT, the patient had been refractory to CHOEP-based chemotherapy, interferon, extracorporeal photopheresis (ECP), and bexarotene. Directly prior to alloHSCT brentuximab-vedotin (BV) was applied resulting in a partial remission of the skin compartment and overall in a stable disease. Prior to HSCT, flow cytometry of the bone marrow and peripheral blood showed an infiltration with T-cells positive for CD5, CD4, low CD3, low CD2 and negative for CD7, CD38, HLA-DR and CD8. The trephine biopsy showed a 7% infiltration of SS cells. The CD4:CD8 ratio in peripheral blood (pb) was massively increased at 76.67, with 63.5% of white blood cells expressing a SS immune phenotype. The conditioning regimen included 30 mg/m2 fludarabine on days -5, -4 and -3 and total body irradiation with 2 Gy on day -1. Immunosuppression consisted of cyclosporine A from day-1 and mycophenolate mofetil from day 0. The patient received 6.55x106 CD34+ cells and 1.11x108 CD3+ cells/kg body weight. Bone marrow evaluation on day 28 still showed persistent SS cells by flow cytometry. After tapering immunosuppression until day 169, the CD4:CD8 ratio in pb normalized. CR was documented on day 169 after alloHSCT and is now ongoing for almost 3 years after alloHSCT. Conclusions: We confirm that an alloHSCT can be a curative option for refractory patients with SS. The achievement of a CR after tapering the immunosuppressive therapy indicates a significant role of the GvL effect. In present treatment algorithms for patients with SS, the timing of an alloHSCT and the intensity of conditioning should be further explored.
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Affiliation(s)
- Georg-Nikolaus Franke
- Medical Clinic and Policlinic 1, Hematology, Cellular Therapy and Hemostaseology, University of Leipzig, Leipzig Medical Center, Leipzig, Germany
| | | | - Madlen Jentzsch
- Medical Clinic and Policlinic 1, Hematology, Cellular Therapy and Hemostaseology, University of Leipzig, Leipzig Medical Center, Leipzig, Germany
| | - Astrid Monecke
- Institute for Pathology, Leipzig Medical Center, Leipzig, Germany
| | - Christine Doehring
- Medical Clinic and Policlinic 1, Hematology, Cellular Therapy and Hemostaseology, University of Leipzig, Leipzig Medical Center, Leipzig, Germany
| | - Claudia Nehring-Vucinic
- Department for Hematology, Internal Oncology and Gastroenterology, Asklepios Hospital Weissenfels, Weissenfels, Germany
| | - Sebastian Schwind
- Medical Clinic and Policlinic 1, Hematology, Cellular Therapy and Hemostaseology, University of Leipzig, Leipzig Medical Center, Leipzig, Germany
| | - Dietger Niederwieser
- Medical Clinic and Policlinic 1, Hematology, Cellular Therapy and Hemostaseology, University of Leipzig, Leipzig Medical Center, Leipzig, Germany
| | - Uwe Platzbecker
- Medical Clinic and Policlinic 1, Hematology, Cellular Therapy and Hemostaseology, University of Leipzig, Leipzig Medical Center, Leipzig, Germany
| | - Mirjana Ziemer
- Clinic for Dermatology, Leipzig Medical Center, Leipzig, Germany
| | - Vladan Vucinic
- Medical Clinic and Policlinic 1, Hematology, Cellular Therapy and Hemostaseology, University of Leipzig, Leipzig Medical Center, Leipzig, Germany
- *Correspondence: Vladan Vucinic,
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5
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Stokes J, Molina MS, Hoffman EA, Simpson RJ, Katsanis E. Immunomodulatory Effects of Bendamustine in Hematopoietic Cell Transplantation. Cancers (Basel) 2021; 13:1702. [PMID: 33916711 PMCID: PMC8038415 DOI: 10.3390/cancers13071702] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 03/25/2021] [Accepted: 04/01/2021] [Indexed: 12/22/2022] Open
Abstract
Bendamustine (BEN) is a unique alkylating agent with efficacy against a broad range of hematological malignancies, although investigations have only recently started to delve into its immunomodulatory effects. These immunomodulatory properties of BEN in the context of hematopoietic cell transplantation (HCT) are reviewed here. Pre- and post-transplant use of BEN in multiple murine models have consistently resulted in reduced GvHD and enhanced GvL, with significant changes to key immunological cell populations, including T-cells, myeloid derived suppressor cells (MDSCs), and dendritic cells (DCs). Further, in vitro studies find that BEN enhances the suppressive function of MDSCs, skews DCs toward cDC1s, enhances Flt3 expression on DCs, increases B-cell production of IL-10, inhibits STAT3 activation, and suppresses proliferation of T- and B-cells. Overall, BEN has a broad range of immunomodulatory effects that, as they are further elucidated, may be exploited to improve clinical outcomes. As such, clinical trials are currently underway investigating new potential applications of BEN in the setting of allogeneic HCT.
