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Munshi PN, McCurdy SR. Age barriers in allogeneic hematopoietic cell transplantation: Raising the silver curtain. Am J Hematol 2024; 99:922-937. [PMID: 38414188 DOI: 10.1002/ajh.27228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 12/13/2023] [Accepted: 01/01/2024] [Indexed: 02/29/2024]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) is no longer exclusively for the young. With an aging population, development of non-intensive remission-inducing strategies for hematologic malignancies, and novel graft-versus-host disease-prevention platforms, an older population of patients is pursuing HCT. The evolving population of HCT recipients requires an overhaul in the way we risk-stratify and optimize patients prior to HCT. Here, we review the history and current state of HCT for older adults and propose an assessment and intervention flow to bridge the gaps in today's clinical guidelines.
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Affiliation(s)
- Pashna N Munshi
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Shannon R McCurdy
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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2
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Tomlinson B, de Lima M, Cogle CR, Thompson MA, Grinblatt DL, Pollyea DA, Komrokji RS, Roboz GJ, Savona MR, Sekeres MA, Abedi M, Garcia-Manero G, Kurtin SE, Maciejewski JP, Patel JL, Revicki DA, George TI, Flick ED, Kiselev P, Louis CU, DeGutis IS, Nifenecker M, Erba HP, Steensma DP, Scott BL. Transplantation Referral Patterns for Patients with Newly Diagnosed Higher-Risk Myelodysplastic Syndromes and Acute Myeloid Leukemia at Academic and Community Sites in the Connect® Myeloid Disease Registry: Potential Barriers to Care. Transplant Cell Ther 2023; 29:460.e1-460.e9. [PMID: 37086851 PMCID: PMC11104018 DOI: 10.1016/j.jtct.2023.04.011] [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: 10/13/2022] [Revised: 02/23/2023] [Accepted: 04/14/2023] [Indexed: 04/24/2023]
Abstract
Hematopoietic stem cell transplantation (HCT) is indicated for patients with higher-risk (HR) myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML). Age, performance status, patient frailty, comorbidities, and nonclinical factors (eg, cost, distance to site) are all recognized as important clinical factors that can influence HCT referral patterns and patient outcomes; however, the proportion of eligible patients referred for HCT in routine clinical practice is largely unknown. This study aimed to assess patterns of consideration for HCT among patients with HR-MDS and AML enrolled in the Connect® Myeloid Disease Registry at community/government (CO/GOV)- or academic (AC)-based sites, as well as to identify factors associated with rates of transplantation referral. We assessed patterns of consideration for and completion of HCT in patients with HR-MDS and AML enrolled between December 12, 2013, and March 6, 2020, in the Connect Myeloid Disease Registry at 164 CO/GOV and AC sites. Registry sites recorded whether patients were considered for transplantation at baseline and at each follow-up visit. The following answers were possible: "considered potentially eligible," "not considered potentially eligible," or "not assessed." Sites also recorded whether patients subsequently underwent HCT at each follow-up visit. Rates of consideration for HCT between CO/GOV and AC sites were compared using multivariable logistic regression analysis with covariates for age and comorbidity. Among the 778 patients with HR-MDS or AML enrolled in the Connect Myeloid Disease Registry, patients at CO/GOV sites were less likely to be considered potentially eligible for HCT than patients at AC sites (27.9% versus 43.9%; P < .0001). Multivariable logistic regression analysis with factors for age (<65 versus ≥65 years) and ACE-27 comorbidity grade (<2 versus ≥2) showed that patients at CO/GOV sites were significantly less likely than those at AC sites to be considered potentially eligible for HCT (odds ratio, 1.6, 95% confidence interval, 1.1 to 2.4; P = .0155). Among patients considered eligible for HCT, 45.1% (65 of 144) of those at CO/GOV sites and 35.7% (41 of 115) of those at AC sites underwent transplantation (P = .12). Approximately one-half of all patients at CO/GOV (50.1%) and AC (45.4%) sites were not considered potentially eligible for HCT; the most common reasons were age at CO/GOV sites (71.5%) and comorbidities at AC sites (52.1%). Across all sites, 17.4% of patients were reported as not assessed (and thus not considered) for HCT by their treating physician (20.7% at CO/GOV sites and 10.7% at AC sites; P = .0005). These findings suggest that many patients with HR-MDS and AML who may be candidates for HCT are not receiving assessment or consideration for transplantation in clinical practice. In addition, treatment at CO/GOV sites and age remain significant barriers to ensuring that all potentially eligible patients are assessed for HCT.
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Affiliation(s)
- Benjamin Tomlinson
- Seidman Cancer Center, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio.
| | - Marcos de Lima
- Department of Hematology, Ohio State University, Columbus, Ohio
| | - Christopher R Cogle
- Division of Hematology and Oncology, Department of Medicine, University of Florida, Gainesville, Florida
| | | | - David L Grinblatt
- NorthShore Medical Group, NorthShore University Health System, Evanston, Illinois
| | | | - Rami S Komrokji
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Gail J Roboz
- Weill Cornell College of Medicine and New York-Presbyterian Hospital, New York, New York
| | - Michael R Savona
- Vanderbilt-Ingram Cancer Center, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Mikkael A Sekeres
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida
| | - Mehrdad Abedi
- University of California Davis, Comprehensive Cancer Center, Sacramento, California
| | | | | | | | - Jay L Patel
- Department of Pathology, University of Utah and ARUP Laboratories, Salt Lake City, Utah
| | | | - Tracy I George
- Department of Pathology, University of Utah and ARUP Laboratories, Salt Lake City, Utah
| | | | | | | | | | | | | | | | - Bart L Scott
- Fred Hutchinson Cancer Research Center, Seattle, Washington
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Duda K, Wieczorkiewicz-Kabut A, Koclęga A, Zielińska P, Woźniczka K, Krzemień H, Armatys A, Helbig G. Allogeneic hematopoietic stem cell transplantation remains a feasible approach for elderly with acute myeloid leukemia: a 10-year experience. Ann Hematol 2023:10.1007/s00277-023-05226-1. [PMID: 37074379 DOI: 10.1007/s00277-023-05226-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 04/10/2023] [Indexed: 04/20/2023]
Abstract
The incidence of AML increases with age. The implementation of reduced intensity conditioning and progress in supportive care enabled to perform allo-HSCT in elderly patients. The main objective of the study was to assess the safety and efficacy of allotransplantation in elderly AML.Forty nine patients (33 males) at median age of 68 years were identified. Data on patients' and transplant's related variables were retrieved from our local transplant registry. Most patients (65%) were transplanted from 10/10-HLA or 9/10-HLA matched unrelated donor, seven patients (14%) received stem cells from matched related donor and ten patients (20%) from haploidentical donor. All patients received reduced-intensity conditioning (RIC). Peripheral blood was a source of stem cells in all patients except one (98%). Acute GVHD developed in 22 patients (44%) with 5 individuals presenting grade III-IV. CMV reactivation was demonstrated in 19 patients (39%) till day + 100. In total, 22 patients (45%) have died. The main causes of death included infectious complications (n = 9), relapse with subsequent chemotherapy resistance (n = 7), steroid-resistant GvHD (n = 4) and other causes (n = 2). Twenty-seven patients (55%) were alive at the last contact, presented full donor chimerism and remained in the complete remission. The probability of OS and relapse-free survival (RFS) were 57% and 81% at 2 years, respectively. Older donor age showed negative impact on relapse. CMV reactivation, the severity of acute graft versus host disease and older donor age negatively influenced survival. Allo-HSCT remains a safe, feasible and effective procedure for elderly AML patients.
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Affiliation(s)
- Katarzyna Duda
- Department of Hematology and Bone Marrow Transplantation, Faculty of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Agata Wieczorkiewicz-Kabut
- Department of Hematology and Bone Marrow Transplantation, Faculty of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Anna Koclęga
- Department of Hematology and Bone Marrow Transplantation, Faculty of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Patrycja Zielińska
- Department of Hematology and Bone Marrow Transplantation, Faculty of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Krzysztof Woźniczka
- Department of Hematology and Bone Marrow Transplantation, Faculty of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Helena Krzemień
- Department of Hematology and Bone Marrow Transplantation, Faculty of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Anna Armatys
- Department of Hematology and Bone Marrow Transplantation, Faculty of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Grzegorz Helbig
- Department of Hematology and Bone Marrow Transplantation, Faculty of Medicine in Katowice, Medical University of Silesia, Katowice, Poland.
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Impact of age on hospitalization and outcomes post allogeneic hematopoietic cell transplantation outcome, a single center experience. Ann Hematol 2023; 102:917-926. [PMID: 36820907 DOI: 10.1007/s00277-023-05135-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 02/08/2023] [Indexed: 02/24/2023]
Abstract
The outcomes of allogeneic hematopoietic cell transplantation (HCT) in older patients are not well defined. We retrospectively analyzed the outcomes of 332 patients, with the median age of 65 years (range, 60-76), between 2014 and 2019. We categorized them to 3 age groups (G): G1, 60-65 years (n = 175); G2, > 65-70 years (n = 127); and G3, > 70 years (n = 30). The median length of hospitalization during the initial HCT period was 30 days, with a significant difference when stratified by age (p = 0.049). Overall, 183 (58.7%) patients were re-hospitalized within the first 6 months post HCT, and 60 (21.6%) in the second 6-month period. The 2-year OS was 56% in G1, 53% in G2, and 34% in G3 (p = 0.05). The 2-year event-free survival (EFS) was 54% for G1, 49% for G2, and 31% for G3 (p = 0.04). Non-relapse mortality (NRM) at 2 years was 25% in G1, 36% in G2, and 52% in G3 (p = 0.008). In multivariable analysis, patients aged 60-65 years had significantly better EFS (p = 0.04) and had a trend toward lower NRM (p = 0.05) than those aged > 70 years. Re-admission in the first 6 months post HCT had a significant impact on OS, EFS, and NRM. HCT-specific comorbidity index > 3 had significantly affected NRM. Finally, age had a significant influence on length of hospitalization during HCT. In conclusion, patients aged > 70 years have an inferior EFS and higher NRM. This likely related to higher rate of re-admissions due to infectious complications (84%).
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Prognostic significance of frailty status in patients with primary lung cancer. BMC Geriatr 2023; 23:46. [PMID: 36698160 PMCID: PMC9878966 DOI: 10.1186/s12877-023-03765-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 01/20/2023] [Indexed: 01/27/2023] Open
Abstract
Lung cancer has one of the highest morbidity and mortality rates in the world. Frailty is common in many countries and is a major cause of premature functional decline and premature death in older adults, and may affect the treatment and prognosis of lung cancer patients. To investigate the predictive value of frailty at diagnosis on all-cause mortality in lung cancer patients, this study retrospectively collected and analysed clinical information on lung cancer patients from 2015-2018. A total of 1667 patients with primary lung cancer were finally included in this study. The median follow-up time of patients was 650 (493, 1001.5) days. A total of 297(17.8%) patients had FI-LAB(the frailty index based on laboratory test) status of frail at the moment of diagnosis and the all-cause mortality rate for all patients was 61.1% (1018/1667). In a univariate model, we found a higher total all-cause mortality risk in frail patients (frail vs. robust, HR(hazard ratio) = 1.616, 95% CI(confidence interval) = 1.349,1.936), after balancing other variables combined into model 1 to model 6. The results were analyzed visually using ROC(Receiver operating characteristic) curves with nomogram and the AUC values ranged from 0.866-0.874. The final inclusion of age, TNM stage, CCI(Charlson comorbidity index) score, surgery history and chemotherapy into a multifactorial model balanced the predictive power of frailty grading on all-cause mortality. The study showed that for lung cancer patients, the higher the level of frailty at diagnosis, the higher the risk of all-cause mortality. In the context of widespread electronic medical records in hospitals, it is convenient and feasible to use FI-LAB to assess the prognosis of lung cancer patients.
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Aubrey BJ, Brunner AM. SOHO State of the Art and Next Questions: Treatment of Higher-Risk Myelodysplastic Syndromes. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:869-877. [PMID: 36030175 DOI: 10.1016/j.clml.2022.07.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 07/13/2022] [Accepted: 07/19/2022] [Indexed: 01/26/2023]
Abstract
Higher-risk myelodysplastic syndromes (MDS) carry a dismal prognosis with rapid disease progression, disease-related complications that impact quality of life, high risk of transformation to acute myeloid leukemia (AML), and poor long-term survival. Higher-risk disease is determined by a number of factors including the depth and type of cytopenias, percentage of myeloblasts occupying the bone marrow, cytogenetic abnormalities, and increasingly also by the presence of higher-risk molecular alterations. In addition to disease characteristics, a patient's performance status and degree of co-morbidity strongly influence treatment decisions and clinical outcomes. A critical first step in the management of patients with higher-risk MDS is evaluating eligibility for allogeneic hematopoietic stem cell transplant (HCT), which currently remains the only curative therapy, and is available to an ever-increasing number of patients. Outside of stem cell transplant, treatment with hypomethylating agent chemotherapy, azacitidine or decitabine, remains the cornerstone of therapy with improvements in overall survival and reduced transformation to AML; however, these approaches are palliative in nature and outcomes remain very poor overall. With a deepening understanding of disease pathophysiology has come a burgeoning array of novel targeted therapies that are currently in pre-clinical and early phase clinical trials offering hope for new treatment options for this malignancy.
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Affiliation(s)
- Brandon J Aubrey
- Harvard Medical School, Massachusetts General Hospital, Boston, MA
| | - Andrew M Brunner
- Harvard Medical School, Massachusetts General Hospital, Boston, MA.
