1
|
Choi SW. Unveiling amphiregulin: a blood-based biomarker for graft- versus-host disease risk assessment and monitoring. Haematologica 2024; 109:1315-1316. [PMID: 37822241 PMCID: PMC11063830 DOI: 10.3324/haematol.2023.284148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 10/05/2023] [Indexed: 10/13/2023] Open
Abstract
Not available.
Collapse
Affiliation(s)
- Sung Won Choi
- University of Michigan, Michigan Medicine, Blood and Marrow Transplantation Program; Ann Arbor, MI.
| |
Collapse
|
2
|
Iacobescu M, Pop C, Uifălean A, Mogoşan C, Cenariu D, Zdrenghea M, Tănase A, Bergthorsson JT, Greiff V, Cenariu M, Iuga CA, Tomuleasa C, Tătaru D. Unlocking protein-based biomarker potential for graft-versus-host disease following allogenic hematopoietic stem cell transplants. Front Immunol 2024; 15:1327035. [PMID: 38433830 PMCID: PMC10904603 DOI: 10.3389/fimmu.2024.1327035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 02/01/2024] [Indexed: 03/05/2024] Open
Abstract
Despite the numerous advantages of allogeneic hematopoietic stem cell transplants (allo-HSCT), there exists a notable association with risks, particularly during the preconditioning period and predominantly post-intervention, exemplified by the occurrence of graft-versus-host disease (GVHD). Risk stratification prior to symptom manifestation, along with precise diagnosis and prognosis, relies heavily on clinical features. A critical imperative is the development of tools capable of early identification and effective management of patients undergoing allo-HSCT. A promising avenue in this pursuit is the utilization of proteomics-based biomarkers obtained from non-invasive biospecimens. This review comprehensively outlines the application of proteomics and proteomics-based biomarkers in GVHD patients. It delves into both single protein markers and protein panels, offering insights into their relevance in acute and chronic GVHD. Furthermore, the review provides a detailed examination of the site-specific involvement of GVHD. In summary, this article explores the potential of proteomics as a tool for timely and accurate intervention in the context of GVHD following allo-HSCT.
Collapse
Affiliation(s)
- Maria Iacobescu
- Department of Proteomics and Metabolomics, MEDFUTURE Research Center for Advanced Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Cristina Pop
- Department of Pharmacology, Physiology and Pathophysiology, Faculty of Pharmacy, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Alina Uifălean
- Department of Pharmaceutical Analysis, Faculty of Pharmacy, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Cristina Mogoşan
- Department of Pharmacology, Physiology and Pathophysiology, Faculty of Pharmacy, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Diana Cenariu
- Department of Translational Medicine, MEDFUTURE Research Center for Advanced Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Mihnea Zdrenghea
- Department of Hematology, Faculty of Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Alina Tănase
- Department of Stem Cell Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| | - Jon Thor Bergthorsson
- Department of Laboratory Hematology, Stem Cell Research Unit, Biomedical Center, School of Health Sciences, University Iceland, Reykjavik, Iceland
| | - Victor Greiff
- Department of Immunology, University of Oslo, Oslo, Norway
| | - Mihai Cenariu
- Department of Animal Reproduction, University of Agricultural Sciences and Veterinary Medicine, Cluj-Napoca, Romania
| | - Cristina Adela Iuga
- Department of Proteomics and Metabolomics, MEDFUTURE Research Center for Advanced Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
- Department of Pharmaceutical Analysis, Faculty of Pharmacy, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Ciprian Tomuleasa
- Department of Translational Medicine, MEDFUTURE Research Center for Advanced Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
- Department of Hematology, Faculty of Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Dan Tătaru
- Department of Internal Medicine, Faculty of Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
| |
Collapse
|
3
|
Stueck AE, Fiel MI. Hepatic graft-versus-host disease: what we know, when to biopsy, and how to diagnose. Hum Pathol 2023; 141:170-182. [PMID: 37541449 DOI: 10.1016/j.humpath.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 04/19/2023] [Accepted: 07/24/2023] [Indexed: 08/06/2023]
Abstract
Graft-versus-host disease (GVHD) is one of the serious complications that may develop after hematopoietic cell transplantation (HCT), for hematologic malignancies, solid organ transplantation, and other hematologic disorders. GVHD develops due to T lymphocytes present in the graft attacking the host antigens, which results in tissue damage. A significant number of HCT patients develop acute or chronic GVHD, which may affect multiple organs including the liver. The diagnosis of hepatic GVHD (hGVHD) is challenging as many other conditions in HCT patients may lead to liver dysfunction. Particularly challenging among the various conditions that give rise to liver dysfunction is differentiating sinusoidal obstruction syndrome and drug-induced liver injury (DILI) from hGVHD on clinical grounds and laboratory tests. Despite the minimal risks involved in performing a liver biopsy, the information gleaned from the histopathologic changes may help in the management of these very complex patients. There is a spectrum of histologic features found in hGVHD, and most involve histopathologic changes affecting the interlobular bile ducts. These include nuclear and cytoplasmic abnormalities including dysmorphic bile ducts, apoptosis, and cholangiocyte necrosis, among others. The hepatitic form of hGVHD typically shows severe acute hepatitis. With chronic hGVHD, there is progressive bile duct loss and eventually fibrosis. Accurate diagnosis of hGVHD is paramount so that timely treatment and management can be initiated. Techniques to prevent and lower the risk of GVHD from developing have recently evolved. If a diagnosis of acute GVHD is made, the first-line of treatment is steroids. Recurrence is common and steroid resistance or dependency is not unusual in this setting. Second-line therapies differ among institutions and have not been uniformly established. The development of GVHD, particularly hGVHD, is associated with increased morbidity and mortality.
Collapse
Affiliation(s)
- Ashley E Stueck
- Department of Pathology, Dalhousie University, 715 - 5788 University Avenue, Halifax, NS, B3H 2Y9, Canada.
| | - M Isabel Fiel
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, 1468 Madison Ave, New York, NY, 10029, USA.
| |
Collapse
|
4
|
Schultz B, Miller DD, DeFor T, Blazar BR, Panoskaltsis‐Mortari A, Betts BC, MacMillan ML, Weisdorf DJ, Holtan SG. High Cutaneous Amphiregulin Expression Predicts Fatal Acute
Graft‐versus‐Host
Disease. J Cutan Pathol 2022; 49:532-535. [PMID: 35224759 PMCID: PMC9311189 DOI: 10.1111/cup.14218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 02/02/2022] [Accepted: 02/14/2022] [Indexed: 12/05/2022]
Abstract
Background Amphiregulin (AREG) is increased in circulation in acute graft‐versus‐host disease (aGVHD) and is associated with poor steroid response and lower survival. The expression of AREG in aGVHD target organs and its association with clinical outcomes are unknown. Methods We performed AREG immunohistochemical staining on skin specimens from 67 patients with aGVHD between the years 2010 and 2015. Two blinded reviewers assessed AREG expression and scored specimens with a semiquantitative scale ranging from 0 (absent) to 4 (most intense). Results Median AREG score of aGVHD cases was 3. Sixteen of 67 (23.9%) aGVHD cases had an AREG >3. High skin AREG expression (>3 vs. ≤3) was associated with increased overall clinical grade of aGVHD (52.9% vs. 33.4% clinical grade III‐IV, p = 0.02), reduced 3‐year overall survival (OS; 13% vs. 61%, p < 0.01), and increased 3‐year non‐relapse mortality (NRM; 56% vs. 20%, p = 0.05). Conclusion High skin AREG immunohistochemical expression is associated with high clinical grade aGVHD, poor OS, and increased NRM.