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Affiliation(s)
- Jessica Stokes
- Department of Pediatrics, University of Arizona, Tucson, AZ 85721, USA; (J.S.); (M.S.M.); (E.A.H.); (R.J.S.)
| | - Megan S. Molina
- Department of Pediatrics, University of Arizona, Tucson, AZ 85721, USA; (J.S.); (M.S.M.); (E.A.H.); (R.J.S.)
- Department of Immunobiology, University of Arizona, Tucson, AZ 85721, USA
| | - Emely A. Hoffman
- Department of Pediatrics, University of Arizona, Tucson, AZ 85721, USA; (J.S.); (M.S.M.); (E.A.H.); (R.J.S.)
| | - Richard J. Simpson
- Department of Pediatrics, University of Arizona, Tucson, AZ 85721, USA; (J.S.); (M.S.M.); (E.A.H.); (R.J.S.)
- Department of Immunobiology, University of Arizona, Tucson, AZ 85721, USA
- Department of Nutritional Sciences, University of Arizona, Tucson, AZ 85721, USA
- The University of Arizona Cancer Center, Tucson, AZ 85721, USA
| | - Emmanuel Katsanis
- Department of Pediatrics, University of Arizona, Tucson, AZ 85721, USA; (J.S.); (M.S.M.); (E.A.H.); (R.J.S.)
- Department of Immunobiology, University of Arizona, Tucson, AZ 85721, USA
- The University of Arizona Cancer Center, Tucson, AZ 85721, USA
- Department of Medicine, University of Arizona, Tucson, AZ 85721, USA
- Department of Pathology, University of Arizona, Tucson, AZ 85721, USA
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6
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Bridoux F, Cockwell P, Glezerman I, Gutgarts V, Hogan JJ, Jhaveri KD, Joly F, Nasr SH, Sawinski D, Leung N. Kidney injury and disease in patients with haematological malignancies. Nat Rev Nephrol 2021; 17:386-401. [PMID: 33785910 DOI: 10.1038/s41581-021-00405-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2021] [Indexed: 02/07/2023]
Abstract
Acute kidney injury (AKI) is common in patients with cancer, especially in those with haematological malignancies. Kidney injury might be a direct consequence of the underlying haematological condition. For example, in the case of lymphoma infiltration or extramedullary haematopoiesis, it might be caused by a tumour product; in the case of cast nephropathy it might be due to the presence of monoclonal immunoglobulin; or it might result from tumour complications, such as hypercalcaemia. Kidney injury might also be caused by cancer treatment, as many chemotherapeutic agents are nephrotoxic. High-intensity treatments, such as high-dose chemotherapy followed by haematopoietic stem cell transplantation, not only increase the risk of infection but can also cause AKI through various mechanisms, including viral nephropathies, engraftment syndrome and sinusoidal obstruction syndrome. Some conditions, such as thrombotic microangiopathy, might also result directly from the haematological condition or the treatment. Novel immunotherapies, such as immune checkpoint inhibitors and chimeric antigen receptor T cell therapy, can also be nephrotoxic. As new therapies for haematological malignancies with increased anti-tumour efficacy and reduced toxicity are developed, the number of patients receiving these treatments will increase. Clinicians must gain a good understanding of the different mechanisms of kidney injury associated with cancer to better care for these patients.
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Affiliation(s)
- Frank Bridoux
- Department of Nephrology, and Centre d'Investigation Clinique (CIC INSERM 1402), Centre Hospitalier Universitaire et Université de Poitiers, Poitiers, France.,CNRS, UMR7276, Limoges, France.,Centre de référence Amylose AL et autres maladies par dépôt d'immunoglobulines monoclonales, Poitiers, France
| | - Paul Cockwell
- Department of Nephrology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Ilya Glezerman
- Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Weill Cornell Medical College, New York, NY, USA
| | - Victoria Gutgarts
- Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Weill Cornell Medical College, New York, NY, USA
| | - Jonathan J Hogan
- Renal, Electrolyte and Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Kenar D Jhaveri
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Great Neck, NY, USA
| | - Florent Joly
- Department of Nephrology, and Centre d'Investigation Clinique (CIC INSERM 1402), Centre Hospitalier Universitaire et Université de Poitiers, Poitiers, France
| | - Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Deirdre Sawinski
- Renal, Electrolyte and Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Nelson Leung
- Division of Nephrology and Hypertension, Division of Hematology, Mayo Clinic, Rochester, MN, USA.