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Rosko AE, Cordoba R, Abel G, Artz A, Loh KP, Klepin HD. Advances in Management for Older Adults With Hematologic Malignancies. J Clin Oncol 2021; 39:2102-2114. [PMID: 34043442 PMCID: PMC8260925 DOI: 10.1200/jco.21.00242] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 02/23/2021] [Accepted: 03/10/2021] [Indexed: 12/11/2022] Open
Affiliation(s)
- Ashley E. Rosko
- Division of Hematology, The Ohio State University, Columbus, OH
| | - Raul Cordoba
- Lymphoma Unit, Department of Hematology, Fundacion Jimenez Diaz University Hospital, Health Research Institute IIS-FJD, Madrid, Spain
| | - Gregory Abel
- Leukemia Program, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Andrew Artz
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA
| | - Kah Poh Loh
- James P. Wilmot Cancer Center, Division of Hematology/Oncology, Department of Medicine, University of Rochester Medical Center, Rochester, NY
| | - Heidi D. Klepin
- Section on Hematology and Oncology, Wake Forest Baptist Health, Winston-Salem, NC
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Survival Rate and Prognostic Factors Among Patients Undergoing Hematopoietic Stem Cell Transplantation: Using the Joint Model. INTERNATIONAL JOURNAL OF CANCER MANAGEMENT 2021. [DOI: 10.5812/ijcm.106846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Hematopoietic stem cell transplantation (HSCT) is the most effective of all hematologic malignancies treatments, resulting in a significant improvement in survival rate. Objectives: This study aimed at determining the survival rate and factors affecting the survival in patients undergoing hematopoietic stem cell transplantation, using the joint model. Methods: This study was a retrospective cohort study, used for collecting data from patients with hematopoietic malignancies who underwent hematopoietic stem cell transplantation in Taleghani Hospital (Shahid Beheshti University of Medical Sciences), Tehran, Iran during the years 2007 and 2015 and were followed up till 2017. A Bayesian joint model of longitudinal and survival was chosen, using Win Bugs software. Results: A total of 395 patients were enrolled. The median overall survival was 6.3 years (95% CI (5.86, 6.76)). Eighty-one patients had died. The obtained results from this study manifested that age (HR: 1.02, 95% CI: (1.002, 1.04)) and pre-transplantation relapse (HR = 1.64, 95% CI: (1.09, 2.4)) have incremental impact on death after transplantation, while malignancy type (NHL (HR: 0.33, 95%CI: (0.152, 0.73)) and AML (HR: 0.62, 95% CI: (0.29, 0.7)) are also effective in reducing death after transplantation. Similarly, the correlation index between longitudinal and survival models proved to be significant (HR: 0.6, 95% CI: (0.0802, 0.37)). Conclusions: This study showed that age, per-transplantation relapse, and malignancy type are the effective factors in the survival rate. Moreover, the link parameter between longitudinal response (WBC) and the survival indicated that an increase in WBC count leads to a decrease in the death risk.
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Isobe M, Konuma T, Masuko M, Uchida N, Miyakoshi S, Sugio Y, Yoshida S, Tanaka M, Matsuhashi Y, Hattori N, Onizuka M, Aotsuka N, Kouzai Y, Wake A, Kimura T, Ichinohe T, Atsuta Y, Yanada M. Single cord blood transplantation for acute myeloid leukemia patients aged 60 years or older: a retrospective study in Japan. Ann Hematol 2021; 100:1849-1861. [PMID: 33624134 DOI: 10.1007/s00277-021-04464-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 02/15/2021] [Indexed: 12/14/2022]
Abstract
The availability of alternative donor sources could allow elderly patients to receive allogeneic hematopoietic cell transplantation (HCT). We retrospectively evaluated the outcomes of single-unit cord blood transplantation (CBT) in 1577 patients aged ≥60 years with acute myeloid leukemia (AML) in Japan between 2002 and 2017. In total, 990 (63%) patients were not in complete remission (CR) at the time of CBT. A myeloablative conditioning regimen (52%) and calcineurin inhibitor (CI) + mycophenolate mofetil (MMF)-based graft-versus-host disease (GVHD) prophylaxis (45%) were more commonly used. With a median follow-up for survivors of 31 months, the probability of overall survival and the cumulative incidence of leukemia-related mortality at 3 years was 31% and 29%, respectively. The cumulative incidence of non-relapse mortality (NRM) at 100 days and 3 years were 24% and 41%, respectively. The cumulative incidences of grade II-IV and grade III-IV acute GVHD at 100 days and extensive chronic GVHD at 2 years were 44%, 16%, and 14%, respectively. The cumulative incidence of neutrophil engraftment was 80% at 42 days. Results of multivariate analysis indicated that the following factors were significantly associated with higher overall mortality: performance status ≥1, hematopoietic cell transplantation-specific comorbidity index ≥3, adverse cytogenetics, extramedullary disease at diagnosis, and non-CR status at CBT. By contrast, female sex, HLA disparities ≥2, mycophenolate mofetil-based GVHD prophylaxis, and recent CBT were significantly associated with lower overall mortality. In conclusion, single CBT offers a curative option for AML patients aged ≥60 years with careful patient selection.
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Affiliation(s)
- Masamichi Isobe
- Department of Hematology/Oncology, The Institute of Medical Science, The University of Tokyo, 4-6-1, Shirokanedai, Minato-ku, Tokyo, 108-8639, Japan
| | - Takaaki Konuma
- Department of Hematology/Oncology, The Institute of Medical Science, The University of Tokyo, 4-6-1, Shirokanedai, Minato-ku, Tokyo, 108-8639, Japan.
| | - Masayoshi Masuko
- Department of Hematopoietic Cell Transplantation, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Naoyuki Uchida
- Department of Hematology, Toranomon Hospital, Tokyo, Japan
| | | | - Yasuhiro Sugio
- Department of Internal Medicine, Kitakyushu City Hospital Organization, Kitakyushu Municipal Medical Center, Kitakyushu, Japan
| | - Shuro Yoshida
- Department of Hematology, Hamanomachi Hospital, Fukuoka, Japan
| | - Masatsugu Tanaka
- Department of Hematology, Kanagawa Cancer Center, Yokohama, Japan
| | - Yoshiko Matsuhashi
- Department of Hematology, Kawasaki Medical School Hospital, Kurashiki, Japan
| | - Norimichi Hattori
- Division of Hematology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Makoto Onizuka
- Department of Hematology and Oncology, Tokai University School of Medicine, Isehara, Japan
| | - Nobuyuki Aotsuka
- Division of Hematology-Oncology, Japanese Red Cross Society Narita Hospital, Narita, Japan
| | - Yasushi Kouzai
- Department of Transfusion Medicine, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Atsushi Wake
- Department of Hematology, Toranomon Hospital Kajigaya, Kawasaki, Japan
| | - Takafumi Kimura
- Preparation Department, Japanese Red Cross Kinki Block Blood Center, Osaka, Japan
| | - Tatsuo Ichinohe
- Department of Hematology and Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Yoshiko Atsuta
- Japanese Data Center for Hematopoietic Cell Transplantation, Nagoya, Japan.,Department of Healthcare Administration, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masamitsu Yanada
- Department of Hematology and Cell Therapy, Aichi Cancer Center, Nagoya, Japan
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Jamy O, Chen A, Battles K, Francisco L, Salzman D, Bal S, Di Stasi A, Costa L, Bhatia R, Bhatia S. Impact of access to care on 1-year mortality following allogeneic blood or marrow transplantation. Bone Marrow Transplant 2021; 56:1364-1372. [PMID: 33420395 DOI: 10.1038/s41409-020-01184-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 11/16/2020] [Accepted: 11/30/2020] [Indexed: 01/07/2023]
Abstract
Mortality is highest in the first year following an allogeneic hematopoietic stem cell transplant. With recent advancements, we have expanded the pool of patients to whom we are able to offer transplant as a treatment option. In this context, we analyzed socioeconomic, patient, disease and transplant-related variables that predicted for 1-year all-cause, relapse-related (RRM) and non-relapse related mortality (NRM) in 304 patients at the University of Alabama at Birmingham. The 1-year overall survival, RRM and NRM rates were 60.5%, 13.5% and 22.7% respectively. A KPS score < 80, pre-transplant infection and hypertension and non-complete remission disease status adversely effected all-cause mortality. For NRM, increasing age, pre-transplant infection and diabetes, and poor access to care were associated with higher mortality whereas haploidentical donor type was associated with improved survival. For RRM, a KPS score <80, high/very high disease risk index and the presence of comorbidities were risk factors for higher mortality. Poor access to care, in addition to individual comorbidities, performance status and high-risk disease characteristics, is associated with adverse outcomes following transplant. We propose the incorporation of socioeconomic variables with patient, disease, and transplant-related variables to predict 1-year NRM.
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Affiliation(s)
- Omer Jamy
- Division of Hematology and Oncology, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Alice Chen
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kevin Battles
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Liton Francisco
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Donna Salzman
- Division of Hematology and Oncology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Susan Bal
- Division of Hematology and Oncology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Antonio Di Stasi
- Division of Hematology and Oncology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Luciano Costa
- Division of Hematology and Oncology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ravi Bhatia
- Division of Hematology and Oncology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL, USA
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Chien SH, Yao M, Li CC, Chang PY, Yu MS, Huang CE, Tan TD, Lin CH, Yeh SP, Li SS, Wang PN, Liu YC, Gau JP. Charlson comorbidity index predicts outcomes of elderly after allogeneic hematopoietic stem cell transplantation for acute myeloid leukemia and myelodysplastic syndrome. J Formos Med Assoc 2021; 120:2144-2152. [PMID: 33423899 DOI: 10.1016/j.jfma.2020.12.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 12/09/2020] [Accepted: 12/21/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND/PURPOSE Allogeneic hematopoietic stem cell transplantation (allo-HSCT) remains the curative therapy for acute myeloid leukemia (AML) or high-risk myelodysplastic syndrome (MDS), but advanced age with multiple comorbidities limits the eligibility for allo-HSCT. We conducted a retrospective study to investigate the comorbidities assessments and prognostic factors that predict outcomes for these patients. METHODS Clinical data of patients older than 50 years who had received diagnoses of AML or MDS and underwent allo-HSCT were obtained. Information on patient characteristics, including age, gender, allogeneic transplant type, conditioning regimens, Charlson comorbidity index (CCI), and presence of acute graft-versus-host disease (GVHD) or chronic GVHD, were collected and analyzed. RESULTS Two hundred fifty-five elderly patients with a median age at allo-HSCT of 57 years were included. The significant prognostic factors associated with worse overall survival (OS) were CCI ≥3 (hazard ratio: 1.88) and grade III-IV acute GVHD (3.18). Similar findings were noted in the non-relapse mortality analysis. To investigate the effects of chronic GVHD on patient outcomes, OS analysis was performed for those with survival >100 days after transplantation. The results revealed CCI ≥3 (1.88) and grade III-IV acute GVHD (2.73) remained poor prognostic factors for OS, whereas mild chronic GVHD (0.43) was associated with better OS. CONCLUSION This cohort study suggests that CCI ≥3 predicts poor outcomes, primarily due to a higher NRM risk. Careful management of GVHD after transplantation could improve outcomes in elderly patients with AML or MDS after allo-HSCT.
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Affiliation(s)
- Sheng-Hsuan Chien
- Division of Transfusion Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan; Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan; Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ming Yao
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chi-Cheng Li
- Department of Hematology and Oncology, Buddhist Tzu-Chi General Hospital, Hualien, Taiwan; Tai Cheng Stem Cell Therapy Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Ping-Ying Chang
- Division of Hematology and Oncology, Department of Medicine, Tri-Service General Hospital, Taiwan; National Defense Medical Center, Taiwan
| | - Ming-Sun Yu
- Division of Hematology and Oncology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Cih-En Huang
- Division of Hematology and Oncology, Department of Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan; Graduate Institute of Clinical Medical Science, Chang Gung University, Tao-Yuan, Taiwan
| | - Tran-Der Tan
- Koo Foundation Sun Yat-Sen Cancer Center, Taiwan
| | - Cheng-Hsien Lin
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Su-Peng Yeh
- Division of Hematology and Oncology, Department of Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Sin-Syue Li
- Division of Hematology and Oncology, Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Po-Nan Wang
- Division of Hematology, Chang Gung Medical Foundation, Linkou Branch, Tao-Yuan, Taiwan
| | - Yi-Chang Liu
- Division of Hematology and Oncology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Department of Internal Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jyh-Pyng Gau
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan; Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.
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12
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Allogeneic Hematopoietic Stem Cell Transplantation for Acute Myeloid Leukemia of the Elderly: Review of Literature and New Perspectives. Mediterr J Hematol Infect Dis 2020; 12:e2020081. [PMID: 33194155 PMCID: PMC7643805 DOI: 10.4084/mjhid.2020.081] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 10/18/2020] [Indexed: 12/31/2022] Open
Abstract
Acute myeloid leukemia (AML) in patients over the age of 60 carries a poor prognosis, mainly due to unsatisfactory control of leukemia with chemotherapy alone. Allogeneic hemopoietic stem cell transplantation (HSCT) would provide significant anti-leukemic effect but is associated with morbidity and mortality, especially in older patients with comorbidities. Reduced-intensity conditioning (RIC) and non-myeloablative (NMA) conditioning regimens have been designed and have led to improved outcomes in this older patient population. New targeted agents, such as Flt3 inhibitors, are currently being used to improve the control of AML further and may be incorporated in a transplant approach. The increasing knowledge of AML in the elderly is currently being associated with a multidimensional approach to identify eligibility and design tailored transplant platforms.