Collapse
Affiliation(s)
- Brittney Schultz
- Department of Dermatology University of Minnesota Minneapolis MN
| | - Daniel D. Miller
- Department of Dermatology University of Minnesota Minneapolis MN
| | - Todd DeFor
- Hematology and Transplant University of Minnesota Minneapolis MN
- Biostatistics and Informatics University of Minnesota Minneapolis MN
| | - Bruce R. Blazar
- Hematology and Transplant University of Minnesota Minneapolis MN
| | - Angela Panoskaltsis‐Mortari
- Hematology and Transplant University of Minnesota Minneapolis MN
- Department of Pediatrics University of Minnesota Minneapolis MN
| | - Brian C. Betts
- Hematology and Transplant University of Minnesota Minneapolis MN
| | - Margaret L. MacMillan
- Hematology and Transplant University of Minnesota Minneapolis MN
- Biostatistics and Informatics University of Minnesota Minneapolis MN
| | | | | |
Collapse
|
5
|
Kozanoglu I, Pepedil-Tanrikulu F. Functions of the endothelium and its role in hematopoietic cell transplantation. Transfus Apher Sci 2022; 61:103368. [DOI: 10.1016/j.transci.2022.103368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
6
|
Serum follistatin level as a prognostic marker in Haploidentical stem cell transplantation. Transpl Immunol 2022; 71:101542. [DOI: 10.1016/j.trim.2022.101542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 01/20/2022] [Accepted: 01/21/2022] [Indexed: 11/21/2022]
|
7
|
Abstract
PURPOSE OF REVIEW Graft-versus-host disease (GVHD) following hematopoietic cell transplant (HCT) has a significant impact on morbidity and mortality among recipients. Predicting the long-term outcomes at the time of diagnosis of GVHD or even after response to up-front therapy can be challenging and only has modest accuracy. With biomarkers available to help guide decision-making, the landscape of GVHD is evolving. RECENT FINDINGS Several acute GVHD biomarkers have been identified, with some better able to categorize patients based on their GVHD severity and potential for refractory disease than standard clinical staging or response criteria. SUMMARY Biomarkers are now being incorporated into the clinical trial design for both high and low-risk GVHD. These findings will likely impact how clinical care is delivered in the future as improved risk stratification has the potential to improve outcomes by providing individualized treatment plans for affected patients.
Collapse
Affiliation(s)
- Saara Kaviany
- Monroe Carell Jr Children's Hospital, Vanderbilt University Medical Center, Department of Pediatrics, Division of Hematology/Oncology, Nashville, Tennessee, USA
| | | |
Collapse
|
8
|
Satırer Ö, Cevher Zeytin İ, Alkan B, Karakaya J, Çetinkaya D, Visal Okur F. Association of Pre-Transplant Angiopoietin-2 Index with the Risk of Acute Graft versus Host Disease After Hematopoietic Stem Cell Transplantation. Turk J Haematol 2021; 39:61-65. [PMID: 34617432 PMCID: PMC8886278 DOI: 10.4274/tjh.galenos.2021.2021.0434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Objective: Angiogenic factors (AFs) released under endothelial stress are reflective of tissue healing, while some may also contribute to tissue damage/inflammation. We investigated whether alterations in the pre-transplant levels of AFs were associated with the risk of acute graft-versus-host disease (aGvHD). Materials and Methods: The pre-conditioning plasma levels of angiopoietin-2 (Ang2), endoglin, and follistatin were measured for 37 patients together with inflammatory markers. The index values defined were evaluated to better identify the alterations. Results: The patients had higher pre-conditioning levels of Ang2, endoglin, and follistatin compared to controls. The patients with aGvHD had higher Ang2 index and lower albumin index scores in comparison to those without aGvHD. Multivariate analysis revealed that the pre-transplant Ang2 index was an independent risk factor for aGvHD development. Conclusion: Pre-transplant evaluation of plasma Ang2 levels along with inflammatory status even before conditioning is associated with endothelial vulnerability. The pre-transplant Ang2 index could be a promising candidate to estimate the risk of aGvHD.
Collapse
Affiliation(s)
- Özlem Satırer
- Faculty of Medicine, Department of Pediatrics, Hacettepe University, Ankara, Turkey
| | - İnci Cevher Zeytin
- Center for Stem Cell Research and Development (PEDI-STEM), Hacettepe University, Ankara, Turkey
| | - Berna Alkan
- Center for Stem Cell Research and Development (PEDI-STEM), Hacettepe University, Ankara, Turkey
| | - Jale Karakaya
- Faculty of Medicine, Department of Biostatistics, Hacettepe University, Ankara, Turkey
| | - Duygu Çetinkaya
- Center for Stem Cell Research and Development (PEDI-STEM), Hacettepe University, Ankara, Turkey.,Faculty of Medicine, Department of Pediatrics, Division of Pediatric Hematology and Bone Marrow Transplantation Unit, Hacettepe University, Ankara, Turkey
| | - Fatma Visal Okur
- Center for Stem Cell Research and Development (PEDI-STEM), Hacettepe University, Ankara, Turkey.,Faculty of Medicine, Department of Pediatrics, Division of Pediatric Hematology and Bone Marrow Transplantation Unit, Hacettepe University, Ankara, Turkey
| |
Collapse
|
9
|
Luft T, Dreger P, Radujkovic A. Endothelial cell dysfunction: a key determinant for the outcome of allogeneic stem cell transplantation. Bone Marrow Transplant 2021; 56:2326-2335. [PMID: 34253879 PMCID: PMC8273852 DOI: 10.1038/s41409-021-01390-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 06/08/2021] [Accepted: 06/22/2021] [Indexed: 01/26/2023]
Abstract
Allogeneic hematopoietic stem cell transplantation (alloSCT) carries the promise of cure for many malignant and non-malignant diseases of the lympho-hematopoietic system. Although outcome has improved considerably since the pioneering Seattle achievements more than 5 decades ago, non-relapse mortality (NRM) remains a major burden of alloSCT. There is increasing evidence that endothelial dysfunction is involved in many of the life-threatening complications of alloSCT, such as sinusoidal obstruction syndrome/venoocclusive disease, transplant-associated thrombotic microangiopathy, and refractory acute graft-versus host disease. This review delineates the role of the endothelium in severe complications after alloSCT and describes the current status of search for biomarkers predicting endothelial complications, including markers of endothelial vulnerability and markers of endothelial injury. Finally, implications of our current understanding of transplant-associated endothelial pathology for prevention and management of complications after alloSCT are discussed.
Collapse
Affiliation(s)
- Thomas Luft
- Department Medicine V, University of Heidelberg, Heidelberg, Germany.
| | - Peter Dreger
- Department Medicine V, University of Heidelberg, Heidelberg, Germany.
| | | |
Collapse
|
10
|
Sumransub N, El Jurdi N, Chiraphapphaiboon W, Maakaron JE. Putting function back in dysfunction: Endothelial diseases and current therapies in hematopoietic stem cell transplantation and cellular therapies. Blood Rev 2021; 51:100883. [PMID: 34429234 DOI: 10.1016/j.blre.2021.100883] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 07/16/2021] [Accepted: 08/12/2021] [Indexed: 01/28/2023]
Abstract
Endothelial dysfunction is characterized by altered vascular permeability and prothrombotic, pro-inflammatory phenotypes. Endothelial dysfunction results in end-organ damage and has been associated with diverse disease pathologies. Complications observed after hematopoietic stem cell transplantation (HCT) and chimeric antigen receptor-T cell (CAR-T) therapy for hematologic and neoplastic disorders share overlapping clinical manifestations and there is increasing evidence linking these complications to endothelial dysfunction. Despite advances in supportive care and treatments, end-organ toxicity remains the leading cause of mortality. A new strategy to mitigate endothelial dysfunction could lead to improvement of clinical outcomes for patients. Statins have demonstrated pleiotropic effects of immunomodulatory and endothelial protection by various molecular mechanisms. Recent applications in immune-mediated diseases such as autoimmune disorders, chronic inflammatory conditions, and graft-versus-host disease (GVHD) have shown promising results. In this review, we cover the mechanisms underlying endothelial dysfunction in GVHD and CAR-T cell-related toxicities. We summarize the current knowledge about statins and other agents used as endothelial protectants. We propose further studies using statins for prophylaxis and prevention of end-organ damage related to extensive endothelial dysfunction in HCT and CAR-T.