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7
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Sabloff M, Tisseverasinghe S, Babadagli ME, Samant R. Total Body Irradiation for Hematopoietic Stem Cell Transplantation: What Can We Agree on? ACTA ACUST UNITED AC 2021; 28:903-917. [PMID: 33617507 PMCID: PMC7985756 DOI: 10.3390/curroncol28010089] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 01/19/2021] [Accepted: 02/02/2021] [Indexed: 01/23/2023]
Abstract
Total body irradiation (TBI), used as part of the conditioning regimen prior to allogeneic and autologous hematopoietic cell transplantation, is the delivery of a relatively homogeneous dose of radiation to the entire body. TBI has a dual role, being cytotoxic and immunosuppressive. This allows it to eliminate disease and create “space” in the marrow while also impairing the immune system from rejecting the foreign donor cells being transplanted. Advantages that TBI may have over chemotherapy alone are that it may achieve greater tumour cytotoxicity and better tissue penetration than chemotherapy as its delivery is independent of vascular supply and physiologic barriers such as renal and hepatic function. Therefore, the so-called “sanctuary” sites such as the central nervous system (CNS), testes, and orbits or other sites with limited blood supply are not off-limits to radiation. Nevertheless, TBI is hampered by challenging logistics of administration, coordination between hematology and radiation oncology departments, increased rates of acute treatment-related morbidity and mortality along with late toxicity to other tissues. Newer technologies and a better understanding of the biology and physics of TBI has allowed the field to develop novel delivery systems which may help to deliver radiation more safely while maintaining its efficacy. However, continued research and collaboration are needed to determine the best approaches for the use of TBI in the future.
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Affiliation(s)
- Mitchell Sabloff
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, ON K1H 8L6, Canada;
- The Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada
| | | | - Mustafa Ege Babadagli
- Division of Radiation Oncology, The Ottawa Hospital, Ottawa, ON K1H 8L6, Canada;
- Correspondence:
| | - Rajiv Samant
- Division of Radiation Oncology, The Ottawa Hospital, Ottawa, ON K1H 8L6, Canada;
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8
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Ueda Oshima M, Storer BE, Qiu H, Chauncey T, Asch J, Boyer MW, Giaccone L, Flowers M, Mielcarek M, Storb R, Maloney DG, Sandmaier BM. Long-term Outcomes with Nonmyeloablative HLA-Identical Related Hematopoietic Cell Transplantation Using Tacrolimus and Mycophenolate Mofetil for Graft-versus-Host Disease Prophylaxis. Transplant Cell Ther 2020; 27:163.e1-163.e7. [PMID: 33830025 DOI: 10.1016/j.jtct.2020.10.016] [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: 09/02/2020] [Revised: 09/29/2020] [Accepted: 10/12/2020] [Indexed: 11/17/2022]
Abstract
Nonmyeloablative allogeneic hematopoietic cell transplantation (HCT) from HLA-identical related donors using cyclosporine (CSP) and mycophenolate mofetil (MMF) for postgrafting immunosuppression is effective therapy for hematologic cancers. However, graft-versus-host-disease (GVHD) remains a major cause of morbidity and mortality. Pilot data suggested lower acute GVHD incidence with tacrolimus/MMF compared to historical experience using CSP/MMF after nonmyeloablative HCT. In a phase II multicenter trial, we evaluated the effect of tacrolimus/MMF for GVHD prophylaxis after HLA-identical related donor peripheral blood HCT in patients with hematologic malignancies (n = 150) using conditioning with 2 Gy total body irradiation (TBI) for patients with a preceding (within 6 months) planned autologous HCT (n = 50) or combined with 90 mg/m2 fludarabine for those without recent autologous HCT (n = 100). Oral tacrolimus was given from days -3 to 56 (tapered by day +180 if no GVHD). Oral MMF was given from days 0 to 27. Patient median age was 57 (range, 20 to 74) years. The cumulative incidences (CI) of day 100 grade II to IV and III to IV acute GVHD were 27% and 4%, respectively. With median follow-up of 10.3 (range, 3.1 to 14.5) years, the 5-year CI of chronic extensive GVHD was 48%. One-year and 5-year estimates of nonrelapse mortality, relapse/progression, survival, and progression-free survival were 9% and 13%, 35% and 50%, 73% and 53%, and 56% and 37%, respectively. GVHD prophylaxis with tacrolimus/MMF resulted in a low risk of acute GVHD and compared favorably with results from a concurrent trial using CSP/MMF. A randomized phase III trial to investigate tacrolimus/MMF versus CSP/MMF in nonmyeloablative HCT is warranted.