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13
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Wolff D, Herzberg PY, Herrmann A, Pavletic SZ, Heussner P, Mumm F, Höfer C, Hilgendorf I, Hemmati PG, Holler E, Greinix H, Mitchell SA. Post-transplant multimorbidity index and quality of life in patients with chronic graft-versus-host disease-results from a joint evaluation of a prospective German multicenter validation trial and a cohort from the National Institutes of Health. Bone Marrow Transplant 2020; 56:243-256. [PMID: 32737446 PMCID: PMC8376641 DOI: 10.1038/s41409-020-01017-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 07/09/2020] [Accepted: 07/24/2020] [Indexed: 12/19/2022]
Abstract
Comorbidity after allogeneic hematopoietic stem cell transplantation (alloHSCT) impairs quality of life (QoL), physical functioning, and survival. We developed a new standardized measure to capture comorbidity after transplantation, the Post-transplant Multimorbidity Index (PTMI) in a cohort of 50 long term survivors. We subsequently evaluated the content validity and impact on survival and QoL within a multicenter trial, including 208 patients (pts) after alloHSCT, who were prospectively evaluated applying the FACT-BMT, the Human Activity Profile (HAP), the SF-36 v.2, PTMI and the Hematopoietic Cell Transplantation-Comorbidity Index (HCT-CI). The most prevalent comorbidities were compensated arterial hypertension (28.4%), ambulatory infections (25.5%), iron overload (23%), mild renal function impairment (20%), and osteoporosis (13%). Applying the PTMI 13% of patients had no comorbidity, while 37.1% had 1–3 comorbidities, 27.4% had 4–6 comorbidities, and 13.5% had > 6 comorbidities. Chronic graft-versus-host disease (cGvHD) was significantly associated with the PTMI, while age and prior acute GvHD were not. In contrast, the HCT-CI was not associated with the presence of cGvHD. cGvHD was significantly associated with depression (r = 0.16), neurological disease (r = 0.21), osteoporosis (r = 0.18) and nonmelanoma skin cancer (r = 0.26). The PTMI demonstrated strong measurement properties and compared to the HCT-CI captured a wider range of comorbidities associated with cGvHD.
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Affiliation(s)
- Daniel Wolff
- Department of Internal Medicine III, University Hospital of Regensburg, Regensburg, Germany.
| | - Philipp Y Herzberg
- Faculty of Humanities and Social Sciences, Personality Psychology and Psychological Assessment, Helmut Schmidt University of the Federal Armed Forces Hamburg, Hamburg, Germany
| | - Anne Herrmann
- Department of Internal Medicine III, University Hospital of Regensburg, Regensburg, Germany
| | - Steven Z Pavletic
- Immune Deficiency Cellular Therapy Program, Center of Cancer Research, National Cancer Institute, Bethesda, MD, USA
| | - Pia Heussner
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - Friederike Mumm
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - Christina Höfer
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - Inken Hilgendorf
- Klinik für Innere Medizin II, Abteilung für Hämatologie und Onkologie, Universitätsklinikum Jena, Jena, Germany
| | - Philipp G Hemmati
- Department of Hematology, Oncology and Tumor Immunology, Campus Virchow Klinikum Charité-University Hospital Berlin, Berlin, Germany
| | - Ernst Holler
- Department of Internal Medicine III, University Hospital of Regensburg, Regensburg, Germany
| | | | - Sandra A Mitchell
- Outcomes Research Branch, National Institutes of Health, Bethesda, MD, USA
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14
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Chien SH, Liu YC, Liu CJ, Ko PS, Wang HY, Hsiao LT, Lin JS, Chiou TJ, Liu CY, Gau JP. European Group for Blood and Marrow Transplantation score correlates with outcomes of older patients undergoing allogeneic hematopoietic stem cell transplantation. J Chin Med Assoc 2020; 83:238-244. [PMID: 31904659 DOI: 10.1097/jcma.0000000000000255] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS) are hematological diseases predominantly occurring in older patients. Although allogeneic hematopoietic stem cell transplantation (allo-HSCT) remains the curative therapy for refractory AML or high-risk MDS, old age is often a hurdle to the procedure. We conducted a retrospective study to analyze the prognostic factors predicting outcomes of older patients undergoing allo-HSCT for acute leukemia and MDS. METHODS We collected data from patients diagnosed with acute leukemia or MDS, who underwent allo-HSCT at >50 years of age and reviewed clinical characteristics, including age, sex, underlying disease, European Group for Blood and Bone Marrow Transplantation (EBMT) risk score, and presence of acute graft-versus-host disease (aGVHD) or chronic GVHD (cGVHD). The Cox proportional hazard model was adopted to explore the independent prognostic factors for overall survival (OS), progression-free survival (PFS), and non-relapse mortality (NRM). RESULTS A total of 85 older patients were included, with the median age at allo-HSCT being 55 years. The significant prognostic factors for worse OS or PFS were an EBMT risk score > 3 and grade III-IV aGVHD, while patients with moderate to severe cGVHD would have better OS or PFS. Interestingly, it is not cGVHD but grade III-IV aGVHD that significantly correlated with NRM. CONCLUSION This cohort study suggests that an EBMT risk score >3 and grade III-IV aGVHD predict poor outcomes, and careful management of GVHD may allow better survival for older patients undergoing allo-HSCT.
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Affiliation(s)
- Sheng-Hsuan Chien
- Division of Transfusion Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Yao-Chung Liu
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chia-Jen Liu
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Po-Shen Ko
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Hao-Yuan Wang
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Liang-Tsai Hsiao
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Jeong-Shi Lin
- Division of Transfusion Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Tzeon-Jye Chiou
- Division of Transfusion Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Chun-Yu Liu
- Division of Transfusion Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Jyh-Pyng Gau
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
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15
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Abadir E, Gasiorowski RE, Silveira PA, Larsen S, Clark GJ. Is Hematopoietic Stem Cell Transplantation Required to Unleash the Full Potential of Immunotherapy in Acute Myeloid Leukemia? J Clin Med 2020; 9:E554. [PMID: 32085578 PMCID: PMC7073661 DOI: 10.3390/jcm9020554] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 02/13/2020] [Accepted: 02/13/2020] [Indexed: 12/22/2022] Open
Abstract
From monoclonal antibodies (mAbs) to Chimeric Antigen Receptor (CAR) T cells, immunotherapies have enhanced the efficacy of treatments against B cell malignancies. The same has not been true for Acute Myeloid Leukemia (AML). Hematologic toxicity has limited the potential of modern immunotherapies for AML at preclinical and clinical levels. Gemtuzumab Ozogamicin has demonstrated hematologic toxicity, but the challenge of preserving normal hematopoiesis has become more apparent with the development of increasingly potent immunotherapies. To date, no single surface molecule has been identified that is able to differentiate AML from Hematopoietic Stem and Progenitor Cells (HSPC). Attempts have been made to spare hematopoiesis by targeting molecules expressed only on later myeloid progenitors as well as AML or using toxins that selectively kill AML over HSPC. Other strategies include targeting aberrantly expressed lymphoid molecules or only targeting monocyte-associated proteins in AML with monocytic differentiation. Recently, some groups have accepted that stem cell transplantation is required to access potent AML immunotherapy and envision it as a rescue to avoid severe hematologic toxicity. Whether it will ever be possible to differentiate AML from HSPC using surface molecules is unclear. Unless true specific AML surface targets are discovered, stem cell transplantation could be required to harness the true potential of immunotherapy in AML.
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Affiliation(s)
- Edward Abadir
- Dendritic Cell Research, ANZAC Research Institute, Concord 2139, NSW, Australia;
- Institute of Haematology, Royal Prince Alfred Hospital, Camperdown 2050, NSW, Australia;
- The University of Sydney, Camperdown 2039, NSW, Australia;
| | - Robin E. Gasiorowski
- The University of Sydney, Camperdown 2039, NSW, Australia;
- Department of Haematology, Concord Repatriation and General Hospital, Concord 2039, NSW, Australia
| | - Pablo A. Silveira
- Dendritic Cell Research, ANZAC Research Institute, Concord 2139, NSW, Australia;
- The University of Sydney, Camperdown 2039, NSW, Australia;
| | - Stephen Larsen
- Institute of Haematology, Royal Prince Alfred Hospital, Camperdown 2050, NSW, Australia;
- The University of Sydney, Camperdown 2039, NSW, Australia;
| | - Georgina J. Clark
- Dendritic Cell Research, ANZAC Research Institute, Concord 2139, NSW, Australia;
- The University of Sydney, Camperdown 2039, NSW, Australia;
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16
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Hsu J, Chen Z, Shore T, Gergis U, Mayer S, Phillips A, Guarner D, Hsu YM, Cushing MM, Van Besien K. Outcomes of Allogeneic Stem Cell Transplant for Elderly Patients with Hematologic Malignancies. Biol Blood Marrow Transplant 2019; 26:789-797. [PMID: 31891814 DOI: 10.1016/j.bbmt.2019.12.766] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 11/03/2019] [Accepted: 12/26/2019] [Indexed: 12/23/2022]
Abstract
Reduced-intensity conditioning (RIC) regimens, improved HLA matching, and better supportive care allow allogeneic stem cell transplant (alloSCT) to be offered to older patients. Only a small percentage of eligible patients between ages 65 and 74 years actually undergo alloSCT, and comprehensive outcome data from the aging population are still lacking. We examined the outcome of older patients who underwent alloSCT using melphalan-based RIC for hematologic malignancies at our institution. We identified 125 patients older than 65 years (median, 69; range, 66 to 77) who underwent matched related donor, matched unrelated donor, or combined haploidentical/umbilical cord alloSCT between 2012 through November, 2017. Among them, 52 (41.6%) and 70 (56%) had, respectively, intermediate and high/very high Center for International Blood and Marrow Transplant Research (CIBMTR) disease risk index (DRI). One hundred six patients (85%) received fludarabine/melphalan-based RIC regimen with either antithymocyte globulin (ATG) or alemtuzumab. The median time to neutrophil engraftment was 13 days (range, 8 to 37) and platelet engraftment 17 days (range, 9 to 169). The cumulative incidence of nonrelapse mortality was 11.5% at 100 days and 30.1% and 34.8% at 1 and 2 years, respectively. The cumulative incidence of relapse was 35% and 40% at 1 and 2 years. The cumulative incidence of grades II to IV acute graft-versus-host disease (GVHD) at day 100 and 6 months was 29.5% and 34.5%, and chronic GVHD at 6, 12, and 24 months was 2.5%, 5.2%, and 6.3%, respectively. With a median follow-up of 32 months, the 1-, 2-, and 3-year progression-free survival (PFS) was 34.6%, 24.4%, and 16.5%, respectively. The graft GVHD-free survival was 24.6%, 16.1%, and 9.3%, respectively. The 1-, 2-, and 3-year overall survival (OS) was 44.5%, 30.7%, and 26.5%, respectively. In multivariable analysis, low albumin was predictive of poor PFS and OS and high hematopoietic cell transplantation-specific comorbidity index, and CIBMTR DRI was predictive of worse graft GVHD-free survival. Among long-term survivors the median Karnofsky performance status was 80. Older patients, even when referred with advanced disease, can benefit from melphalan-based alloSCT with HLA-matched or alternative donor sources without discernible impact of donor source on outcome. Using alemtuzumab- or ATG-based in vivo T cell depletion, the incidence of chronic GVHD is extremely low. Performance status in survivors is excellent. Better predictors for outcome in this patient population need to be identified.
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Affiliation(s)
- Jingmei Hsu
- Department of Medicine, Division of Hematology/Oncology, Weill Cornell Medical Center/New York Presbyterian Hospital, New York, New York.
| | - Zhengming Chen
- Biostatistics and Epidemiology, Healthcare Policy and Research, Weill Cornell Medical College, New York, New York
| | - Tsiporah Shore
- Department of Medicine, Division of Hematology/Oncology, Weill Cornell Medical Center/New York Presbyterian Hospital, New York, New York
| | - Usama Gergis
- Department of Medicine, Division of Hematology/Oncology, Weill Cornell Medical Center/New York Presbyterian Hospital, New York, New York
| | - Sebastian Mayer
- Department of Medicine, Division of Hematology/Oncology, Weill Cornell Medical Center/New York Presbyterian Hospital, New York, New York
| | - Adrienne Phillips
- Department of Medicine, Division of Hematology/Oncology, Weill Cornell Medical Center/New York Presbyterian Hospital, New York, New York
| | - Danielle Guarner
- Department of Medicine, Division of Hematology/Oncology, Weill Cornell Medical Center/New York Presbyterian Hospital, New York, New York
| | - Yen-Michael Hsu
- Department of Pathology, Weill Cornell Medical Center/New York Presbyterian Hospital, New York, New York
| | - Melissa M Cushing
- Department of Pathology, Weill Cornell Medical Center/New York Presbyterian Hospital, New York, New York
| | - Koen Van Besien
- Department of Medicine, Division of Hematology/Oncology, Weill Cornell Medical Center/New York Presbyterian Hospital, New York, New York
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17
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Imus PH, Tsai HL, Luznik L, Fuchs EJ, Huff CA, Gladstone DE, Lowery P, Ambinder RF, Borrello IM, Swinnen LJ, Wagner-Johnston N, Gocke CB, Ali SA, Bolaños-Meade FJ, Varadhan R, Jones RJ. Haploidentical transplantation using posttransplant cyclophosphamide as GVHD prophylaxis in patients over age 70. Blood Adv 2019; 3:2608-2616. [PMID: 31492679 PMCID: PMC6737415 DOI: 10.1182/bloodadvances.2019000155] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 07/09/2019] [Indexed: 01/14/2023] Open
Abstract
Hematologic malignancies in older people are unlikely to be cured with chemotherapy alone. Advances in allogeneic blood or marrow transplantation (alloBMT), especially nonmyeloablative (NMA) conditioning and the use of haploidentical donors, now make this therapy available to older people; however, long-term outcomes and predictors of success are unclear. We reviewed the outcomes of 93 consecutive patients aged 70 and older (median, 72; range, 70-78), who underwent haploidentical BMT at Johns Hopkins Hospital between 1 September 2009 and 1 April 2018. All patients received NMA conditioning and posttransplantation cyclophosphamide (PTCy) as graft-versus-host disease (GVHD) prophylaxis. The 2-year overall survival was 53%, and 2-year event-free survival was 43%. The 180-day cumulative incidence (CuI) of nonrelapse mortality (NRM) was 14%, and the 2-year CuI was 27%. The 2-year CuI of relapse was 30%. Of 78 patients who were alive and had their weight recorded on day 180, weight loss predicted subsequent NRM (subdistribution hazard ratio, 1.0; 95% CI, 1-1.13; P = .048). In conclusion, haploidentical BMT with PTCy is feasible and relatively safe in septuagenarians. Although early, 6-month NRM was relatively low at 14%, but overall NRM continued to climb to 27% at 2 years, at least in part because of late deaths that appeared to be somewhat age related. Further studies to elucidate predictors of NRM are warranted.