Collapse
Affiliation(s)
- Nuttavut Sumransub
- Department of Medicine, University of Minnesota, 420 Delaware St. SE MMC 480, Minneapolis, MN 55455, United States of America
| | - Najla El Jurdi
- Department of Medicine, University of Minnesota, 420 Delaware St. SE MMC 480, Minneapolis, MN 55455, United States of America
| | - Wannasiri Chiraphapphaiboon
- Division of Molecular Medicine, Research Department, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Rd, Bangkok-Noi, Bangkok 10700, Thailand
| | - Joseph E Maakaron
- Department of Medicine, University of Minnesota, 420 Delaware St. SE MMC 480, Minneapolis, MN 55455, United States of America.
| |
Collapse
|
11
|
Lia G, Giaccone L, Leone S, Bruno B. Biomarkers for Early Complications of Endothelial Origin After Allogeneic Hematopoietic Stem Cell Transplantation: Do They Have a Potential Clinical Role? Front Immunol 2021; 12:641427. [PMID: 34093530 PMCID: PMC8170404 DOI: 10.3389/fimmu.2021.641427] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 05/04/2021] [Indexed: 12/17/2022] Open
Abstract
Endothelial cell (EC) dysfunction causes a number of early and life-threatening post hematopoietic stem cell transplant (HCT) complications that result in a rapid clinical decline. The main early complications are graft-vs.-host disease (GVHD), transplant associated thrombotic microangiopathy (TA-TMA), and sinusoidal obstruction syndrome (SOS). Post-HCT endothelial dysfunction occurs as a result of chemotherapy, infections, and allogeneic reactivity. Despite major advances in transplant immunology and improvements in supportive care medicine, these complications represent a major obstacle for successful HCT. In recent years, different biomarkers have been investigated for early detection of post-transplant endothelial cell dysfunction, but few have been validated. In this review we will define GVHD, TA-TMA and SOS, summarize the current data available in HCT biomarker research and identify promising biomarkers for detection and diagnosis of early HCT complications.
Collapse
Affiliation(s)
- Giuseppe Lia
- Stem Cell Transplant Program, Department of Oncology, A.O.U. Città della Salute e della Scienza di Torino, Torino, Italy
- Department of Molecular Biotechnology and Health Sciences, University of Torino, Torino, Italy
| | - Luisa Giaccone
- Stem Cell Transplant Program, Department of Oncology, A.O.U. Città della Salute e della Scienza di Torino, Torino, Italy
- Department of Molecular Biotechnology and Health Sciences, University of Torino, Torino, Italy
| | - Sarah Leone
- Department of Internal Medicine, New York University Grossman School of Medicine, New York, NY, United States
| | - Benedetto Bruno
- Department of Molecular Biotechnology and Health Sciences, University of Torino, Torino, Italy
- Division of Hematology and Medical Oncology, New York University Grossman School of Medicine, Perlmutter Cancer Center, New York University Langone Health, New York, NY, United States
| |
Collapse
|
12
|
Facilitating resolution of life-threatening acute GVHD with human chorionic gonadotropin and epidermal growth factor. Blood Adv 2021; 4:1284-1295. [PMID: 32236525 DOI: 10.1182/bloodadvances.2019001259] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 02/20/2020] [Indexed: 12/15/2022] Open
Abstract
Acute graft-versus-host disease (aGVHD) is a potentially fatal complication of allogeneic hematopoietic cell transplantation that fails to improve with intense immunosuppression in some patients. We hypothesized that urinary-derived human chorionic gonadotropin (uhCG) could help facilitate resolution of life-threatening aGVHD when added as supportive care via 2 potential mechanisms: immunomodulation (akin to its role in pregnancy) and supplementation of epidermal growth factor (EGF; to aid in epithelial repair). In a phase 1 study, 26 participants received subcutaneous injections of uhCG in addition to standard immunosuppression (13 receiving initial therapy for high-risk aGVHD [according to the Minnesota criteria] and 13 receiving second-line therapy). Participants underwent serial blood testing for biomarkers of hormone response, immune modulation, and aGVHD activity on study. uhCG was well tolerated, with no dose-limiting toxicities. Sixty-two percent of patients in the high-risk cohort and 54% of patients in the second-line cohort had a complete response at study day 28. Plasma EGF was elevated sixfold (from 4 to 24 pg/mL; P = .02) at 6 hours postdose in the high-risk cohort, in contrast to no peak in plasma EGF in the more severe second-line cohort. After 1 week of uhCG, patients reported a twofold increase in the regulatory T cell to conventional T-cell ratio, suggesting immune modulation despite high-dose steroids. Responding patients reported significantly lower plasma amphiregulin and higher plasma butyrate levels at study completion, suggesting improvement in mucosal damage over time. uhCG is a novel, safe, supportive therapy, proceeding to phase 2 testing at 2000 units/m2 in high-risk aGVHD. This study was registered at www.clinicaltrials.gov as #NCT02525029.
Collapse
|
13
|
Abstract
Purpose of Review Graft-versus-host disease (GVHD) is an immune mediated disorder affecting 30 - 70% of patients after allogeneic hematopoietic stem cell transplantation (alloHSCT), and is a major cause of morbidity and non-relapse mortality (NRM) [1]. Dermatologists play a critical role in acute and chronic GVHD, as skin involvement is common and often the earliest involved site of disease [2]. Recent Findings GVHD shares clinical and histopathological features with a variety of other skin diseases, requiring thorough consideration of differential diagnoses in hematopoietic stem cell transplantation (HSCT) recipients with lesions suggestive of cutaneous GVHD. Treatment considerations for GVHD are influenced by factors such as disease classification, overall grading, organ involvement, associated symptoms, and immunological anti-tumor effect. Several treatments are available and may be indicated as monotherapy or adjuvant therapy to allow faster withdrawal or tapering of immunosuppression. While corticosteroids are often first line therapy, oral ruxolitinib has been recently approved for treatment of steroid-refractory aGHVD, and oral ibrutinib has been approved for steroid-refractory cGHVD. Summary This article provides current clinical, diagnostic, and therapeutic considerations relevant to the hospitalist for both acute and chronic mucocutaneous GVHD. Optimal inpatient management of these diseases requires an interdisciplinary team.
Collapse
|
14
|
Hildebrandt GC, Chao N. Endothelial cell function and endothelial-related disorders following haematopoietic cell transplantation. Br J Haematol 2020; 190:508-519. [PMID: 32319084 PMCID: PMC7496350 DOI: 10.1111/bjh.16621] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 03/09/2020] [Indexed: 12/16/2022]
Abstract
Use of haematopoietic cell transplantation (HCT) in the treatment of haematologic and neoplastic diseases may lead to life-threatening complications that cause substantial morbidity and mortality if untreated. In addition to patient- and disease-related factors, toxicity associated with HCT puts patients at risk for complications that share a similar pathophysiology involving endothelial cells (ECs). Normally, the endothelium plays a role in maintaining homeostasis, including regulation of coagulation, vascular tone, permeability and inflammatory processes. When activated, ECs acquire cellular features that may lead to phenotypic changes that induce procoagulant, pro-inflammatory and pro-apoptotic mediators leading to EC dysfunction and damage. Elevated levels of coagulation factors, cytokines and adhesion molecules are indicative of endothelial dysfunction, and endothelial damage may lead to clinical signs and symptoms of pathological post-HCT conditions, including veno-occlusive disease/sinusoidal obstruction syndrome, graft-versus-host disease, transplant-associated thrombotic microangiopathy and idiopathic pneumonia syndrome/diffuse alveolar haemorrhage. The endothelium represents a rational target for preventing and treating HCT complications arising from EC dysfunction and damage. Additionally, markers of endothelial damage may be useful in improving diagnosis of HCT-related complications and monitoring treatment effect. Continued research to effectively manage EC activation, injury and dysfunction may be important in improving patient outcomes after HCT.