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Affiliation(s)
- Masumi Ueda Oshima
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, Washington.
| | - Barry E Storer
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Huiying Qiu
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Thomas Chauncey
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, Washington; VA Puget Sound Health Care System, Seattle, Washington
| | - Julie Asch
- Intermountain Healthcare, Salt Lake City, Utah
| | | | | | - Mary Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, Washington
| | - Marco Mielcarek
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, Washington
| | - Rainer Storb
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, Washington
| | - David G Maloney
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, Washington
| | - Brenda M Sandmaier
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, Washington
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9
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Dierckx de Casterlé I, Billiau AD, Sprangers B. Recipient and donor cells in the graft-versus-solid tumor effect: It takes two to tango. Blood Rev 2018; 32:449-456. [PMID: 29678553 DOI: 10.1016/j.blre.2018.04.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 03/05/2018] [Accepted: 04/06/2018] [Indexed: 12/16/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (alloHSCT) produces -similar to the long-established graft-versus-leukemia effect- graft-versus-solid-tumor effects. Clinical trials reported response rates of up to 53%, occurring mostly but not invariably in association with full donor chimerism and/or graft-versus-host disease. Although donor-derived T cells are considered the principal effectors of anti-tumor immunity after alloHSCT or donor leukocyte infusion (DLI), growing evidence indicate that recipient-derived immune cells may also contribute. Whereas the role of recipient-derived antigen-presenting cells in eliciting graft-versus-host reactions and priming donor T cells following DLI is well known, resulting inflammatory responses may also break tolerance of recipient effector cells towards the tumor. Additionally, mouse studies indicated that post-transplant recipient leukocyte infusion produces anti-leukemia and anti-solid-tumor effects that were exclusively mediated by recipient-type effector cells, without graft-versus-host disease. Here, we review current preclinical and clinical evidence on graft-versus-solid-tumor effects and growing evidence on the effector role of recipient-derived immune cells in the anti-tumor effect of alloHSCT.
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Affiliation(s)
- Isabelle Dierckx de Casterlé
- Department of Microbiology and Immunology, Laboratory of Experimental Transplantation, KU Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | - An D Billiau
- Department of Microbiology and Immunology, Laboratory of Experimental Transplantation, KU Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | - Ben Sprangers
- Department of Microbiology and Immunology, Laboratory of Experimental Transplantation, KU Leuven, Herestraat 49, 3000 Leuven, Belgium; Department of Nephrology, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium.
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10
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Storb R, Sandmaier BM. Nonmyeloablative allogeneic hematopoietic cell transplantation. Haematologica 2017; 101:521-30. [PMID: 27132278 DOI: 10.3324/haematol.2015.132860] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 02/05/2016] [Indexed: 11/09/2022] Open
Abstract
Most hematological malignancies occur in older patients. Until recently these patients and those with comorbidities were not candidates for treatment with allogeneic hematopoietic transplantation because they were unable to tolerate the heretofore used high-dose conditioning regimens. The finding that many of the cures achieved with allogeneic hematopoietic transplantation were due to graft-versus-tumor effects led to the development of less toxic and well-tolerated reduced intensity and nonmyeloablative regimens. These regimens enabled allogeneic engraftment, thereby setting the stage for graft-versus-tumor effects. This review summarizes the encouraging early results seen with the new regimens and discusses the two hurdles that need to be overcome for achieving even greater success, disease relapse and graft-versus-host disease.