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Affiliation(s)
| | - Hua-Ling Tsai
- Division of Biostatistics and Bioinformatics, Johns Hopkins/Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD
| | - Leo Luznik
- Department of Hematologic Malignancy and
| | | | | | | | | | | | | | | | | | | | | | | | - Ravi Varadhan
- Division of Biostatistics and Bioinformatics, Johns Hopkins/Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD
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18
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Gonçalves SEAB, Ribeiro AAF, Hirose EY, Santos FPDS, Ferreira FM, Koch LDOM, Tanaka M, de Souza MS, Souza PMR, Gonçalves TJM, Pereira AZ. Brazilian Nutritional Consensus in Hematopoietic Stem Cell Transplantation: Elderly. EINSTEIN-SAO PAULO 2019; 17:eAE4340. [PMID: 31116236 PMCID: PMC6533077 DOI: 10.31744/einstein_journal/2019ae4340] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 09/05/2018] [Indexed: 12/20/2022] Open
Abstract
The Brazilian Nutritional Consensus in Hematopoietic Stem Cell Transplantation: Elderly was elaborated by nutritionists, nutrologists and hematologists physicians from 15 Brazilians reference centers in hematopoietic stem cell transplantation, in order to emphasize the importancy of nutritional status and the body composition during the treatment, as well as the main characteristics related to patient's nutritional assessment. Establishing the consensus, we intended to improve and standardize the nutritional therapy during the hematopoietic stem cell transplantation. The Consensus was approved by the Brazilian Society of Bone Marrow Transplantation.
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Affiliation(s)
| | - Andreza Alice Feitosa Ribeiro
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
- Centro de Transplante de Medula Óssea, Rio de Janeiro, RJ, Brazil
| | | | | | | | | | - Márcia Tanaka
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
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19
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Hematopoietic Cell Transplant (HCT) in the Elderly: Myths, Controversies and Unknowns. Drugs Aging 2019; 35:1055-1064. [PMID: 30302674 DOI: 10.1007/s40266-018-0596-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The incidence of most hematological malignancies increases with age. Despite the higher incidence of hematological malignancies in the elderly, the geriatric population is poorly represented in the early oncology clinical trials that established the current standards of care. Hematopoietic cell transplant (HCT), either upfront or at relapse, provides a potentially life-prolonging, often curative option for many patients with hematological malignancies and is considered the standard of care, at least for younger patients. Historically, the concern that older adults undergoing HCT may experience higher morbidity and transplant-related complications has limited the use of this potentially curative option to younger adults, particularly in allogeneic (allo-) HCT. There is growing evidence to support the feasibility, tolerability, and relatively similar effectiveness of both autologous and allo-HCT in the geriatric population. In the allo-HCT setting, nonmyeloablative/reduced-intensity conditioning (NMA/RIC) has expanded the spectrum of patients that can be considered for this approach. Overall survival is largely affected by disease stage, performance status, and comorbidities rather than by chronological age per se. Comprehensive geriatric assessment (CGA) is a promising tool that can uncover frequently undocumented vulnerabilities in an elderly transplant-eligible patient. Serial study of CGA throughout the peri-HCT period may help predict the short- and long-term impact of HCT on an older adult's functional status and quality of life. Further research is needed to evaluate whether early intervention to improve such vulnerabilities can improve survival and quality of life of these older patients.
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20
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Voshtina E, Szabo A, Hamadani M, Fenske TS, D'Souza A, Chhabra S, Saber W, Drobyski WR, Hari P, Shah NN. Impact of Obesity on Clinical Outcomes of Elderly Patients Undergoing Allogeneic Hematopoietic Cell Transplantation for Myeloid Malignancies. Biol Blood Marrow Transplant 2019; 25:e33-e38. [DOI: 10.1016/j.bbmt.2018.08.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Accepted: 08/29/2018] [Indexed: 10/28/2022]
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21
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Relationship between Aging and Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2018; 24:1965-1970. [PMID: 30130587 DOI: 10.1016/j.bbmt.2018.08.015] [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: 05/02/2018] [Accepted: 08/09/2018] [Indexed: 02/07/2023]
Abstract
Hematopoietic cell transplantation (HCT) is increasingly utilized as a treatment for malignancies in the elderly population. At the same time, research has elucidated the impacts of HCT on bone marrow progenitor cells, one of which is accelerated aging. Clonal hematopoiesis has also been observed to occur in the aging population, both with and without HCT. The interplay between natural aging, clonal hemoatpoiesis, and the effects of HCT on the bone marrow, has not yet been addressed. Herein we explore this relationship, and its important clinical implications.
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22
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Al Malki MM, Nathwani N, Yang D, Armenian S, Dadwal S, Salman J, Mokhtari S, Cao T, Sandhu K, Rouse M, Mei M, Ali H, Parker P, Alvarnas J, Smith E, Donnell MO, Marcucci G, Snyder D, Nademanee A, Forman SJ, Stein A, Nakamura R. Melphalan-Based Reduced-Intensity Conditioning is Associated with Favorable Disease Control and Acceptable Toxicities in Patients Older Than 70 with Hematologic Malignancies Undergoing Allogeneic Hematopoietic Stem Cell Transplantation. Biol Blood Marrow Transplant 2018; 24:1828-1835. [PMID: 29753158 DOI: 10.1016/j.bbmt.2018.04.029] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 04/29/2018] [Indexed: 01/06/2023]
Abstract
Allogeneic hematopoietic stem cell transplantation (alloHCT) is offered increasingly to elderly patients with hematologic malignancies. However, outcome data in those who are 70 years or older are limited, and no standard conditioning regimen has been established for this population. In this retrospective study we evaluated the outcome of 53 consecutive patients aged 70 years and older who underwent alloHCT with melphalan-based reduced-intensity conditioning (RIC) at City of Hope. Engraftment was prompt, with median time to neutrophil engraftment of 15 days. More than 95% of patients achieved complete donor chimerism within 6 weeks from HCT, consistent with the "semiablative" nature of this regimen. With a median follow-up of 31.1 months, the 2-year overall survival (OS), progression-free survival (PFS), and nonrelapse mortality (NRM) were 68.9%, 63.8%, and 17.0%, respectively. Cumulative incidence of relapse at 1 and 2 years was 17.0% and 19.3%, respectively. One hundred-day cumulative incidence of grades II to IV acute graft-versus-host disease was 37.7% (grades III to IV, 18.9%), and 2-year cumulative incidence of chronic graft-versus-host disease was 61.9% (extensive, 45.9%). The only significant predictor for poor OS was high/very high disease risk index. Transplant-related complications and morbidities observed here did not differ from the commonly expected in younger patients treated with RIC. In conclusion, alloHCT with a melphalan-based conditioning regimen is associated with acceptable toxicities and NRM, lower incidence of relapse, and favorable OS and PFS in patients aged 70 years or older.
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Affiliation(s)
- Monzr M Al Malki
- Department of Hematology and Hematopoietic Stem Cell Transplantation, City of Hope, Duarte, California.
| | - Nitya Nathwani
- Department of Hematology and Hematopoietic Stem Cell Transplantation, City of Hope, Duarte, California
| | - Dongyun Yang
- Department of Information Sciences, Division of Biostatistics, City of Hope, Duarte, California
| | - Saro Armenian
- Department of Population Sciences, City of Hope, Duarte, California
| | - Sanjeet Dadwal
- Department of Infectious Disease, City of Hope, Duarte, California
| | - Jaroslava Salman
- Department of Psychology & Psychiatry, City of Hope, Duarte, California
| | - Sally Mokhtari
- Department of Clinical Translational Program Development, City of Hope, Duarte, California
| | - Thai Cao
- Department of Hematology and Hematopoietic Stem Cell Transplantation, City of Hope, Duarte, California
| | - Karamjeet Sandhu
- Department of Hematology and Hematopoietic Stem Cell Transplantation, City of Hope, Duarte, California
| | - Michelle Rouse
- Department of Clinical Social Work, City of Hope, Duarte, California
| | - Matthew Mei
- Department of Hematology and Hematopoietic Stem Cell Transplantation, City of Hope, Duarte, California
| | - Haris Ali
- Department of Hematology and Hematopoietic Stem Cell Transplantation, City of Hope, Duarte, California
| | - Pablo Parker
- Department of Hematology and Hematopoietic Stem Cell Transplantation, City of Hope, Duarte, California
| | - Joseph Alvarnas
- Department of Hematology and Hematopoietic Stem Cell Transplantation, City of Hope, Duarte, California
| | - Eileen Smith
- Department of Hematology and Hematopoietic Stem Cell Transplantation, City of Hope, Duarte, California
| | - Margaret O Donnell
- Department of Hematology and Hematopoietic Stem Cell Transplantation, City of Hope, Duarte, California
| | - Guido Marcucci
- Department of Hematology and Hematopoietic Cell Transplantation, Gehr Family Center for Leukemia Research, City of Hope, Duarte, California
| | - David Snyder
- Department of Hematology and Hematopoietic Stem Cell Transplantation, City of Hope, Duarte, California
| | - Auayporn Nademanee
- Department of Hematology and Hematopoietic Stem Cell Transplantation, City of Hope, Duarte, California
| | - Stephen J Forman
- Department of Hematology and Hematopoietic Stem Cell Transplantation, City of Hope, Duarte, California
| | - Anthony Stein
- Department of Hematology and Hematopoietic Stem Cell Transplantation, City of Hope, Duarte, California
| | - Ryotaro Nakamura
- Department of Hematology and Hematopoietic Stem Cell Transplantation, City of Hope, Duarte, California
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Bhatt VR, Chen B, Gyawali B, Lee SJ. Socioeconomic and health system factors associated with lower utilization of hematopoietic cell transplantation in older patients with acute myeloid leukemia. Bone Marrow Transplant 2018; 53:1288-1294. [PMID: 29588500 DOI: 10.1038/s41409-018-0164-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 02/23/2018] [Accepted: 02/26/2018] [Indexed: 12/21/2022]
Abstract
Receipt of hematopoietic cell transplantation (HCT) can improve overall survival in older patients with intermediate or high-risk acute myeloid leukemia (AML); however, utilization of HCT is poor. It is important to understand the factors that affect the receipt of HCT in a real-world setting among the older patients. We utilized the National Cancer Database to determine receipt of HCT in older patients (61-75 years) with intermediate or high-risk AML reported between 2003 and 2012. Multivariate logistic regression analysis was used to determine factors associated with receipt of HCT. Only 5.5% of older patients (n = 17,555) underwent HCT. Factors associated with a lower likelihood of receiving HCT included receipt of care in a non-academic hospital, race other than white, older age, Charlson comorbidity score of ≥1, uninsured status, Medicaid or Medicare insurance, and lower educational status. The receipt of HCT in older patients is low and varies based on biological as well as non-biologic factors, such as hospital type, insurance, and educational status. Nationwide efforts to improve access to HCT for appropriate patients are necessary.