Collapse
Affiliation(s)
| | - Nelson Chao
- Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA
| |
Collapse
|
15
|
Shah O, Tamaresis JS, Kenyon LJ, Xu L, Zheng P, Gupta P, Rangarajan K, Lee S, Spellman S, Nikiforow S, Zehnder J, Meyer EH. Analysis of the Whole CDR3 T Cell Receptor Repertoire after Hematopoietic Stem Cell Transplantation in 2 Clinical Cohorts. Biol Blood Marrow Transplant 2020; 26:1050-1070. [PMID: 32081787 DOI: 10.1016/j.bbmt.2020.01.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 01/12/2020] [Accepted: 01/27/2020] [Indexed: 01/19/2023]
Abstract
A major cause of morbidity and mortality for patients who undergo hematologic stem cell transplantation (HSCT) is acute graft-versus-host disease (aGVHD), a mostly T cell-mediated disease. Examination of the T cell receptor (TCR) repertoire of HSCT recipients and the use of next-generation nucleotide sequencing have raised the question of whether features of TCR repertoire reconstitution might reproducibly associate with aGVHD. We hypothesized that the peripheral blood TCR repertoire of patients with steroid-nonresponsive aGVHD would be less diverse. We also hypothesized that patients with GVHD who shared HLA might also share common clones at the time of GVHD diagnosis, thereby potentially providing potential clinical indicators for treatment stratification. We further hypothesized that HSCT recipients with the same HLA mismatch might share a more similar TCR repertoire based on a potentially shared focus of alloreactive responses. We studied 2 separate patient cohorts and 2 separate platforms for measuring TCR repertoire. The first cohort of patients was from a multicenter Phase III randomized double-blinded clinical trial of patients who developed aGVHD (NCT01002742). The second cohort comprised samples from biobanks from 2 transplantation centers and the Center for International Blood and Marrow Transplant Research of patients who underwent mismatched HSCT. There were no statistically significant differences in the TCR diversity of steroid responders and nonresponders among patients with aGVHD on the day of diagnosis. Most clones in the repertoire were unique to each patient, but a small number of clones were found to be both exclusive to and shared among aGVHD nonresponders. We were also able to show a strong correlation between the presence of Vβ20 and Vβ29 and steroid responsiveness. Using the Bhattacharya coefficient, those patients who shared the same HLA mismatch were shown to be no more similar to one another than to those who had a completely different mismatch. Using 2 separate clinical cohorts and 2 separate platforms for analyzing the TCR repertoire, we have shown that the sampled human TCR repertoire is largely unique to each patient but contains glimmers of common clones of subsets of clones based on responsiveness to steroids in aGVHD on the day of diagnosis. These studies are informative for future strategies to assess for reproducible TCR responses in human alloreactivity and possible markers of GVHD responsiveness to therapy.
Collapse
Affiliation(s)
- Omid Shah
- Division of Blood and Marrow Transplantation, Stanford University School of Medicine, Stanford, California
| | - John S Tamaresis
- Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, California
| | - Laura Jean Kenyon
- Division of Blood and Marrow Transplantation, Stanford University School of Medicine, Stanford, California
| | - Liwen Xu
- Department of Pathology, Stanford University School of Medicine, Stanford, California
| | - Pingping Zheng
- Division of Blood and Marrow Transplantation, Stanford University School of Medicine, Stanford, California
| | - Puja Gupta
- Division of Blood and Marrow Transplantation, Stanford University School of Medicine, Stanford, California
| | - Krish Rangarajan
- Division of Blood and Marrow Transplantation, Stanford University School of Medicine, Stanford, California
| | - Stephanie Lee
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Stephen Spellman
- National Marrow Donor Program/C Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota
| | | | - James Zehnder
- Department of Pathology, Stanford University School of Medicine, Stanford, California
| | - Everett H Meyer
- Division of Blood and Marrow Transplantation, Stanford University School of Medicine, Stanford, California.
| |
Collapse
|
16
|
Favourable survival in "Discordant" acute gastrointestinal graft versus host disease (GI-GVHD) is explained by mild clinical course and treatment-responsive disease. Int J Hematol 2020; 111:574-578. [PMID: 31912373 DOI: 10.1007/s12185-019-02813-9] [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: 10/02/2019] [Revised: 12/17/2019] [Accepted: 12/25/2019] [Indexed: 10/25/2022]
Abstract
We have previously reported that haematopoietic progenitor cell transplantation recipients with biopsy-negative acute Gastrointestinal Graft versus Host Disease (Discordant GVHD) demonstrate superior survival compared to "True Positive" cases. We aimed to elucidate this discrepancy by examining clinical and laboratory predictors of survival among patients treated for True Positive or Discordant GVHD. Data were obtained by retrospective chart review. At diagnosis, the incidence of severe symptoms, hypoalbuminaemia, hyperbilirubinaemia, and poor performance status were recorded. Following treatment, the incidence of non-response to first-line corticosteroids was assessed. Differences between cohorts were compared using Fisher's exact test. 74 patients were identified, comprising 55 (74%) True Positive and 19 (26%) Discordant GVHD cases. True Positive cases were significantly more likely to have baseline severe symptoms (84% vs. 36%; p = 0.0002) and hypoalbuminaemia (94% vs. 75%; p = 0.023). There was no significant difference between cohorts in terms of hyperbilirubinaemia or performance status. Non-response to corticosteroid therapy was observed significantly more frequently in the True Positive cohort (55% vs. 11%; p = 0.001). In summary, the superior survival observed in Discordant GVHD is explained by a less severe GI-GVHD phenotype at diagnosis and a greater likelihood of response to corticosteroids. Further research is warranted to explain biological mechanisms for these findings.
Collapse
|
17
|
Follistatin and Soluble Endoglin Predict 1-Year Nonrelapse Mortality after Allogeneic Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2019; 26:606-611. [PMID: 31715306 DOI: 10.1016/j.bbmt.2019.11.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 10/21/2019] [Accepted: 11/03/2019] [Indexed: 12/17/2022]
Abstract
Damage-associated angiogenic factors (AFs), including follistatin (FS) and soluble endoglin (sEng), are elevated in circulation at the onset of acute graft-versus-host disease (GVHD). We hypothesized that regimen-related tissue injury also might be associated with aberrant AF levels and sought to determine the relevance of these AF on nonrelapse mortality (NRM) in patients with acute GVHD and those without acute GVHD. To test our hypothesis, we analyzed circulating levels of FS, sEng, angiopoietin-2 (Ang2), epidermal growth factor (EGF), vascular endothelial growth factor (VEGF) A and B, placental growth factor (PlGF), and soluble VEGF receptor (sVEGFR)-1 and -2, in plasma samples from patients enrolled on Blood and Marrow Transplant Clinical Trials Network (BMT CTN) 0402 (n = 221), which tested GVHD prophylaxis after myeloablative hematopoietic stem cell transplantation (HCT). We found that the interaction between FS and sEng had an additive effect in their association with 1-year NRM. In multivariate analysis, patients with the highest levels of day +28 FS and sEng had a 14.9-fold greater hazard ratio (HR) of NRM (95% confidence interval, 3.2 to 69.4; P < .01) when compared with low levels of FS and sEng. We validated these findings using an external cohort of patients (n = 106). Pre-HCT measurements of FS and sEng were not associated with NRM, suggesting that elevations in these factors early post-HCT may be consequences of early regimen-related toxicity. Determining the mechanisms responsible for patient-specific vulnerability to treatment toxicities and endothelial damage associated with specific AF elevation may guide interventions to reduce NRM post-HCT.