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Affiliation(s)
- Rainer Storb
- Fred Hutchinson Cancer Research Center and the University of Washington, Seattle, WA, USA
| | - Brenda M Sandmaier
- Fred Hutchinson Cancer Research Center and the University of Washington, Seattle, WA, USA
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11
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Pharmacokinetics, Pharmacodynamics, and Pharmacogenomics of Immunosuppressants in Allogeneic Hematopoietic Cell Transplantation: Part II. Clin Pharmacokinet 2016; 55:551-93. [PMID: 26620047 DOI: 10.1007/s40262-015-0340-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Part I of this article included a pertinent review of allogeneic hematopoietic cell transplantation (alloHCT), the role of postgraft immunosuppression in alloHCT, and the pharmacokinetics, pharmacodynamics, and pharmacogenomics of the calcineurin inhibitors and methotrexate. In this article (Part II), we review the pharmacokinetics, pharmacodynamics, and pharmacogenomics of mycophenolic acid (MPA), sirolimus, and the antithymocyte globulins (ATG). We then discuss target concentration intervention (TCI) of these postgraft immunosuppressants in alloHCT patients, with a focus on current evidence for TCI and on how TCI may improve clinical management in these patients. Currently, TCI using trough concentrations is conducted for sirolimus in alloHCT patients. Several studies demonstrate that MPA plasma exposure is associated with clinical outcomes, with an increasing number of alloHCT patients needing TCI of MPA. Compared with MPA, there are fewer pharmacokinetic/dynamic studies of rabbit ATG and horse ATG in alloHCT patients. Future pharmacokinetic/dynamic research of postgraft immunosuppressants should include '-omics'-based tools: pharmacogenomics may be used to gain an improved understanding of the covariates influencing pharmacokinetics as well as proteomics and metabolomics as novel methods to elucidate pharmacodynamic responses.
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12
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Pingali SR, Champlin RE. Pushing the envelope-nonmyeloablative and reduced intensity preparative regimens for allogeneic hematopoietic transplantation. Bone Marrow Transplant 2015; 50:1157-67. [PMID: 25985053 PMCID: PMC4809137 DOI: 10.1038/bmt.2015.61] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Accepted: 11/17/2014] [Indexed: 12/30/2022]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) was originally developed to allow delivery of myeloablative doses of chemotherapy and radiotherapy. With better understanding of disease pathophysiology, the graft vs malignancy (GVM) effect of allogeneic hematopoietic transplantation and toxicities associated with myeloablative conditioning (MAC) regimens, the focus shifted to developing less toxic conditioning regimens to reduce treatment-related morbidity without compromising survival. Although HCT with MAC is preferred to reduced intensity conditioning (RIC) for most patients ⩽60 years with AML/myelodysplastic syndrome and ALL, RIC and nonmyeloablative (NMA) regimens allow HCT for many otherwise ineligible patients. Reduced intensity preparative regimens have produced high rates of PFS for diagnoses, which are highly sensitive to GVM. Relapse of the malignancy is the major cause of treatment failure with RIC/NMA HCT. Incorporation of novel agents like bortezomib or lenalidomide, addition of cellular immunotherapy and use of targeted radiation therapies could further improve outcome. In this review, we discuss commonly used RIC/NMA regimens and promising novel regimens.
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Affiliation(s)
- S R Pingali
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - R E Champlin
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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13
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McCune JS, Mager DE, Bemer MJ, Sandmaier BM, Storer BE, Heimfeld S. Association of fludarabine pharmacokinetic/dynamic biomarkers with donor chimerism in nonmyeloablative HCT recipients. Cancer Chemother Pharmacol 2015; 76:85-96. [PMID: 25983023 DOI: 10.1007/s00280-015-2768-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 05/05/2015] [Indexed: 12/13/2022]
Abstract
PURPOSE Fludarabine monophosphate (fludarabine) is an integral component of many reduced-intensity conditioning regimens for hematopoietic cell transplantation (HCT). Fludarabine's metabolite, 9-β-D-arabinofuranosyl-2-fluoroadenine (F-ara-A), undergoes cellular uptake and activation to form the active cytotoxic metabolite fludarabine triphosphate (F-ara-ATP), which inhibits cellular DNA synthesis in CD4(+) and CD8(+) cells. In this study, we evaluated whether fludarabine-based pharmacologic biomarkers were associated with clinical outcomes in HCT recipients. METHODS Participants with hematologic diseases were conditioned with fludarabine and low-dose total body irradiation (TBI) followed by allogeneic HCT and post-grafting immunosuppression. After fludarabine administration, we evaluated pharmacological biomarkers for fludarabine-F-ara-A area under the curve (AUC) and the ratio of circulating CD4(+) and CD8(+) cells (CD4(+)/CD8(+) ratio) after fludarabine administration-in 102 patients; F-ara-ATP accumulation rate in enriched CD4(+) and CD8(+) cells was evaluated in 36 and 34 patients, respectively. RESULTS Interpatient variability in the pharmacological biomarkers was high, ranging from 3.7-fold (F-ara-A AUC) to 39-fold (F-ara-ATP in CD8(+) cells). Circulating CD8(+) cells were more sensitive to fludarabine administration. A population pharmacokinetic-based sampling schedule successfully allowed for estimation of F-ara-A AUC in this outpatient population. There was a poor correlation between the F-ara-AUC and the F-ara-ATP accumulation rate in CD4(+) (R (2) = 0.01) and CD8(+) cells (R (2) = 0.00). No associations were seen between the four biomarkers and clinical outcomes (day +28 donor T cell chimerism, acute graft-versus-host disease (GVHD), neutrophil nadirs, cytomegalovirus reactivation, chronic GVHD, relapse, non-relapse mortality, or overall mortality). CONCLUSIONS Considerable interpatient variability exists in pharmacokinetic and fludarabine-based biomarkers, but these biomarkers are not associated with clinical outcomes in fludarabine/TBI-conditioned patients.