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Affiliation(s)
- Vijaya Raj Bhatt
- Department of Internal Medicine, Division of Hematology-Oncology, University of Nebraska Medical Center, Omaha, NE, USA.
| | - Baojiang Chen
- Department of Biostatistics and Data Science, University of Texas Health Science Center at Houston, School of Public Health in Austin, Austin, TX, USA
| | - Bishal Gyawali
- Department of Hematology-Oncology, Nobel Hospital, Kathmandu, Nepal
| | - Stephanie J Lee
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
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24
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Lin Y. AFT survival model to capture the rate of aging and age-specific mortality trajectories among first-allogeneic hematopoietic stem cells transplant patients. PLoS One 2018; 13:e0193287. [PMID: 29499050 PMCID: PMC5834196 DOI: 10.1371/journal.pone.0193287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Accepted: 02/08/2018] [Indexed: 12/25/2022] Open
Abstract
Accelerated failure time (AFT) model is commonly applied in engineering studies to address the failure rate of a machine. In humans, survival profile of transplant patients is among the rare scenarios whereby AFT is applicable. To date, it is uncertain whether reliable risk estimates and age-specific mortality trajectories have been published using conventional statistics approach. By investigating mortality trajectory, the rate of aging d(log(μ(x)))/dx of Hematopoietic Stem Cells Transplants (HSCTs) patients who had underwent first-allogeneic transplants can be obtained, and to unveil the possibility of elasticity of human aging rate in HSCTs. A modified parametric frailty survival model was introduced to the survival profiles of 11,160 patients who had underwent first-allogeneic HSCTs in the United States between 1995 and 2006; data was shared by Center for International Bone and Marrow Transplant Research. In comparison to stratification, the modification permits two entities in relation to time to be presented; age and calendar time. To consider its application in empirical studies, the data contains arbitrary right-censoring, a statistical condition which is preferred by choice in many transplant studies. The finalized multivariate AFT model was adjusted for clinical and demographic covariates, and age-specific mortality trajectories were presented by donor source and post-transplant time-lapse intervals. Two unexpected findings are presented: i) an inverse J-shaped hazard in unrelated donor-source t≤100-day; ii) convergence of unrelated-related hazard lines in 100-day365-day) must consider for periodic medical improvements, and transplant year as a standalone time-variable is not sufficient for statistical adjustment in the finalized multivariate model. In relevance to clinical studies, biennial event-history analysis and age-specific mortality trajectories of long-term survivors provide a more relevant intervention audit report for transplant protocols than the popular statistical presentation; i.e. survival probabilities among donor-source.
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Affiliation(s)
- Yuhui Lin
- NaoRococo at The Waterhouse, Singapore, Singapore
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25
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Seong GM, Lee Y, Hong SB, Lim CM, Koh Y, Huh JW. Prognosis of Acute Respiratory Distress Syndrome in Patients With Hematological Malignancies. J Intensive Care Med 2018; 35:364-370. [PMID: 29343171 DOI: 10.1177/0885066617753566] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION The intensive care unit (ICU) admission of patients with hematologic malignancies is gradually increasing. Life-threatening events are common, and acute respiratory distress syndrome (ARDS) is one of the most critical conditions. The aim of this study was to investigate the clinical characteristics and outcomes of ARDS in patients with hematological malignancies admitted to the ICU. METHODS A retrospective study was performed on all patients with ARDS with hematological malignancies in a single tertiary teaching hospital between 2008 and 2015. Data on the treatment of and the outcomes of ARDS were collected to determine the clinical characteristics associated with ICU mortality. RESULTS During the 8-year study period, among a total of 821 patients with ARDS admitted to the ICU, all 185 patients with hematological malignancies were included in the analysis. Most of the patients (88.1%) had moderate-to-severe ARDS, and the median PaO2/FiO2 ratio was 122 (interquartile range: 88-157). The overall ICU mortality rate was 57.3% (50.0% for mild, 52.0% for moderate, and 67.7% for severe ARDS). After the univariate and the multivariate logistic regressions, the factors independently associated with a higher ICU mortality were severe ARDS (odds ratio [OR]: 2.47; 95% confidence interval [CI]: 1.17-5.25), identification of carbapenem-resistant gram-negative bacteria (OR: 6.61; 95% CI: 1.31-33.41), the amount of blood product transfusion (OR: 1.25; 95% CI: 1.13-1.38), and the progressive or refractory disease (OR: 3.01; 95% CI: 1.31-6.91). Mortality was independently lower in patients who received the initial low tidal volume ventilation (OR: 0.37, 95% CI: 0.14-0.96). CONCLUSION The outcome of ARDS in patients with hematological malignancies is associated with the severity of the underlying diseases, the presence of multidrug-resistance pathogens, and the amount of transfusion; however, strict application of low tidal volume ventilation may improve the outcome of these patients at the time of diagnosis.
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Affiliation(s)
- Gil Myeong Seong
- Division of Pulmonology and Allergy, Department of Internal Medicine, Jeju National University School of Medicine, Jeju National University Hospital, Jeju, Republic of Korea
| | - Yunkyoung Lee
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Bum Hong
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Chae-Man Lim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Younsuck Koh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jin Won Huh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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27
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Park SH, Han SH. Effect of Oral Cryotherapy for Reducing Oral Mucositis in Hematopoietic Stem Cell Transplantation: A Systematic Review and Meta-analysis. ACTA ACUST UNITED AC 2018. [DOI: 10.7475/kjan.2018.30.4.362] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Seong-Hi Park
- Assistant Professor, School of Nursing, Soonchunhyang University, Asan, Korea
| | - Su Ha Han
- Assistant Professor, School of Nursing, Soonchunhyang University, Asan, Korea
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28
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Poiré X, Labopin M, Polge E, Passweg J, Craddock C, Blaise D, Cornelissen JJ, Volin L, Russell NH, Socié G, Michallet M, Fegueux N, Chevallier P, Brecht A, Hunault-Berger M, Mohty M, Esteve J, Nagler A. Allogeneic stem cell transplantation benefits for patients ≥ 60 years with acute myeloid leukemia and FLT3 internal tandem duplication: a study from the Acute Leukemia Working Party of the European Society for Blood and Marrow Transplantation. Haematologica 2017; 103:256-265. [PMID: 29242299 PMCID: PMC5792270 DOI: 10.3324/haematol.2017.178251] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 12/07/2017] [Indexed: 11/17/2022] Open
Abstract
Intermediate-risk cytogenetic acute myeloid leukemia with an internal tandem duplication of FLT3 (FLT3-ITD) is associated with a high risk of relapse, and is now a standard indication for allogeneic stem cell transplantation. Nevertheless, most studies supporting this strategy have been performed in young patients. To address the benefit of allogeneic transplantation in the elderly, we made a selection from the European Society for Blood and Marrow Transplantation registry of de novo intermediate-risk cytogenetic acute myeloid leukemia harboring FLT3-ITD in patients aged 60 or over and transplanted from a related or unrelated donor between January 2000 and December 2015. Two hundred and ninety-one patients were identified. Most patients received a reduced-intensity conditioning (82%), while donors consisted of an unrelated donor in 161 (55%) patients. Two hundred and twelve patients received their transplantation in first remission, 37 in second remission and 42 in a more advanced stage of the disease. The 2-year leukemia-free survival rate was 56% in patients in first remission, 22% in those in second remission and 10% in patients with active disease, respectively (P<0.005). Non-relapse mortality for the entire cohort was 20%. In multivariate analysis, disease status at transplantation was the most powerful predictor of worse leukemia-free survival, graft-versus-host disease and relapse-free survival, and overall survival. In this elderly population, age was not associated with outcome. Based on the current results, allogeneic transplantation translates into a favorable outcome in fit patients ≥ 60 with FLT3-ITD acute myeloid leukemia in first remission, similarly to current treatment recommendations for younger patients.
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Affiliation(s)
- Xavier Poiré
- Section of Hematology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Myriam Labopin
- Acute Leukemia Working Party of the EBMT.,Service d'Hématologie, Hôpital Saint-Antoine, Paris, France
| | - Emmanuelle Polge
- Acute Leukemia Working Party of the EBMT.,Service d'Hématologie, Hôpital Saint-Antoine, Paris, France
| | | | - Charles Craddock
- Center for Clinical Haematology, Queen Elizabeth Hospital, Birmingham, UK
| | - Didier Blaise
- Programme de Transplantation et Thérapie Cellulaire, Centre de Recherche en Cancérologie de Marseille, Institut Paoli Calmettes, France
| | - Jan J Cornelissen
- Daniel den Hoed Cancer Centre, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Liisa Volin
- Stem Cell Transplantation Unit, HUH Comprehensive Cancer Center, Helsinki, Finland
| | | | - Gérard Socié
- Department of Hematology, Hôpital Saint-Louis, Paris, France
| | | | - Nathalie Fegueux
- Département d'Hématologie Clinique, CHU Lapeyronie, Montpellier, France
| | | | - Arne Brecht
- Deutsche Klinik für Diagnostik, KMT Zentrum, Wiesbaden, Germany
| | | | - Mohamad Mohty
- Acute Leukemia Working Party of the EBMT.,Service d'Hématologie, Hôpital Saint-Antoine, Paris, France
| | - Jordi Esteve
- Hematology Department, IDIBAPS, Hospital Clinic, Barcelona, Spain
| | - Arnon Nagler
- Acute Leukemia Working Party of the EBMT.,Chaim Sheba Medical Center, Tel-Hashomer, Israel
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29
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Frailty: the missing piece of the pre- hematopoietic cell transplantation assessment? Bone Marrow Transplant 2017; 53:3-10. [PMID: 29084201 DOI: 10.1038/bmt.2017.192] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 07/03/2017] [Accepted: 07/22/2017] [Indexed: 12/20/2022]
Abstract
Hematopoietic stem cell transplantation (HSCT) represents a curative option for those afflicted with numerous hematologic malignancies and bone marrow failure syndromes. Advances and refinement of the HSCT process have resulted in increasing number of transplants performed on older patients in the recent years. Pre-transplant assessments (PTA) function to risk stratify patients prior to undergoing HSCT in an effort to predict those at higher risk of treatment-related toxicity, to inform risk/benefit assessments and to aid clinical decision making. Traditionally used risk stratification parameters such as chronologic age, comorbidity and performance status may not fully capture physical function, physiologic fitness, highlighting a need for improvement in PTA. Incorporation of frailty measurements in pre-HSCT assessments, particularly in elderly transplant candidates, may result in improving predictive ability of existing tools such as the Hematopoietic Cell Transplantation Comorbidity Index and Karnofsky performance status. Here, we review existing pre-HSCT assessment tools, measures of frailty that may aid in risk stratification for patients undergoing HSCT and directions for future research using frailty in the pre-HSCT setting.
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30
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Jakubowski AA, Petrlik E, Maloy M, Hilden P, Papadopoulos E, Young JW, Boulad F, Castro-Malaspina H, Tamari R, Dahi PB, Goldberg J, Koehne G, Perales MA, Sauter CS, O'Reilly RJ, Giralt S. T Cell Depletion as an Alternative Approach for Patients 55 Years or Older Undergoing Allogeneic Stem Cell Transplantation as Curative Therapy for Hematologic Malignancies. Biol Blood Marrow Transplant 2017; 23:1685-1694. [PMID: 28734876 PMCID: PMC10715069 DOI: 10.1016/j.bbmt.2017.06.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 06/28/2017] [Indexed: 12/27/2022]
Abstract
T cell-depleted (TCD) allogeneic hematopoietic stem cell transplantation (HSCT) is curative treatment for hematologic malignancies in adults, shown to reduce graft-versus-host disease (GVHD) without increased relapse. We retrospectively reviewed a single-center, 11-year experience of 214 patients aged ≥ 55 years to determine tolerability and efficacy in the older adult. Most patients (70%) had myeloid diseases, and most acute leukemias were in remission. Median age was 61 years, with related and unrelated donors ≥8/10 HLA matched. Hematopoietic cell transplantation-specific comorbidity index scores were intermediate and high for 84%. Conditioning regimens were all myeloablative. Grafts were peripheral blood stem cells (97%) containing CD3 dose ≤103-4/kg body weight, without pharmacologic GVHD prophylaxis. With median follow-up of 70 months among survivors, Kaplan-Meier estimates of overall and relapse-free survival were 44% and 41%, respectively (4 years). Cumulative incidence of nonrelapse mortality at day +100 was only 10%. Incidence of GVHD for acute (grades II to IV) was 9% at day +100 and for chronic was 7% at 2 and 4 years (8 extensive, 1 overlap). Median Karnofsky performance status for patients > 2 years post-transplant was 90%. As 1 of the largest reports for patients ≥2 aged ≥55 years receiving TCD HSCTs, it demonstrates curative therapy with minimal GVHD, similar to that observed in a younger population.
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Affiliation(s)
- Ann A Jakubowski
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, Cornell University, New York, New York.
| | - Erica Petrlik
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Molly Maloy
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Patrick Hilden
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Esperanza Papadopoulos
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, Cornell University, New York, New York
| | - James W Young
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, Cornell University, New York, New York
| | - Farid Boulad
- Weill Cornell Medical College, Cornell University, New York, New York; Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Hugo Castro-Malaspina
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, Cornell University, New York, New York
| | - Roni Tamari
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, Cornell University, New York, New York
| | - Parastoo B Dahi
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, Cornell University, New York, New York
| | - Jenna Goldberg
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, Cornell University, New York, New York
| | - Guenther Koehne
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, Cornell University, New York, New York
| | - Miguel-Angel Perales
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, Cornell University, New York, New York
| | - Craig S Sauter
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, Cornell University, New York, New York
| | - Richard J O'Reilly
- Weill Cornell Medical College, Cornell University, New York, New York; Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sergio Giralt
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, Cornell University, New York, New York
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31
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Muffly L, Pasquini MC, Martens M, Brazauskas R, Zhu X, Adekola K, Aljurf M, Ballen KK, Bajel A, Baron F, Battiwalla M, Beitinjaneh A, Cahn JY, Carabasi M, Chen YB, Chhabra S, Ciurea S, Copelan E, D'Souza A, Edwards J, Foran J, Freytes CO, Fung HC, Gale RP, Giralt S, Hashmi SK, Hildebrandt GC, Ho V, Jakubowski A, Lazarus H, Luskin MR, Martino R, Maziarz R, McCarthy P, Nishihori T, Olin R, Olsson RF, Pawarode A, Peres E, Rezvani AR, Rizzieri D, Savani BN, Schouten HC, Sabloff M, Seftel M, Seo S, Sorror ML, Szer J, Wirk BM, Wood WA, Artz A. Increasing use of allogeneic hematopoietic cell transplantation in patients aged 70 years and older in the United States. Blood 2017; 130:1156-1164. [PMID: 28674027 PMCID: PMC5580273 DOI: 10.1182/blood-2017-03-772368] [Citation(s) in RCA: 199] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 06/19/2017] [Indexed: 12/20/2022] Open
Abstract
In this study, we evaluated trends and outcomes of allogeneic hematopoietic cell transplantation (HCT) in adults ≥70 years with hematologic malignancies across the United States. Adults ≥70 years with a hematologic malignancy undergoing first allogeneic HCT in the United States between 2000 and 2013 and reported to the Center for International Blood and Marrow Transplant Research were eligible. Transplant utilization and transplant outcomes, including overall survival (OS), progression-free survival (PFS), and transplant-related mortality (TRM) were studied. One thousand one hundred and six patients ≥70 years underwent HCT across 103 transplant centers. The number and proportion of allografts performed in this population rose markedly over the past decade, accounting for 0.1% of transplants in 2000 to 3.85% (N = 298) in 2013. Acute myeloid leukemia and myelodysplastic syndromes represented the most common disease indications. Two-year OS and PFS significantly improved over time (OS: 26% [95% confidence interval (CI), 21% to 33%] in 2000-2007 to 39% [95% CI, 35% to 42%] in 2008-2013, P < .001; PFS: 22% [16% to 28%] in 2000-2007 to 32% [95% CI, 29% to 36%] in 2008-2013, P = .003). Two-year TRM ranged from 33% to 35% and was unchanged over time (P = .54). Multivariable analysis of OS in the modern era of 2008-2013 revealed higher comorbidity by HCT comorbidity index ≥3 (hazard ratio [HR], 1.27; P = .006), umbilical cord blood graft (HR, 1.97; P = .0002), and myeloablative conditioning (HR, 1.61; P = .0002) as adverse factors. Over the past decade, utilization and survival after allogeneic transplant have increased in patients ≥70 years. Select adults ≥70 years with hematologic malignancies should be considered for transplant.