Collapse
|
18
|
Lee C, Lee SJ, Haneuse S. Time-to-event analysis when the event is defined on a finite time interval. Stat Methods Med Res 2019; 29:1573-1591. [PMID: 31436136 DOI: 10.1177/0962280219869364] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Acute graft-versus-host disease (GVHD) is a frequent complication following hematopoietic cell transplantation (HCT). Research on risk factors for acute GVHD has tended to ignore two important clinical issues. First, post-transplant mortality is high. In our motivating data, 100-day post-HCT mortality was 15.4%. Second, acute GVHD in its classic form is only diagnosed within 100 days of the transplant; beyond 100 days, a patient may be diagnosed with late onset acute or chronic GVHD. Standard modeling of time-to-event outcomes, however, generally conceive of patients being able to experience the event at any point on the time scale. In this paper, we propose a novel multi-state model that simultaneously: (i) accounts for mortality through joint modeling of acute GVHD and death, and (ii) explicitly acknowledges the finite time interval during which the event of interest can take place. The observed data likelihood is derived, with estimation and inference via maximum likelihood. Additionally, we provide methods for estimating the absolute risk of acute GVHD and death simultaneously. The proposed framework is compared via comprehensive simulations to a number of alternative approaches that each acknowledge some but not all aspects of acute GVHD, and illustrated with an analysis of HCT data that motivated this work.
Collapse
Affiliation(s)
- Catherine Lee
- Division of Research, Kaiser Permanente, Oakland, CA, USA
| | - Stephanie J Lee
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Sebastien Haneuse
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| |
Collapse
|
19
|
Zhao XS, Huang XJ. Seeking biomarkers for acute graft-versus-host disease: where we are and where we are heading? Biomark Res 2019; 7:17. [PMID: 31406575 PMCID: PMC6685226 DOI: 10.1186/s40364-019-0167-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 07/10/2019] [Indexed: 12/16/2022] Open
Abstract
Acute graft-versus-host disease (aGVHD) is one of the most important complications after allogeneic hematopoietic stem cell transplantation (allo-HSCT), which would seriously affect the clinical outcomes of patients. Early diagnosis and early intervention are keys for improving its curative efficacy. Thus, seeking the biomarkers of aGVHD that can accurately identify and diagnose aGVHD is very important to guiding the intervention and treatment of aGVHD. For the past decades, many studies have focused on searching for aGVHD-related biological markers to assist in diagnosis, early warning, and risk stratification. Unfortunately, until now, no reliable aGVHD biomarker is available that is recognized and widely used in clinical practice. With the continuous development of biological technology, as well as our in-depth understanding of the pathophysiologic mechanism of aGVHD, the selection, examination and application of biological markers have changed much. In this review, we summarized the progress of aGVHD biological marker screening, identification, preliminary clinical application, and look forward to a promising development direction in the future.
Collapse
Affiliation(s)
- Xiao-Su Zhao
- 1Peking University Peopl's Hospital, Peking University Institute of Hematology, No.11 Xizhimen South Street, Beijing, 100044 China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,3Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Xiao-Jun Huang
- 1Peking University Peopl's Hospital, Peking University Institute of Hematology, No.11 Xizhimen South Street, Beijing, 100044 China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,3Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,4Peking-Tsinghua Center for Life Sciences, Beijing, China
| |
Collapse
|
20
|
Flower VA, Barratt SL, Ward S, Pauling JD. The Role of Vascular Endothelial Growth Factor in Systemic Sclerosis. Curr Rheumatol Rev 2019; 15:99-109. [DOI: 10.2174/1573397114666180809121005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 05/07/2018] [Accepted: 07/23/2018] [Indexed: 11/22/2022]
Abstract
The pathological hallmarks of Systemic Sclerosis (SSc) constitute an inter-related triad of autoimmunity, vasculopathy and tissue remodeling. Many signaling mediators have been implicated in SSc pathology; most focusing on individual components of this pathogenic triad and current treatment paradigms tend to approach management of such as distinct entities. The present review shall examine the role of Vascular Endothelial Growth Factor (VEGF) in SSc pathogenesis. We shall outline potential mechanisms whereby differential Vascular Endothelial Growth Factor-A (VEGF-A) isoform expression (through conventional and alternative VEGF-A splicing,) may influence the relevant burden of vasculopathy and fibrosis offering novel insight into clinical heterogeneity and disease progression in SSc. Emerging therapeutic approaches targeting VEGF signaling pathways might play an important role in the management of SSc, and differential VEGF-A splice isoform expression may provide a tool for personalized medicine approaches to disease management.
Collapse
Affiliation(s)
- Victoria A. Flower
- Department of Pharmacy and Pharmacology, University of Bath, Bath, BA2 7AY, United Kingdom
| | - Shaney L. Barratt
- Academic Respiratory Unit, School of Clinical Sciences, University of Bristol, Bristol, BS10 5NB, United Kingdom
| | - Stephen Ward
- Department of Pharmacy and Pharmacology, University of Bath, Bath, BA2 7AY, United Kingdom
| | - John D. Pauling
- Department of Pharmacy and Pharmacology, University of Bath, Bath, BA2 7AY, United Kingdom
| |
Collapse
|
21
|
Amin K, Yaqoob U, Schultz B, Vaughn BP, Khoruts A, Howard JR, DeFor TE, Forster C, Meyer C, Gandhi I, Weisdorf DJ, Rashidi A, MacMillan ML, Blazar BR, Panoskaltsis-Mortari A, Holtan SG. Amphiregulin in intestinal acute graft-versus-host disease: a possible diagnostic and prognostic aid. Mod Pathol 2019; 32:560-567. [PMID: 30425334 PMCID: PMC6941942 DOI: 10.1038/s41379-018-0170-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 10/01/2018] [Accepted: 10/02/2018] [Indexed: 12/28/2022]
Abstract
Amphiregulin, a weak epidermal growth factor receptor agonist, is elevated, while epidermal growth factor, a strong epidermal growth factor receptor agonist, is low in the blood of patients with severe acute graft-versus-host disease. However, the tissue expression and function of these epidermal growth factor receptor ligands in acute graft-versus-host disease target organs is unknown. We compared by immunohistochemistry expression of amphiregulin and epidermal growth factor in archived, formalin-fixed, paraffin-embedded intestinal tissues of 48 patients with biopsy-proven gastrointestinal acute graft-versus-host disease to 3 groups: (1) 10 non-hematopoietic cell transplant normal controls, (2) 11 patients with newly diagnosed ulcerative colitis (ulcerative colitis), (3) 8 patients with a clinical diagnosis of acute graft-versus-host disease despite pathologically non-diagnostic biopsies, (4) and 10 cases of cytomegalovirus colitis. We used a semi-quantitative score of 0 (absent) through 3 (strong) to describe the intensity of immunohistochemical staining. We correlated serum and tissue amphiregulin and epidermal growth factor in patients with acute graft-versus-host disease. Gastrointestinal amphiregulin was significantly lower in acute graft-versus-host disease biopsies (median score 1), ulcerative colitis (median score 1.5), and cytomegalovirus colitis (median score 1) than in normal colon (median score 2, p = 0.004, p = 0.03, p = 0.009 respectively). Amphiregulin expression in was low in 74% of acute graft-versus-host disease cases with or without significant apoptosis. Patients with acute graft-versus-host disease exhibiting the pattern of high gastrointestinal amphiregulin but low serum amphiregulin (n = 14) had the best 1-year survival at 71%, but patients with high serum amphiregulin had poorer survival (<30%) regardless of gastrointestinal amphiregulin expression. Overall, our results lead to the hypothesis that amphiregulin is released into the circulation from damaged intestinal epithelium and stroma, although contributions from other cellular sources are likely. Low gastrointestinal amphiregulin expression by immunohistochemistry may be further studied for its utility in the pathologic acute graft-versus-host disease diagnosis without classic apoptotic changes.