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Affiliation(s)
- Jeannine S McCune
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA,
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14
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Reduced-intensity conditioned allogeneic SCT in adults with AML. Bone Marrow Transplant 2015; 50:759-69. [PMID: 25730186 DOI: 10.1038/bmt.2015.7] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 01/13/2015] [Accepted: 01/14/2015] [Indexed: 02/08/2023]
Abstract
AML is currently the most common indication for reduced-intensity conditioned (RIC) allo-SCT. Reduced-intensity regimens allow a potent GVL response to occur with minimized treatment-related toxicity in patients of older age or with comorbidities that preclude the use of myeloablative conditioning. Whether RIC SCT is appropriate for younger and more standard risk patients is not well defined and the field is changing rapidly; a prospective randomized trial of myeloablative vs RIC (BMT-CTN 0901) was recently closed when early results indicated better outcomes for myeloablative regimens. However, detailed results are not available, and all patients in that study were eligible for myeloablative conditioning. RIC transplants will likely remain the standard of care as many patients with AML are not eligible for myeloablative conditioning. Recent publication of mature results from retrospective and prospective cohorts provide contemporary efficacy and toxicity data for these attenuated regimens. In addition, recent studies explore the use of alternative donors, introduce regimens that attempt to reduce toxicity without reducing intensity, and identify predictive factors that pave the way to personalized approaches. These studies paint a picture of the future of RIC transplants. Here we review the current status of RIC allogeneic SCT in AML.
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Baron F, Zachée P, Maertens J, Kerre T, Ory A, Seidel L, Graux C, Lewalle P, Van Gelder M, Theunissen K, Willems E, Emonds MP, De Becker A, Beguin Y. Non-myeloablative allogeneic hematopoietic cell transplantation following fludarabine plus 2 Gy TBI or ATG plus 8 Gy TLI: a phase II randomized study from the Belgian Hematological Society. J Hematol Oncol 2015; 8:4. [PMID: 25652604 PMCID: PMC4332717 DOI: 10.1186/s13045-014-0098-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 12/20/2014] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Few studies thus far have compared head-to-head different non-myelooablative conditioning regimens for allogeneic hematopoietic cell transplantation (allo-HCT). METHODS Here, we report the results of a phase II multicenter randomized study comparing non-myeloablative allo-HCT from HLA-identical siblings (n = 54) or from 10/10 HLA-matched unrelated donors (n = 40) with either fludarabine plus 2 Gy total body irradiation (Flu-TBI arm; n = 49) or 8 Gy TLI + anti-thymocyte globulin (TLI-ATG arm; n = 45) conditioning. RESULTS The 180-day cumulative incidences of grade II-IV acute GVHD (primary endpoint) were 12.2% versus 8.9% in Flu-TBI and TLI-ATG patients, respectively (P = 0.5). Two-year cumulative incidences of moderate/severe chronic GVHD were 40.8% versus 17.8% in Flu-TBI and TLI-ATG patients, respectively (P = 0.017). Five Flu-TBI patients and 10 TLI-ATG patients received pre-emptive DLI for low donor chimerism levels, while 1 Flu-TBI patient and 5 TLI-ATG patients (including 2 patients given prior pre-emptive DLIs) received a second HCT for poor graft function, graft rejection, or disease progression. Four-year cumulative incidences of relapse/progression were 22% and 50% in Flu-TBI and TLI-ATG patients, respectively (P = 0.017). Four-year cumulative incidences of nonrelapse mortality were 24% and 13% in Flu-TBI and TLI-ATG patients, respectively (P = 0.5). Finally, 4-year overall (OS) and progression-free survivals (PFS) were 53% and 54%, respectively, in the Flu-TBI arm, versus 54% (P = 0.9) and 37% (P = 0.12), respectively, in the TLI-ATG arm. CONCLUSIONS In comparison to patients included in the Flu-TBI arm, patients included in the TLI-ATG arm had lower incidence of chronic GVHD, higher incidence of relapse and similar OS. TRIAL REGISTRATION The study was registered on ClinicalTrial.gov ( NCT00603954 ) and EUDRACT (2010-024297-19) .