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Affiliation(s)
- Lori Muffly
- Division of Blood and Marrow Transplantation, Stanford University, Stanford, CA
| | | | - Michael Martens
- Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, WI
| | - Ruta Brazauskas
- Center for International Blood and Marrow Transplant Research and
- Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, WI
| | - Xiaochun Zhu
- Center for International Blood and Marrow Transplant Research and
| | | | - Mahmoud Aljurf
- Department of Oncology, King Faisal Specialist Hospital Center and Research, Riyadh, Saudi Arabia
| | - Karen K Ballen
- Department of Hematology/Oncology, Massachusetts General Hospital, Boston, MA
| | - Ashish Bajel
- Royal Melbourne Hospital, Victoria, VIC, Australia
| | - Frederic Baron
- Centre Hospitalier Universitaire de Liege, Domaine Universitaire du Sart Tilman, Liege, Belgium
| | - Minoo Battiwalla
- Hematology Branch, National Heart, Lung, and Blood Institute, Bethesda, MD
| | - Amer Beitinjaneh
- Department of Hematology and Oncology, University of Miami, Miami, FL
| | - Jean-Yves Cahn
- Department of Hematology, University Hospital, Grenoble, France
| | - Mathew Carabasi
- Department of Medical Oncology, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Yi-Bin Chen
- Division of Hematology/Oncology, Massachusetts General Hospital, Boston, MA
| | - Saurabh Chhabra
- Department of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - Stefan Ciurea
- Department of Stem Cell Transplantation and Cellular Therapy and
- Transplant Myeloid Study Group, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Edward Copelan
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Carolinas HealthCare System, Charlotte, NC
| | - Anita D'Souza
- Center for International Blood and Marrow Transplant Research and
| | - John Edwards
- Indiana Blood and Marrow Transplantation, Indianapolis, IN
| | | | | | - Henry C Fung
- Department of Medical Oncology, Fox Chase Cancer Center, Temple Health, Philadelphia, PA
| | - Robert Peter Gale
- Hematology Research Centre, Division of Experimental Medicine, Department of Medicine, Imperial College London, London, United Kingdom
| | - Sergio Giralt
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Shahrukh K Hashmi
- Department of Internal Medicine, Mayo Clinic, Minneapolis, MN
- Oncology Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Gerhard C Hildebrandt
- Department of Internal Medicine, University of Kentucky Chandler Medical Center, Lexington, KY
| | - Vincent Ho
- Center for Hematologic Oncology, Dana-Farber Cancer Institute, Boston, MA
| | | | - Hillard Lazarus
- Seidman Cancer Center, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Marlise R Luskin
- Abramson Cancer Center, University of Pennsylvania Medical Center, Philadelphia, PA
| | - Rodrigo Martino
- Divison of Clinical Hematology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Richard Maziarz
- Adult Blood and Marrow Stem Cell Transplant Program, Knight Cancer Institute, Oregon Health and Science University, Portland, OR
| | - Philip McCarthy
- Blood and Marrow Transplant Program, Department of Medicine, Roswell Park Cancer Institute, Buffalo, NY
| | - Taiga Nishihori
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Rebecca Olin
- Department of Medicine, University of California San Francisco Medical Center, San Francisco, CA
| | - Richard F Olsson
- Division of Therapeutic Immunology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
- Center for Clinical Research Sormland, Uppsala University, Uppsala, Sweden
| | - Attaphol Pawarode
- Blood and Marrow Transplantation Program, Division of Hematology/Oncology, Department of Internal Medicine, The University of Michigan Medical School, Ann Arbor, MI
| | - Edward Peres
- Bone Marrow Transplant Program, Henry Ford Hospital, Detroit, MI
| | - Andrew R Rezvani
- Division of Blood and Marrow Transplantation, Stanford University, Stanford, CA
| | - David Rizzieri
- Division of Hematologic Malignancies and Cellular Therapy, Blood and Marrow Transplant Clinic, Duke University, Durham, NC
| | - Bipin N Savani
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Harry C Schouten
- Department of Hematology, Academische Ziekenhuis, Maastricht, The Netherlands
| | - Mitchell Sabloff
- Division of Hematology, Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Matthew Seftel
- Department of Medical Oncology and Hematology, CancerCare Manitoba, Winnipeg, MB, Canada
| | - Sachiko Seo
- National Cancer Research Center, East Hospital, Kashiwa, Chiba, Japan
| | - Mohamed L Sorror
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
- Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Jeff Szer
- Department Clinical Haematology and Bone Marrow Transplantation, Royal Melbourne Hospital, Victoria, VIC, Australia
| | - Baldeep M Wirk
- Division of Bone Marrow Transplant, Seattle Cancer Care Alliance, Seattle, WA
| | - William A Wood
- Division of Hematology/Oncology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC; and
| | - Andrew Artz
- Section of Hematology/Oncology, University of Chicago School of Medicine, Chicago, IL
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32
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Hoogland AI, Nelson AM, Small BJ, Hyland KA, Gonzalez BD, Booth-Jones M, Anasetti C, Jacobsen PB, Jim HSL. The Role of Age in Neurocognitive Functioning among Adult Allogeneic Hematopoietic Cell Transplant Recipients. Biol Blood Marrow Transplant 2017; 23:1974-1979. [PMID: 28797784 DOI: 10.1016/j.bbmt.2017.08.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 08/02/2017] [Indexed: 01/02/2023]
Abstract
Improvements in supportive care have enabled allogeneic hematopoietic cell transplantation (HCT) to be performed in increasingly older patients. HCT is associated with neurocognitive impairment, which may be exacerbated in older adults due to normal neurocognitive decline associated with aging. The goal of this study was to evaluate whether increasing age of allogeneic HCT recipients is associated with worse neurocognitive outcomes over time relative to a matched sample of individuals without cancer. Patients (n = 140; 42% female; M age, 51 years; range, 20 to 76 years; 31% with acute myelogenous leukemia) completed neurocognitive assessments before transplantation and 3 months and 1 year after transplantation. Controls (n = 75; 56% female; M age, 53 years; range, 21 to 74 years) completed assessments at comparable time intervals. Linear mixed models revealed that regardless of age, patients demonstrated worse performance than controls before transplantation in verbal memory, visual memory, and total neuropsychological performance, and over time in executive functioning. In addition, older age was associated with worse performance in verbal memory (P = .02) and verbal fluency (P = .05) over time in patients compared with controls. Specifically, older (65+ years) patients had worse verbal memory and verbal fluency than older and younger (<65 years) controls post-transplantation (Cohen's d = .22 to .39). These data indicate that age may be a risk factor for worse neurocognitive outcomes after allogeneic HCT. If replicated, our results suggest that older candidates for allogeneic HCT should be counseled regarding the risk of cognitive problems after transplantation.
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Affiliation(s)
- Aasha I Hoogland
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida; Department of Oncologic Sciences, Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Ashley M Nelson
- Department of Psychology, University of South Florida, Tampa, Florida
| | - Brent J Small
- School of Aging Studies, University of South Florida, Tampa, Florida
| | - Kelly A Hyland
- Department of Psychology, University of South Florida, Tampa, Florida
| | - Brian D Gonzalez
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida
| | - Margaret Booth-Jones
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida
| | - Claudio Anasetti
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida
| | - Paul B Jacobsen
- Healthcare Delivery Research Program, National Cancer Institute, Bethesda, Maryland
| | - Heather S L Jim
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida.
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Ghosh N, Ye X, Tsai HL, Bolaños-Meade J, Fuchs EJ, Luznik L, Swinnen LJ, Gladstone DE, Ambinder RF, Varadhan R, Shanbhag S, Brodsky RA, Borrello IM, Jones RJ, Matsui W, Huff CA. Allogeneic Blood or Marrow Transplantation with Post-Transplantation Cyclophosphamide as Graft-versus-Host Disease Prophylaxis in Multiple Myeloma. Biol Blood Marrow Transplant 2017; 23:1903-1909. [PMID: 28711728 DOI: 10.1016/j.bbmt.2017.07.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 07/02/2017] [Indexed: 02/07/2023]
Abstract
Allogeneic blood or marrow transplantation (alloBMT) may lead to long-term disease control in patients with multiple myeloma (MM). However, historically, the use of alloBMT in MM has been limited by its high nonrelapse mortality (NRM) rates, primarily from graft-versus-host disease (GVHD). We previously demonstrated that post-transplantation cyclophosphamide (PTCy) decreases the toxicities of both acute and chronic GVHD after alloBMT. Here, we examine the impact of PTCy in patients with MM undergoing alloBMT at Johns Hopkins Hospital. From 2003 to 2011, 39 patients with MM underwent bone marrow or peripheral blood alloBMT from HLA-matched related/unrelated or haploidentical related donors after either myeloablative or nonmyeloablative conditioning. Post-transplantation GVHD prophylaxis consisted of cyclophosphamide (50 mg/kg) on days +3 and +4 with or without mycophenolate mofetil and tacrolimus. Engraftment was detected in 95% of patients, with neutrophil and platelet recovery at a median of 15 and 16 days, respectively. The cumulative incidences of acute grades 2 to 4 and grades 3 and 4 GVHD were .41 and .08, respectively, and no cases of grade 4 acute GVHD were observed. The cumulative incidence of chronic GVHD was .13. One patient succumbed to NRM. All cases of chronic GVHD involved extensive disease and 60% of these patients received systemic therapy with complete resolution. After alloBMT, the overall response rate was 62% with complete, very good partial, and partial response rates of 26%, 21%, and 15%, respectively. The median progression-free survival was 12 months and was associated with the depth of response but not cytogenetic risk. The estimated cumulative incidence of relapse was .46 (95% confidence interval [CI], .3 to .62) at 1 year and .56 (95% CI, .41 to .72) at 2 years. At last follow-up, 23% of patients remain without evidence of disease at a median follow-up of 10.3 years after alloBMT. The median overall survival was 4.4 years and the 5-year and 10-year overall survival probabilities were 49% (95% CI, 35% to 67%) and 43% (95% CI, 29% to 62%), respectively. The use of PTCy after alloBMT for MM is feasible and results in low NRM and GVHD rates. The safety of this approach may allow the development of novel post-transplantation maintenance strategies to improve long-term disease control.
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Affiliation(s)
- Nilanjan Ghosh
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Xiaobu Ye
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Hua-Ling Tsai
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | | | - Ephraim J Fuchs
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Leo Luznik
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Lode J Swinnen
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | | | | | - Ravi Varadhan
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Satish Shanbhag
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Robert A Brodsky
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Ivan M Borrello
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Richard J Jones
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - William Matsui
- School of Medicine, Johns Hopkins University, Baltimore, Maryland.
| | - Carol Ann Huff
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
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Reprint of: Aging: Treating the Older Patient. Biol Blood Marrow Transplant 2017; 23:S10-S17. [PMID: 28236837 DOI: 10.1016/j.bbmt.2017.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 11/04/2016] [Indexed: 12/23/2022]
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Rosko A, Artz A. Aging: Treating the Older Patient. Biol Blood Marrow Transplant 2017; 23:193-200. [PMID: 27864162 PMCID: PMC5967228 DOI: 10.1016/j.bbmt.2016.11.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 11/04/2016] [Indexed: 12/15/2022]
Affiliation(s)
- Ashley Rosko
- Department of Internal Medicine, Ohio State University, Columbus, Ohio
| | - Andrew Artz
- Department of Medicine, University of Chicago, Chicago, Illinois.