Collapse
Affiliation(s)
- Khalid Amin
- Department of Laboratory Medicine and Pathology, University
of Minnesota, Minneapolis, MN, USA
| | | | - Brittney Schultz
- Department of Internal Medicine, University of Minnesota,
Minneapolis, MN, USA
| | - Byron P. Vaughn
- Department of Internal Medicine, Division of
Gastroenterology, University of Minnesota, Minneapolis, MN, USA
| | - Alexander Khoruts
- Department of Internal Medicine, Division of
Gastroenterology, University of Minnesota, Minneapolis, MN, USA
| | - Justin R. Howard
- Department of Internal Medicine, Division of
Gastroenterology, University of Minnesota, Minneapolis, MN, USA
| | - Todd E. DeFor
- Biostatistics and Informatics, University of Minnesota,
Minneapolis, MN, USA,Hematology, Oncology and Transplant, University of
Minnesota, Minneapolis, MN, USA
| | - Colleen Forster
- Department of Laboratory Medicine and Pathology, University
of Minnesota, Minneapolis, MN, USA
| | - Carolyn Meyer
- Department of Pediatrics, University of Minnesota,
Minneapolis, MN, USA
| | - Isha Gandhi
- College of Biological Sciences, University of Minnesota,
Minneapolis, MN, USA
| | - Daniel J. Weisdorf
- Hematology, Oncology and Transplant, University of
Minnesota, Minneapolis, MN, USA
| | - Armin Rashidi
- Hematology, Oncology and Transplant, University of
Minnesota, Minneapolis, MN, USA
| | | | - Bruce R. Blazar
- Hematology, Oncology and Transplant, University of
Minnesota, Minneapolis, MN, USA
| | - Angela Panoskaltsis-Mortari
- Department of Pediatrics, University of Minnesota,
Minneapolis, MN, USA,Hematology, Oncology and Transplant, University of
Minnesota, Minneapolis, MN, USA
| | - Shernan G. Holtan
- Hematology, Oncology and Transplant, University of
Minnesota, Minneapolis, MN, USA
| |
Collapse
|
22
|
Holtan SG, DeFor TE, Panoskaltsis-Mortari A, Khera N, Levine JE, Flowers MED, Lee SJ, Inamoto Y, Chen GL, Mayer S, Arora M, Palmer J, Cutler CS, Arai S, Lazaryan A, Newell LF, Jagasia MH, Pusic I, Wood WA, Renteria AS, Yanik G, Hogan WJ, Hexner E, Ayuk F, Holler E, Bunworasate U, Efebera YA, Ferrara JLM, Pidala J, Howard A, Wu J, Bolaños-Meade J, Ho V, Alousi A, Blazar BR, Weisdorf DJ, MacMillan ML. Amphiregulin modifies the Minnesota Acute Graft-versus-Host Disease Risk Score: results from BMT CTN 0302/0802. Blood Adv 2018; 2:1882-1888. [PMID: 30087106 PMCID: PMC6093743 DOI: 10.1182/bloodadvances.2018017343] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 06/26/2018] [Indexed: 01/07/2023] Open
Abstract
Amphiregulin (AREG) is an epidermal growth factor receptor ligand that can restore integrity to damaged intestinal mucosa in murine models of acute graft-versus-host disease (aGVHD). We previously reported that circulating AREG is elevated in late-onset aGVHD (occurring after 100 days posttransplant), but its clinical relevance in the context of aGVHD risk is unknown. We measured AREG in 251 aGVHD onset blood samples from Blood and Marrow Clinical Trials Network (BMT CTN) primary treatment trials and determined their association with GVHD severity, day 28 complete or partial response (CR/PR) to first-line therapy, overall survival (OS), and nonrelapse mortality (NRM). Every doubling of plasma AREG was associated with a 33% decrease in the odds of day 28 CR/PR (odds ratio [OR], 0.67; P < .01). An AREG threshold of 33 pg/mL or greater divided patients with Minnesota standard-risk (SR) aGVHD into a distinct group with a significantly lower likelihood of: day 28 CR/PR (72% vs 85%; P = .02); greater 2-year NRM (42% vs 15%; P < .01); and inferior OS (40% vs 66%; P < .01). High AREG ≥ 33 pg/mL also stratified patients with Minnesota high-risk (HR) aGVHD: day 28 CR/PR (54% vs 83%; P = .03) and 2-year NRM (53% vs 11%; P < .01), with a trend toward inferior 2-year OS (37% vs 60%; P = .09). High-circulating AREG (≥33 pg/mL) reclassifies patients into HR subgroups and thereby further refines the Minnesota aGVHD clinical risk score.
Collapse
Affiliation(s)
- Shernan G Holtan
- Hematology, Oncology and Transplant, University of Minnesota, Minneapolis, MN
| | - Todd E DeFor
- Hematology, Oncology and Transplant, University of Minnesota, Minneapolis, MN
| | | | | | - John E Levine
- Blood and Marrow Transplantation Program, The Icahn School of Medicine at Mount Sinai, New York, NY
| | - Mary E D Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Stephanie J Lee
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Yoshihiro Inamoto
- Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - George L Chen
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, NY
| | - Sebastian Mayer
- Department of Medicine, Weill Cornell Medical Center, New York, NY
| | - Mukta Arora
- Hematology, Oncology and Transplant, University of Minnesota, Minneapolis, MN
| | | | - Corey S Cutler
- Hematologic Malignancies, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Sally Arai
- Division of Blood and Marrow Transplantation, Stanford University Medical Center, Stanford, CA
| | - Aleksandr Lazaryan
- Hematology, Oncology and Transplant, University of Minnesota, Minneapolis, MN
| | - Laura F Newell
- Center for Hematologic Malignancies, Oregon Health and Science University, Portland, OR
| | - Madan H Jagasia
- Division of Hematology/Oncology, Stem Cell Transplantation, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Iskra Pusic
- Medical Oncology, Washington University Medical Center, St. Louis, MO
| | - William A Wood
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | - Anne S Renteria
- Blood and Marrow Transplantation Program, The Icahn School of Medicine at Mount Sinai, New York, NY
| | - Gregory Yanik
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, MI
| | - William J Hogan
- Blood and Marrow Transplantation Program, Mayo Clinic, Rochester, MN
| | - Elizabeth Hexner
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Center, Hamburg-Eppendorf, Germany
| | - Ernst Holler
- Blood and Marrow Transplantation Program, University of Regensburg, Regensburg, Germany
| | - Udomsak Bunworasate
- Blood and Marrow Transplantation Program, Chulalongkorn University, Bangkok, Thailand
| | - Yvonne A Efebera
- Blood and Marrow Transplantation Program, The Ohio State University, Columbus, OH
| | - James L M Ferrara
- Blood and Marrow Transplantation Program, The Icahn School of Medicine at Mount Sinai, New York, NY
| | - Joseph Pidala
- Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Alan Howard
- National Marrow Donor Program, Minneapolis, MN
| | - Juan Wu
- The EMMES Corporation, Rockville, MD
| | - Javier Bolaños-Meade
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD; and
| | - Vincent Ho
- Division of Blood and Marrow Transplantation, Stanford University Medical Center, Stanford, CA
| | | | - Bruce R Blazar
- Hematology, Oncology and Transplant, University of Minnesota, Minneapolis, MN
| | - Daniel J Weisdorf
- Hematology, Oncology and Transplant, University of Minnesota, Minneapolis, MN
| | | |
Collapse
|
23
|
He FC, Holtan SG. Biomarkers in Graft-Versus-Host Disease: from Prediction and Diagnosis to Insights into Complex Graft/Host Interactions. Curr Hematol Malig Rep 2018; 13:44-52. [DOI: 10.1007/s11899-018-0433-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
|
24
|
Naymagon S, Naymagon L, Wong SY, Ko HM, Renteria A, Levine J, Colombel JF, Ferrara J. Acute graft-versus-host disease of the gut: considerations for the gastroenterologist. Nat Rev Gastroenterol Hepatol 2017; 14:711-726. [PMID: 28951581 PMCID: PMC6240460 DOI: 10.1038/nrgastro.2017.126] [Citation(s) in RCA: 98] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Haematopoietic stem cell transplantation (HSCT) is central to the management of many haematological disorders. A frequent complication of HSCT is acute graft-versus-host disease (GVHD), a condition in which immune cells from the donor attack healthy recipient tissues. The gastrointestinal system is among the most common sites affected by acute GVHD, and severe manifestations of acute GVHD of the gut portends a poor prognosis in patients after HSCT. Acute GVHD of the gastrointestinal tract presents both diagnostic and therapeutic challenges. Although the clinical manifestations are nonspecific and overlap with those of infection and drug toxicity, diagnosis is ultimately based on clinical criteria. As reliable serum biomarkers have not yet been validated outside of clinical trials, endoscopic and histopathological evaluation continue to be utilized in diagnosis. Once a diagnosis of gastrointestinal acute GVHD is established, therapy with systemic corticosteroids is typically initiated, and non-responders can be treated with a wide range of second-line therapies. In addition to treating the underlying disease, the management of complications including profuse diarrhoea, severe malnutrition and gastrointestinal bleeding is paramount. In this Review, we discuss strategies for the diagnosis and management of acute GVHD of the gastrointestinal tract as they pertain to the practising gastroenterologist.