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Affiliation(s)
- Frédéric Baron
- Department of Hematology, University of Liège, and CHU of Liège, Sart-Tilman, 4000, Liège, Belgium.
| | | | | | | | - Aurélie Ory
- Department of Hematology, University of Liège, and CHU of Liège, Sart-Tilman, 4000, Liège, Belgium.
| | - Laurence Seidel
- Department of Statistics, University of Liège, and CHU of Liège, Liège, Belgium.
| | - Carlos Graux
- Mont-Godine University Hospital (UCL), Yvoir, Belgium.
| | | | | | | | - Evelyne Willems
- Department of Hematology, University of Liège, and CHU of Liège, Sart-Tilman, 4000, Liège, Belgium.
| | | | - Ann De Becker
- Universitair Ziekenhuis Brussel (UZ Brussels), Brussels, Belgium.
| | - Yves Beguin
- Department of Hematology, University of Liège, and CHU of Liège, Sart-Tilman, 4000, Liège, Belgium.
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16
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Comparison of non-myeloablative conditioning regimens for lymphoproliferative disorders. Bone Marrow Transplant 2014; 50:367-74. [PMID: 25437248 PMCID: PMC4351124 DOI: 10.1038/bmt.2014.269] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Revised: 09/24/2014] [Accepted: 09/25/2014] [Indexed: 11/17/2022]
Abstract
Hematopoietic cell transplantation (HCT) with non-myeloablative conditioning (NMA) for lymphoproliferative diseases (LD) includes fludarabine with and without low-dose total body irradiation (TBI). Transplant outcomes were compared among patients ≥40 years with LD who received a HCT with TBI (N=382) and no-TBI (N=515) NMA from 2001 to 2011. The groups were comparable except for donor, graft, prophylaxis for graft-versus-host disease (GVHD), disease status and year of HCT. Cumulative incidences of grades II–IV GVHD at 100 days, were 29% and 20% (p=0.001), and chronic GVHD at 1 year were 54% and 44% (p=0.004) for TBI and no-TBI, respectively. Multivariate analysis of progression/relapse, treatment failure and mortality showed no outcome differences by conditioning. Full donor chimerism at day 100 was observed in 82% vs. 64% in the TBI and no-TBI groups, respectively (p=0.006). Subset of four most common conditioning/ GVHD prophylaxis combinations demonstrated higher rates of grades II–IV acute (p<0.001) and chronic GVHD (p<0.001) among recipients of TBI-mycophenolate mofetil (MMF) compared to other combinations. TBI-based NMA conditioning induces faster full donor chimerism but overall survival outcomes are comparable to no-TBI regimens. Combination of TBI and MMF are associated with higher rates of GVHD without impact on survival outcomes in patients with LD.
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17
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Bemer MJ, Risler LJ, Phillips BR, Wang J, Storer BE, Sandmaier BM, Duan H, Raccor BS, Boeckh MJ, McCune JS. Recipient pretransplant inosine monophosphate dehydrogenase activity in nonmyeloablative hematopoietic cell transplantation. Biol Blood Marrow Transplant 2014; 20:1544-52. [PMID: 24923537 PMCID: PMC4163086 DOI: 10.1016/j.bbmt.2014.05.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Accepted: 05/30/2014] [Indexed: 10/25/2022]
Abstract
Mycophenolic acid, the active metabolite of mycophenolate mofetil (MMF), inhibits inosine monophosphate dehydrogenase (IMPDH) activity. IMPDH is the rate-limiting enzyme involved in de novo synthesis of guanosine nucleotides and catalyzes the oxidation of inosine 5'-monophosphate to xanthosine 5'-monophosphate (XMP). We developed a highly sensitive liquid chromatography-mass spectrometry method to quantitate XMP concentrations in peripheral blood mononuclear cells (PMNCs) isolated from the recipient pretransplant and used this method to determine IMPDH activity in 86 nonmyeloablative allogeneic hematopoietic cell transplantation (HCT) patients. The incubation procedure and analytical method yielded acceptable within-sample and within-individual variability. Considerable between-individual variability was observed (12.2-fold). Low recipient pretransplant IMPDH activity was associated with increased day +28 donor T cell chimerism, more acute graft-versus-host disease (GVHD), lower neutrophil nadirs, and more cytomegalovirus reactivation but not with chronic GVHD, relapse, nonrelapse mortality, or overall mortality. We conclude that quantitation of the recipient's pretransplant IMPDH activity in PMNC lysate could provide a useful biomarker to evaluate a recipient's sensitivity to MMF. Further trials should be conducted to confirm our findings and to optimize postgrafting immunosuppression in nonmyeloablative HCT recipients.