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Michelis FV, Gupta V, Zhang MJ, Wang HL, Aljurf M, Bacher U, Beitinjaneh A, Chen YB, DeFilipp Z, Gale RP, Kebriaei P, Kharfan-Dabaja M, Lazarus HM, Nishihori T, Olsson RF, Oran B, Rashidi A, Rizzieri DA, Tallman MS, de Lima M, Khoury HJ, Sandmaier BM, Weisdorf D, Saber W. Cytogenetic risk determines outcomes after allogeneic transplantation in older patients with acute myeloid leukemia in their second complete remission: A Center for International Blood and Marrow Transplant Research cohort analysis. Cancer 2017; 123:2035-2042. [PMID: 28117898 DOI: 10.1002/cncr.30567] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 12/06/2016] [Accepted: 12/19/2016] [Indexed: 01/25/2023]
Abstract
BACKGROUND Allogeneic hematopoietic cell transplantation (HCT) offers curative potential to a number of older patients with acute myeloid leukemia (AML) in their first complete remission. However, there are limited data in the literature concerning post-HCT outcomes for older patients in their second complete remission (CR2). METHODS The purpose of the current study was to retrospectively investigate within the Center for International Blood and Marrow Transplant Research database parameters influencing posttransplant outcomes for patients 60 years of age or older undergoing HCT for AML in CR2. RESULTS In total, 196 patients from 78 centers were identified; the median age was 64 years (range, 60-78 years). Seventy-one percent had a Karnofsky performance status ≥ 90 at the time of HCT. Reduced-intensity conditioning regimens were used in 159 patients (81%). A univariate analysis demonstrated a 3-year overall survival (OS) rate of 42% (95% confidence interval [CI], 35%-49%), a leukemia-free survival rate of 37% (95% CI, 30%-44%), a cumulative incidence of nonrelapse mortality of 25% (95% CI, 19%-32%), and a cumulative incidence of relapse (CIR) of 38% (95% CI, 31%-45%). A multivariate analysis demonstrated that cytogenetic risk was the only independent risk factor for OS (P = .023) with a hazard ratio (HR) of 1.14 (95% CI, 0.59-2.19) for intermediate-risk cytogenetics and an HR of 2.32 (95% CI, 1.05-5.14) for unfavorable-risk cytogenetics. For CIR, cytogenetic risk was also the only independent prognostic factor (P = .01) with an HR of 1.10 (95% CI, 0.47-2.56) for intermediate-risk cytogenetics and an HR of 2.98 (95% CI, 1.11-8.00) for unfavorable-risk cytogenetics. CONCLUSIONS Allogeneic HCT is a curative treatment option for older patients with AML in CR2, particularly for those with favorable or intermediate cytogenetic risk. Cancer 2017;123:2035-2042. © 2017 American Cancer Society.
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Affiliation(s)
- Fotios V Michelis
- Allogeneic Blood and Marrow Transplant Program, Princes Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Vikas Gupta
- Allogeneic Blood and Marrow Transplant Program, Princes Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Mei-Jie Zhang
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
- Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Hai-Lin Wang
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Mahmoud Aljurf
- Department of Oncology, King Faisal Specialist Hospital Center & Research, Riyadh, Saudi Arabia
| | - Ulrike Bacher
- Department of Hematology/Oncology, University Medicine Gottingen, Gottingen, Germany
- Interdisciplinary Clinic for Stem Cell Transplantation, University Cancer Center Hamburg, Hamburg, Germany
| | | | - Yi-Bin Chen
- Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Robert Peter Gale
- Hematology Research Centre, Division of Experimental Medicine, Department of Medicine, Imperial College London, London, United Kingdom
| | - Partow Kebriaei
- Department of Stem Cell Transplantation, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mohamed Kharfan-Dabaja
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Hillard M Lazarus
- Department of Medicine, Seidman Cancer Center, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Taiga Nishihori
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Richard F Olsson
- Division of Therapeutic Immunology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
- Centre for Clinical Research Sormland, Uppsala University, Uppsala, Sweden
| | - Betul Oran
- Department of Stem Cell Transplantation, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Armin Rashidi
- Division of Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - David A Rizzieri
- Division of Hematologic Malignancies and Cellular Therapy, Duke University, Durham, North Carolina
| | - Martin S Tallman
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marcos de Lima
- Department of Medicine, Seidman Cancer Center, University Hospitals Case Medical Center, Cleveland, Ohio
| | | | - Brenda M Sandmaier
- Division of Medical Oncology, University of Washington, Seattle, Washington
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Daniel Weisdorf
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Wael Saber
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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Fürst D, Niederwieser D, Bunjes D, Wagner EM, Gramatzki M, Wulf G, Müller CR, Neuchel C, Tsamadou C, Schrezenmeier H, Mytilineos J. Increased age-associated mortality risk in HLA-mismatched hematopoietic stem cell transplantation. Haematologica 2017; 102:796-803. [PMID: 28057735 PMCID: PMC5395120 DOI: 10.3324/haematol.2016.151340] [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: 06/20/2016] [Accepted: 12/28/2016] [Indexed: 02/06/2023] Open
Abstract
We investigated a possible interaction between age-associated risk and HLA-mismatch associated risk on prognosis in different age categories of recipients of unrelated hematopoietic stem cell transplants (HSCT) (n=3019). Patients over 55 years of age transplanted with 8/10 donors showed a mortality risk of 2.27 (CI 1.70–3.03, P<0.001) and 3.48 (CI 2.49–4.86, P<0.001) when compared to 10/10 matched patients in the same age group and to 10/10 matched patients aged 18–35 years, respectively. Compared to 10/10 matched transplantations within each age category, the Hazards Ratio for 8/10 matched transplantation was 1.14, 1.40 and 2.27 in patients aged 18–35 years, 36–55 and above 55 years. Modeling age as continuous variable showed different levels of risk attributed to age at the time of transplantation [OS: 10/10: Hazards Ratio 1.015 (per life year); 9/10: Hazards Ratio: 1.019; 8/10: Hazards Ratio 1.026]. The interaction term was significant for 8/10 transplantations (P=0.009). Findings for disease-free survival and transplant-related mortality were similar. Statistical models were stratified for diagnosis and included clinically relevant predictors except cytomegalovirus status and Karnofsky performance status. The risk conferred by age at the time of transplantation varies according to the number of HLA-mismatches and leads to a disproportional increase in risk for elderly patients, particularly with double mismatched donors. Our findings highlight the importance of HLA-matching, especially in patients over 55 years of age, as HLA-mismatches are less well tolerated in these patients. The interaction between age-associated risk and HLA-mismatches should be considered in donor selection and in the risk assessment of elderly HSCT recipients.
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Affiliation(s)
- Daniel Fürst
- Institute of Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Transfusion Service, Baden Wuerttemberg - Hessen, Ulm, Germany.,Institute of Transfusion Medicine, University of Ulm, Germany
| | | | - Donald Bunjes
- Department of Internal Medicine III, University of Ulm, Germany
| | - Eva M Wagner
- Department of Medicine III, Johannes Gutenberg-University Mainz, Germany
| | - Martin Gramatzki
- Division of Stem Cell Transplantation and Immunotherapy, 2nd Department of Medicine, University of Kiel, Germany
| | - Gerald Wulf
- Department of Hematology/Oncology, Georg-August-University Göttingen, Germany
| | - Carlheinz R Müller
- ZKRD-Zentrales Knochenmarkspender-Register für Deutschland (German National Bone Marrow Donor Registry), Ulm, Germany.,DRST - German Registry for Stem Cell Transplantation, Ulm, Germany
| | - Christine Neuchel
- Institute of Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Transfusion Service, Baden Wuerttemberg - Hessen, Ulm, Germany.,Institute of Transfusion Medicine, University of Ulm, Germany
| | - Chrysanthi Tsamadou
- Institute of Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Transfusion Service, Baden Wuerttemberg - Hessen, Ulm, Germany.,Institute of Transfusion Medicine, University of Ulm, Germany
| | - Hubert Schrezenmeier
- Institute of Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Transfusion Service, Baden Wuerttemberg - Hessen, Ulm, Germany.,Institute of Transfusion Medicine, University of Ulm, Germany
| | - Joannis Mytilineos
- Institute of Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Transfusion Service, Baden Wuerttemberg - Hessen, Ulm, Germany .,Institute of Transfusion Medicine, University of Ulm, Germany.,DRST - German Registry for Stem Cell Transplantation, Ulm, Germany
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Allogeneic Hematopoietic Cell Transplantation Is Safe and Effective Treatment in Patients with Myelodysplastic Syndromes Seventy Years and Older. Biol Blood Marrow Transplant 2016; 23:1-2. [PMID: 27865911 DOI: 10.1016/j.bbmt.2016.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 11/11/2016] [Indexed: 11/24/2022]
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39
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Lu Y, Wu T, Liu DY, Cao XY, Xiong M, Zhang JP, Zhou JR, Lu DP. [Clinical studies of myeloablative dose conditioning prior to allogeneic hematopoietic stem cell transplantation for treatment of 12 patients over 55 years with high- risk malignant blood diseases]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2016; 37:708-11. [PMID: 27587256 PMCID: PMC7348528 DOI: 10.3760/cma.j.issn.0253-2727.2016.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Indexed: 11/05/2022]
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40
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Allogeneic hematopoietic cell transplantation in patients ⩾70 years: which patients may benefit? Blood Cancer J 2016; 6:e443. [PMID: 27391575 PMCID: PMC5030379 DOI: 10.1038/bcj.2016.54] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
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Grunwald MR, Avalos BR, Copelan EA. Hematopoietic cell transplantation in MDS: undervalued and underutilized. Bone Marrow Transplant 2016; 51:1069-70. [PMID: 27322851 DOI: 10.1038/bmt.2016.169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 05/06/2016] [Indexed: 01/03/2023]
Affiliation(s)
- M R Grunwald
- Levine Cancer Institute-Carolinas HealthCare System, Charlotte, NC, USA
| | - B R Avalos
- Levine Cancer Institute-Carolinas HealthCare System, Charlotte, NC, USA
| | - E A Copelan
- Levine Cancer Institute-Carolinas HealthCare System, Charlotte, NC, USA
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Blaes A, Konety S, Hurley P. Cardiovascular Complications of Hematopoietic Stem Cell Transplantation. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2016; 18:25. [PMID: 26909819 PMCID: PMC4766226 DOI: 10.1007/s11936-016-0447-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OPINION STATEMENT Survivors of hematopoietic stem cell transplant (HSCT) are at significant risk for cardiac disease and cardiac complications. While there may be cardiac complications during the acute period of HSCT, long-term survivors remain at risk for cardiovascular disease at a rate at least fourfold higher than the general population. Aggressive screening for cardiac risk factors such as diabetes, hypertension, and arrhythmias is warranted pretransplant. For those with risk factors, particularly a history of cardiovascular disease or atrial fibrillation, cardiology consultation is warranted in the pretransplantation period. Aggressive screening for cardiac risk factors such as diabetes, hypertension, and hyperlipidemia is warranted in HSCT survivors as well; early and aggressive treatment of left ventricular dysfunction is warranted. Collaboration between hematology/oncology and cardiology through a cardio-oncology clinic is an optimal way to help manage these patients.
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Affiliation(s)
- Anne Blaes
- Division of Hematology/Oncology/Transplantion, University of Minnesota, 420 Delaware Street, S.E., MMC 480, Minneapolis, MN, 55455, USA.
| | - Suma Konety
- Division of Cardiology, University of Minnesota, Minneapolis, MN, USA
| | - Peter Hurley
- Division of Hematology/Oncology/Transplantion, University of Minnesota, 420 Delaware Street, S.E., MMC 480, Minneapolis, MN, 55455, USA
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43
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Hematopoietic stem cell transplantation for patients with AML in first complete remission. Blood 2016; 127:62-70. [DOI: 10.1182/blood-2015-07-604546] [Citation(s) in RCA: 184] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 10/07/2015] [Indexed: 12/31/2022] Open
Abstract
Abstract
Postremission therapy in patients with acute myeloid leukemia (AML) may consist of continuing chemotherapy or transplantation using either autologous or allogeneic stem cells. Patients with favorable subtypes of AML generally receive chemotherapeutic consolidation, although recent studies have also suggested favorable outcome after hematopoietic stem cell transplantation (HSCT). Although allogeneic HSCT (alloHSCT) is considered the preferred type of postremission therapy in poor- and very-poor-risk AML, the place of alloHSCT in intermediate-risk AML is being debated, and autologous HSCT is considered a valuable alternative that may be preferred in patients without minimal residual disease after induction chemotherapy. Here, we review postremission transplantation strategies using either autologous or allogeneic stem cells. Recent developments in the field of alternative donors, including cord blood and haploidentical donors, are highlighted, and we discuss reduced-intensity alloHSCT in older AML recipients who represent the predominant category of patients with AML who have a high risk of relapse in first remission.