Collapse
Affiliation(s)
- Steven Naymagon
- Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai
| | - Leonard Naymagon
- Division of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai
| | - Serre-Yu Wong
- Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai
| | - Huaibin Mabel Ko
- Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai.,Lillian and Henry M. Stratton-Hans Popper Department of Pathology and Laboratory Medicine, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, New York, New York 10029, USA
| | - Anne Renteria
- Division of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai
| | - John Levine
- Division of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai
| | | | - James Ferrara
- Division of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai
| |
Collapse
|
25
|
Crossland RE, Norden J, Kralj Juric M, Pearce KF, Lendrem C, Bibby LA, Collin M, Greinix HT, Dickinson AM. Serum and Extracellular Vesicle MicroRNAs miR-423, miR-199, and miR-93* As Biomarkers for Acute Graft-versus-Host Disease. Front Immunol 2017; 8:1446. [PMID: 29176973 PMCID: PMC5686047 DOI: 10.3389/fimmu.2017.01446] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 10/17/2017] [Indexed: 02/06/2023] Open
Abstract
Acute graft-versus-host disease (aGvHD) is a major cause of adverse outcome in hematopoietic stem cell transplantation (HSCT), with a high incidence (20–50%). A novel, non-invasive diagnostic test to predict for prevalence and severity would enable improved prophylaxis and reduce morbidity. Circulatory microRNAs (miRNAs) miR-423, miR-199, miR-93*, and miR-377 have previously been associated with aGvHD in post-HSCT patient plasma, but validation is lacking and their expression within extracellular vesicles (EVs) has not been explored. This study replicated elevated serum expression of miR-423 (p < 0.001), miR-199 (p = 0.04), miR-93* (p < 0.001), and miR-377 (p = 0.03) in aGvHD, using a prognostic cohort of day 14 (D14) post-HSCT patient samples (n = 81). Expression also associated with disease severity. Further analysis at aGvHD diagnosis in an independent cohort (n = 65) confirmed high miR-423 (p = 0.02), miR-199 (p = 0.007), and miR-93* (p = 0.004) expression at disease onset. Investigation of expression patterns during early HSCT sequential timepoints (pre-HSCT to D28) identified elevated miRNAs at D7 post-HSCT in all transplant patients. In a novel investigation of miRNA expression in serum EVs (n = 15), miR-423 (p = 0.09), miR-199 (p = 0.008), and miR-93* (p = 0.001) levels were lower at D14 in patients who later developed aGvHD, and this was replicated for miR-423 (p = 0.02) and miR-199 (p = 0.04) (n = 47). Comparing serum to circulating EVs, at D14 patients remaining aGvHD-free had higher expression of miR-423 (p = 0.03), miR-199 (p = 0.009), and miR-93* (p = 0.002) in the EV fraction. Results verify the capacity for circulating miR-423, miR-199, and miR-93* as diagnostic and prognostic aGvHD biomarkers. The novel finding of their differential expression in EVs suggests a potential role in aGvHD etiology.
Collapse
Affiliation(s)
- Rachel E Crossland
- Medical School, Institute for Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Jean Norden
- Medical School, Institute for Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Mateja Kralj Juric
- Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Kim F Pearce
- Medical School, Institute for Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Clare Lendrem
- Medical School, Institute for Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Louis A Bibby
- Medical School, Institute for Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Matthew Collin
- Medical School, Institute for Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | | | - Anne M Dickinson
- Medical School, Institute for Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| |
Collapse
|
26
|
Turcotte LM, DeFor TE, Newell LF, Cutler CS, Verneris MR, Wu J, Howard A, MacMillan ML, Antin JH, Vercellotti GM, Slungaard A, Blazar BR, Weisdorf DJ, Panoskaltsis-Mortari A, Holtan SG. Donor and recipient plasma follistatin levels are associated with acute GvHD in Blood and Marrow Transplant Clinical Trials Network 0402. Bone Marrow Transplant 2017; 53:64-68. [PMID: 29058696 PMCID: PMC5752567 DOI: 10.1038/bmt.2017.236] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 08/25/2017] [Accepted: 09/13/2017] [Indexed: 12/13/2022]
Abstract
Follistatin is an angiogenic factor elevated in the circulation after
allogeneic hematopoietic cell transplantation (HCT). Elevations in follistatin
plasma concentrations are associated with the onset of and poor survival after
acute graft versus host disease (aGVHD). Using data from the Blood and Marrow
Transplant Clinical Trials Network 0402 study (n=247), we sought to
further quantify the longitudinal associations between plasma follistatin levels
in transplant recipients, as well as baseline HCT donor follistatin levels, and
allogeneic HCT outcomes. Higher recipient baseline follistatin levels were
predictive of development of aGVHD (P=0.04). High donor
follistatin levels were also associated with the incidence of aGVHD
(P<0.01). Elevated follistatin levels on day 28 were
associated with the onset of grade II–IV aGVHD prior to day 28, higher
one-year non-relapse mortality, (NRM), and lower overall survival (OS). In
multivariate analyses, individuals with follistatin levels >1088 pg/mL at day
28 had a four-fold increased risk for NRM (RR=4.3, 95% CI
1.9–9.9, P<0.01) and a nearly three-fold increased
overall risk for mortality (RR=2.8, 95% CI 1.5–5.2,
P<0.01). Given the multiple roles of follistatin in
tissue inflammation and repair, and the confirmation that this biomarker is
predictive of important HCT outcomes, the pathobiology of these relationships
need further study.