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Affiliation(s)
- Meagan J Bemer
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; School of Pharmacy, University of Washington, Seattle, Washington
| | - Linda J Risler
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; School of Pharmacy, University of Washington, Seattle, Washington
| | - Brian R Phillips
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; School of Pharmacy, University of Washington, Seattle, Washington
| | - Joanne Wang
- School of Pharmacy, University of Washington, Seattle, Washington
| | - Barry E Storer
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Brenda M Sandmaier
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; School of Medicine, University of Washington, Seattle, Washington
| | - Haichuan Duan
- School of Pharmacy, University of Washington, Seattle, Washington
| | - Brianne S Raccor
- School of Pharmacy, University of Washington, Seattle, Washington
| | - Michael J Boeckh
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; School of Medicine, University of Washington, Seattle, Washington
| | - Jeannine S McCune
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; School of Pharmacy, University of Washington, Seattle, Washington.
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18
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Kornblit B, Maloney DG, Storer BE, Maris MB, Vindeløv L, Hari P, Langston AA, Pulsipher MA, Bethge WA, Chauncey TR, Lange T, Petersen FB, Hübel K, Woolfrey AE, Flowers MED, Storb R, Sandmaier BM. A randomized phase II trial of tacrolimus, mycophenolate mofetil and sirolimus after non-myeloablative unrelated donor transplantation. Haematologica 2014; 99:1624-31. [PMID: 25085357 DOI: 10.3324/haematol.2014.108340] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The study is a randomized phase II trial investigating graft-versus-host disease prophylaxis after non-myeloablative (90 mg/m(2) fludarabine and 2 Gy total body irradiation) human leukocyte antigen matched unrelated donor transplantation. Patients were randomized as follows: arm 1 - tacrolimus 180 days and mycophenolate mofetil 95 days (n=69); arm 2 - tacrolimus 150 days and mycophenolate mofetil 180 days (n=71); arm 3 - tacrolimus 150 days, mycophenolate mofetil 180 days and sirolimus 80 days (n=68). All patients had sustained engraftment. Grade II-IV acute graft-versus-host disease rates in the 3 arms were 64%, 48% and 47% at Day 150, respectively (arm 3 vs. arm 1 (hazard ratio 0.62; P=0.04). Owing to the decreased incidence of acute graft-versus-host disease, systemic steroid use was lower at Day 150 in arm 3 (32% vs. 55% in arm 1 and 49% in arm 2; overall P=0.009 by hazard ratio analysis). The Day 150 incidence of cytomegalovirus reactivation was lower in arm 3 (arm 1, 54%; arm 2, 47%; arm 3, 22%; overall P=0.002 by hazard ratio analysis). Non-relapse mortality was comparable in the three arms at two years (arm 1, 26%; arm 2, 23%; arm 3, 18%). Toxicity rates and other outcome measures were similar between the three arms. The addition of sirolimus to tacrolimus and mycophenolate mofetil is safe and associated with lower incidence of acute graft-versus-host disease and cytomegalovirus reactivation. (clinicaltrials.gov identifier: 00105001).
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Affiliation(s)
- Brian Kornblit
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - David G Maloney
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA Division of Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Barry E Storer
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA Department of Biostatistics, University of Washington, Seattle, WA, USA
| | | | | | | | | | - Michael A Pulsipher
- Division of Hematology and Hematologic Malignancies, Huntsman Cancer Institute, University of Utah School of Medicine, Salt Lake City, UT, USA
| | | | | | | | | | | | - Ann E Woolfrey
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA Division of Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Mary E D Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA Division of Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Rainer Storb
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA Division of Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Brenda M Sandmaier
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA Division of Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
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19
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The Quest for the Optimal Conditioning Regimen: Some Answers, More Questions. Biol Blood Marrow Transplant 2013; 19:1275-6. [DOI: 10.1016/j.bbmt.2013.07.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Accepted: 07/10/2013] [Indexed: 11/18/2022]
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