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44
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Savani BN, Labopin M, Blaise D, Niederwieser D, Ciceri F, Ganser A, Arnold R, Afanasyev B, Vigouroux S, Milpied N, Hallek M, Cornelissen JJ, Schwerdtfeger R, Polge E, Baron F, Esteve J, Gorin NC, Schmid C, Giebel S, Mohty M, Nagler A. Peripheral blood stem cell graft compared to bone marrow after reduced intensity conditioning regimens for acute leukemia: a report from the ALWP of the EBMT. Haematologica 2015; 101:256-62. [PMID: 26565001 DOI: 10.3324/haematol.2015.135699] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Accepted: 11/10/2015] [Indexed: 01/11/2023] Open
Abstract
Increasing numbers of patients are receiving reduced intensity conditioning regimen allogeneic hematopoietic stem cell transplantation. We hypothesized that the use of bone marrow graft might decrease the risk of graft-versus-host disease compared to peripheral blood after reduced intensity conditioning regimens without compromising graft-versus-leukemia effects. Patients who underwent reduced intensity conditioning regimen allogeneic hematopoietic stem cell transplantation from 2000 to 2012 for acute leukemia, and who were reported to the Acute Leukemia Working Party of the European Group for Blood and Marrow Transplantation were included in the study. Eight hundred and thirty-seven patients receiving bone marrow grafts were compared with 9011 peripheral blood transplant recipients after reduced intensity conditioning regimen. Median follow up of surviving patients was 27 months. Cumulative incidence of engraftment (neutrophil ≥0.5×10(9)/L at day 60) was lower in bone marrow recipients: 88% versus 95% (P<0.0001). Grade II to IV acute graft-versus-host disease was lower in bone marrow recipients: 19% versus 24% for peripheral blood (P=0.005). In multivariate analysis, after adjusting for differences between both groups, overall survival [Hazard Ratio (HR) 0.90; P=0.05] and leukemia-free survival (HR 0.88; P=0.01) were higher in patients transplanted with peripheral blood compared to bone marrow grafts. Furthermore, peripheral blood graft was also associated with decreased risk of relapse (HR 0.78; P=0.0001). There was no significant difference in non-relapse mortality between recipients of bone marrow and peripheral blood grafts, and chronic graft-versus-host disease was significantly higher after peripheral blood grafts (HR 1.38; P<0.0001). Despite the limitation of a retrospective registry-based study, we found that peripheral blood grafts after reduced intensity conditioning regimens had better overall and leukemia-free survival than bone marrow grafts. However, there is an increase in chronic graft-versus-host disease after peripheral blood grafts. Long-term follow up is needed to clarify whether chronic graft-versus-host disease might increase the risk of late morbidity and mortality.
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Affiliation(s)
- Bipin N Savani
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Myriam Labopin
- EBMT Paris Study Office/CEREST-TC, Paris, France Department of Haematology, Saint Antoine Hospital, Paris, France INSERM UMR 938, Paris, France Université Pierre et Marie Curie, Paris, France
| | - Didier Blaise
- Département d'Hématologie - Centre de Recherche en Cancérologie de Marseille - Aix-Marseille University, Institut Paoli Calmettes, Marseille, France
| | - Dietger Niederwieser
- University Hospital Leipzig, Hematology, Oncology and Hemostaseology Divisions, Germany
| | - Fabio Ciceri
- Hematology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Arnold Ganser
- Hannover Medical School - Department of Haematology Hemostasis Oncology and Stem Cell Transplantation, Hannover, Germany
| | - Renate Arnold
- Charité Universitätsmedizin Berlin, Campus Virchow Klinikum - Medizinische Klinik m. S. Hämatologie/Onkologie, Berlin, Germany
| | - Boris Afanasyev
- Saint Petersburg State Medical Pavlov University, Ratsa Gorbacheva Memorial Children's Institute, Hematology and Transplantology, St. Petersburg, Russia
| | | | - Noel Milpied
- CHU Bordeaux - Hôpital Haut-leveque, Pessac, France
| | | | - Jan J Cornelissen
- ErasmusMC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Emmanuelle Polge
- EBMT Paris Study Office/CEREST-TC, Paris, France Department of Haematology, Saint Antoine Hospital, Paris, France INSERM UMR 938, Paris, France Université Pierre et Marie Curie, Paris, France
| | - Frédéric Baron
- Department of Medicine, Division of Hematology, University of Liège, Belgium
| | - Jordi Esteve
- Department of Hematology, Hospital Clinic, Barcelona, Spain
| | - Norbert C Gorin
- Department of Hematology, Saint Antoine Hospital, APHP and University UPMS, Paris, France
| | - Christoph Schmid
- Klinikum Augsburg, Department of Hematology and Oncology, University of Munich, Augsburg, Germany
| | - Sebastian Giebel
- Department of Bone Marrow Transplantation and Onco-Hematology, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Poland
| | - Mohamad Mohty
- EBMT Paris Study Office/CEREST-TC, Paris, France Department of Haematology, Saint Antoine Hospital, Paris, France INSERM UMR 938, Paris, France Université Pierre et Marie Curie, Paris, France
| | - Arnon Nagler
- EBMT Paris Study Office/CEREST-TC, Paris, France Hematology Division, Chaim Sheba Medical Center, Tel Hashomer, Israel
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Reduced-intensity conditioning with fludarabine and busulfan for allogeneic hematopoietic cell transplantation in elderly or infirm patients with advanced myeloid malignancies. Ann Hematol 2015; 95:115-124. [PMID: 26411736 DOI: 10.1007/s00277-015-2512-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 09/17/2015] [Indexed: 01/06/2023]
Abstract
We report a retrospective single-center analysis of 112 consecutive patients that underwent allogeneic hematopoietic cell transplantation (HCT) after reduced-intensity conditioning (RIC) with fludarabine (FLU) and busulfan (BU) for the treatment of acute myeloid leukemia (AML), myelodysplastic syndrome (MDS) and myeloproliferative syndrome (MPS) from 2005 to 2014. Three-year event-free survival (EFS) and overall survival (OS) were 46 and 58 %, respectively. Patients ≥60 years of age showed a similar outcome compared to younger patients (3-year OS 55 vs. 61 %, p = 0.96; 3-year EFS 46 vs. 46 %, p = 0.82). Cumulative incidence of non-relapse mortality (NRM) at 3 years adjusted for relapse as competing risk was 25 % for patients aged <60 years and 15 % for older patients (p = 0.15). Infusions of higher CD34(+) blood stem cell doses were associated with a significantly better outcome in the elderly subgroup (3-year OS 82 vs. 39 %, p = 0.007). Moreover, complete donor chimerism at day +100 was associated with a significantly improved survival (3-year OS 69 vs. 23 %, p = 0.003). In conclusion, our data suggest that RIC with FLU/BU enables long-term disease-free survival even in an elderly patient population. Age has no negative impact on the outcome of allogeneic HCT, and decision for transplant should be based on disease risk and performance status rather than age alone.
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Umbilical Cord Blood Transplantation Outcomes in Acute Myelogenous Leukemia/Myelodysplastic Syndrome Patients Aged ≥70 Years. Biol Blood Marrow Transplant 2015; 22:390-393. [PMID: 26415559 DOI: 10.1016/j.bbmt.2015.09.020] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 09/18/2015] [Indexed: 12/19/2022]
Abstract
The maximum age of patients receiving allogeneic hematopoietic stem cell transplantation (alloHCT) has been moving up over time. However, the availability of a suitable HLA-matched sibling donor may limit access of this patient population to alloHCT. We retrospectively investigated the outcomes of umbilical cord blood transplantation (UCBT) after reduced-intensity conditioning regimens in patients aged ≥70 years with myelodysplastic syndrome (MDS) and acute myelogenous leukemia (AML) between 2010 and 2014. During this period 70 patients with AML/MDS were referred to our center for alloHCT consideration. Twenty-two patients (33%) received alloHCT: 10 UCBT, 9 HLA full-matched sibling donor transplantation, 2 haploidentical alloHCT, and 1 unrelated donor alloHCT. In UCBT, cumulative incidences of nonrelapse mortality and relapse were 20% and 30% at 2 years, respectively. The cumulative incidence of acute graft-versus-host disease (GVHD) at day +100 and chronic GVHD at 2 years was 10%. Seven patients had viral reactivation/infections. Rates of overall survival and disease-free survival were 60% and 50% at 2 years, respectively. Moreover, these outcomes seemed to be similar to that of patients aged 60 to 69 years receiving UCBT (n = 60) and patients aged ≥70 years receiving HLA full-matched sibling donor transplantation (n = 9). These results suggest that UCBT is feasible in selected AML/MDS patients aged ≥70 years. In fact, UCBT shortens the required time for an unrelated donor search and thus increases the chance of proceeding with alloHCT, which might contribute to higher rates of alloHCT in the referral group. Outcomes of UCBT are promising; however, larger studies with a longer follow-up are needed.
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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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Chen Y, Wang Y, Xu LP, Liu KY, Chen H, Chen YH, Zhang XH, Wang FR, Han W, Wang JZ, Yan CH, Zhang YY, Sun YQ, Huang XJ. Haploidentical stem cell transplantation in patients aged 50 yr and older with leukemia: similar outcomes compared to younger adults. Clin Transplant 2015; 29:523-30. [PMID: 25809115 DOI: 10.1111/ctr.12545] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2015] [Indexed: 01/21/2023]
Abstract
AIM We aimed to analyze the complications and survival associated with myeloablative haploidentical SCT in patients aged ≥ 50 yr and compare these results with a younger group population. DESIGN AND METHODS In this case-control study, enrolled patients with leukemia were identified from 1262 patients between May 2002 and May 2013 at a single institution. RESULTS Thirty-one patients were aged ≥ 50 yr (the older group) and 165 patients were aged 18-49 yr (the younger group). Of the older group, 20 of 31 (64.5%) had a hematopoietic cell transplantation comorbidity index (HCT-CI) of 0 or 2. Statistical analysis showed no significant differences in the incidences of grades II to IV acute GVHD, extensive chronic GVHD, and non-relapse mortality (NRM), or probability of relapse between the two groups. Furthermore, the 3-yr overall survival (OS) and leukemia-free survival (LFS) were not significantly different between the older and younger groups: 67.0 ± 9.3% vs. 75.3 ± 3.4% (p = 0.406) and 60.5 ± 9.6% vs. 72.5 ± 3.5% (p = 0.183), respectively. CONCLUSION Selected older patients aged ≥ 50 yr with low HCT-CI and good performance status could safely undergo haploidentical SCT.
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Affiliation(s)
- Yao Chen
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Yu Wang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Lan-Ping Xu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Kai-Yan Liu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Huan Chen
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Yu-Hong Chen
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Xiao-Hui Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Feng-Rong Wang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Wei Han
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Jing-Zhi Wang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Chen-Hua Yan
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Yuan-Yuan Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Yu-Qian Sun
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Xiao-Jun Huang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,Peking-Tsinghua Center for Life Sciences, Beijing, China
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Kharfan-Dabaja MA, Labopin M, Bazarbachi A, Socie G, Kroeger N, Blaise D, Veelken H, Bermudez A, Or R, Lioure B, Beelen D, Fegueux N, Hamladji RM, Nagler A, Mohty M. Higher busulfan dose intensity appears to improve leukemia-free and overall survival in AML allografted in CR2: An analysis from the Acute Leukemia Working Party of the European Group for Blood and Marrow Transplantation. Leuk Res 2015; 39:933-7. [PMID: 26003666 DOI: 10.1016/j.leukres.2015.04.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 03/09/2015] [Accepted: 04/15/2015] [Indexed: 10/23/2022]
Abstract
Allogeneic hematopoietic cell transplantation is a potentially curative treatment in patients with acute myeloid leukemia. Recent advances in the field of hematopoietic cell allografting have resulted in a practice shift, favoring less intense preparative regimens. We present results of a retrospective comparative analysis of two preparative regimens, namely FB2 (IV fludarabine plus IV busulfan 6.4mg/kg±10%) and FB4 (IV fludarabine plus IV busulfan 12.8mg/kg ±10%), in patients with acute myeloid leukemia undergoing hematopoietic cell allografting in second complete remission at EBMT participating centers. Between 2003 and 2010, 128 AML patients in second complete remission were allografted following a preparative regimen of FB2 (n=88) or FB4 (n=40). The median time-to-neutrophil engraftment was similar whether patients received FB2 (16 (5-38) days) or FB4 (16 (9-29) days), p=0.45. A multivariate analysis showed that use of FB4 resulted in improved 2-year leukemia-free (HR=0.44 (95%CI=0.21, 0.94), p=0.03) and overall survival (HR=0.38 (95%CI=0.16, 0.86), p=0.02). Cumulative incidence of non-relapse mortality (2-year) for all patients was 21% (95%CI=14-28%). Our analysis suggests that FB4 improves 2-year leukemia-free and overall survival in AML allografted in second complete remission. A confirmatory randomized controlled trial that compares these two preparative regimens (FB2 vs. FB4) in AML in CR2 is definitely warranted.
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Affiliation(s)
- Mohamed A Kharfan-Dabaja
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center, Tampa, FL, United States
| | | | - Ali Bazarbachi
- Division of Hematology-Oncology and BMT Program, American University of Beirut Medical Center, Beirut, Lebanon
| | - Gerard Socie
- Service d'Hématologie Greffe, Hôpital Saint Louis, Paris, France
| | - Nicolaus Kroeger
- Bone Marrow Transplantation Centre, Univ. Hospital Eppendorf, Hamburg, Germany
| | - Didier Blaise
- Unité de Transplantation et de Thérapie Cellulaire (U2T), Institut Paoli-Calmettes, Marseille, France
| | | | - Arancha Bermudez
- Dept of Hematology, Hospital Universitario Marqués de Valdecilla, Instituto de Formación e Investigación Marqués de Valdecilla, Santander, Spain
| | - Reuven Or
- Dept of Bone Marrow Transplantation and Cancer Immunotherapy, Hadassah University Hospital, Jerusalem, Israel
| | - Bruno Lioure
- CHU Hautepierre-Département d'Hématologie et Oncologie, Strasbourg, France
| | - Dietrich Beelen
- University Hospital, Department of Bone Marrow Transplantation, Essen, Germany
| | | | | | - Arnon Nagler
- Acute Leukemia Working Party of EBMT, Paris, France; Hematology Division, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Mohamad Mohty
- Acute Leukemia Working Party of EBMT, Paris, France; Département d'Hématologie, Hopital Saint Antoine, Paris, France.
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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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