Collapse
Affiliation(s)
- L M Turcotte
- Division of Pediatric Hematology/Oncology, University of Minnesota, Minneapolis, MN, USA
| | - T E DeFor
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, MN, USA.,Biostatistics Core, Masonic Cancer Center, University of Minnesota, Minneapolis, MN, USA
| | - L F Newell
- Center for Hematologic Malignancies, Oregon Health & Science University, Portland, OR, USA
| | - C S Cutler
- Hematologic Malignancy Program, Dana Farber Cancer Institute, Boston, MA, USA
| | - M R Verneris
- Pediatric BMT and Cell Therapy, University of Colorado Anschutz Medical Campus and Children's Hospital, Denver, CO, USA
| | - J Wu
- The EMMES Corporation, Rockville, MD, USA
| | - A Howard
- Center for International Blood and Marrow Transplant Research, Minneapolis, MN, USA
| | - M L MacMillan
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, MN, USA
| | - J H Antin
- Hematologic Malignancy Program, Dana Farber Cancer Institute, Boston, MA, USA
| | - G M Vercellotti
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, MN, USA
| | - Ane Slungaard
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, MN, USA
| | - B R Blazar
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, MN, USA
| | - D J Weisdorf
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, MN, USA
| | | | - S G Holtan
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, MN, USA
| |
Collapse
|
27
|
Almici C, Skert C, Bruno B, Bianchetti A, Verardi R, Di Palma A, Neva A, Braga S, Piccinelli G, Piovani G, Malagola M, Bernardi S, Giaccone L, Brunello L, Festuccia M, Baeten K, Russo D, Marini M. Circulating endothelial cell count: a reliable marker of endothelial damage in patients undergoing hematopoietic stem cell transplantation. Bone Marrow Transplant 2017; 52:1637-1642. [PMID: 28892085 DOI: 10.1038/bmt.2017.194] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 08/01/2017] [Accepted: 08/01/2017] [Indexed: 12/12/2022]
Abstract
The physio-pathologic interrelationships between endothelium and GvHD have been better elucidated and have led to definition of the entity 'endothelial GvHD' as an essential early phase prior to the clinical presentation of acute GvHD. Using the CellSearch system, we analyzed circulating endothelial cells (CEC) in 90 allogeneic hematopoietic stem cell transplantation (allo-HSCT) patients at the following time-points: T1 (pre-conditioning), T2 (pre-transplant), T3 (engraftment), T4 (onset of GvHD) and T5 (1 week after steroid treatment). Although CEC changes in allo-HSCT represent a dynamic phenomenon influenced by many variables (that is, conditioning, immunosuppressive treatments, engraftment syndrome and infections), we showed that CEC peaks were constantly seen at onset of acute GvHD and invariably returned to pre-transplant values after treatment response. Since we showed that CEC changes during allo-HSCT has rapid kinetics that may be easily missed if blood samples are drawn at pre-fixed time-points, we rather suggest an 'on demand' evaluation of CEC counts right at onset of GvHD clinical symptoms to possibly help differentiate GvHD from other non-endothelial complications. We confirm that CEC changes are a suitable biomarker to monitor endothelial damage in patients undergoing allo-transplantation and hold the potential to become a useful tool to support GvHD diagnosis (ClinicalTrials.gov NCT02064972).
Collapse
Affiliation(s)
- C Almici
- Department of Trasfusion Medicine, Laboratory for Stem Cells Manipulation and Cryopreservation, ASST Spedali Civili, Brescia, Italy
| | - C Skert
- Chair of Hematology, Unit of Blood Diseases and Stem Cell Transplantation, University of Brescia, ASST Spedali Civili, Brescia, Italy
| | - B Bruno
- BMT Unit, Department of Oncology, AOU Città della Salute e della Scienza di Torino, Torino, Italy
| | - A Bianchetti
- Department of Trasfusion Medicine, Laboratory for Stem Cells Manipulation and Cryopreservation, ASST Spedali Civili, Brescia, Italy
| | - R Verardi
- Department of Trasfusion Medicine, Laboratory for Stem Cells Manipulation and Cryopreservation, ASST Spedali Civili, Brescia, Italy
| | - A Di Palma
- Chair of Hematology, Unit of Blood Diseases and Stem Cell Transplantation, University of Brescia, ASST Spedali Civili, Brescia, Italy
| | - A Neva
- Department of Trasfusion Medicine, Laboratory for Stem Cells Manipulation and Cryopreservation, ASST Spedali Civili, Brescia, Italy
| | - S Braga
- Department of Trasfusion Medicine, Laboratory for Stem Cells Manipulation and Cryopreservation, ASST Spedali Civili, Brescia, Italy
| | - G Piccinelli
- Department of Transfusion Medicine, ASST Spedali Civili, Brescia, Italy
| | - G Piovani
- Biology and Genetics Division, Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - M Malagola
- Chair of Hematology, Unit of Blood Diseases and Stem Cell Transplantation, University of Brescia, ASST Spedali Civili, Brescia, Italy
| | - S Bernardi
- Chair of Hematology, Unit of Blood Diseases and Stem Cell Transplantation, University of Brescia, ASST Spedali Civili, Brescia, Italy
| | - L Giaccone
- BMT Unit, Department of Oncology, AOU Città della Salute e della Scienza di Torino, Torino, Italy
| | - L Brunello
- BMT Unit, Department of Oncology, AOU Città della Salute e della Scienza di Torino, Torino, Italy
| | - M Festuccia
- BMT Unit, Department of Oncology, AOU Città della Salute e della Scienza di Torino, Torino, Italy
| | - K Baeten
- Global Scientific and Medical Affairs, Janssen Diagnostics, Beerse, Belgium
| | - D Russo
- Chair of Hematology, Unit of Blood Diseases and Stem Cell Transplantation, University of Brescia, ASST Spedali Civili, Brescia, Italy
| | - M Marini
- Department of Transfusion Medicine, ASST Spedali Civili, Brescia, Italy
| |
Collapse
|
28
|
Newell LF, Holtan SG, Yates JE, Pereira L, Tyner JW, Burd I, Bagby GC. PlGF enhances TLR-dependent inflammatory responses in human mononuclear phagocytes. Am J Reprod Immunol 2017. [PMID: 28635072 DOI: 10.1111/aji.12709] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
PROBLEM Levels of placental growth factor (PlGF) peak during third trimester of pregnancy, a time when women are at increased risk of virus-induced morbidity. We hypothesized PlGF might contribute to an exaggerated inflammatory response to Toll-like receptor (TLR) activation. METHOD OF STUDY Primary human adult and cord blood CD14+ cells were cultured in the presence of TLR ligands and/or PlGF. RESULTS PlGF significantly enhanced the magnitude and duration of TNF messenger RNA and protein production by TLR-7/8-activated monocytes, and increased subsequent production of TNF-independent inflammatory cytokines. This PlGF/TLR effect involved multiple inflammatory cytokines/chemokines and was seen with the majority of TLR agonists. PlGF enhanced phosphorylation of IkappaB kinase (IKK) in monocytes stimulated with the TLR-7/8 agonist R848, and IKK inhibition completely suppressed the PlGF effect. CONCLUSION PlGF enhances TLR-signaling upstream of IKK and contributes to an exaggerated pathologic pro-inflammatory state in response to activation of maternal and fetal mononuclear phagocytes by specific TLR agonists.
Collapse
Affiliation(s)
- Laura F Newell
- Hematology and Medical Oncology, Oregon Health & Science University, Knight Cancer Institute, Portland, OR, USA
| | - Shernan G Holtan
- Division of Hematology, Oncology and Transplant, University of Minnesota, Minneapolis, MN, USA
| | - Jane E Yates
- Northwest Veterans Affairs Cancer Research Center, Portland, OR, USA
| | - Leonardo Pereira
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR, USA
| | - Jeffrey W Tyner
- Hematology and Medical Oncology, Oregon Health & Science University, Knight Cancer Institute, Portland, OR, USA.,Department of Cell, Development, and Cancer Biology, Oregon Health & Science University, Portland, OR, USA
| | - Irina Burd
- Department of Gynecology and Obstetrics, Integrated Research Center for Fetal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Grover C Bagby
- Hematology and Medical Oncology, Oregon Health & Science University, Knight Cancer Institute, Portland, OR, USA.,Northwest Veterans Affairs Cancer Research Center, Portland, OR, USA
| |
Collapse
|
29
|
Low EGF in myeloablative allotransplantation: association with severe acute GvHD in BMT CTN 0402. Bone Marrow Transplant 2017; 52:1300-1303. [PMID: 28581470 DOI: 10.1038/bmt.2017.89] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 04/05/2017] [Accepted: 04/07/2017] [Indexed: 01/14/2023]
Abstract
Epidermal growth factor (EGF) is a recently described biomarker of acute GvHD (aGvHD). Whether low plasma EGF prior to hematopoietic cell transplantation (HCT) predisposes to the development of aGvHD, or whether EGF levels fall because of severe aGvHD, is unknown. To evaluate this, we tested plasma samples collected at pre-HCT baseline, day +28 and day +100 during the course of the Blood and Marrow Transplant Clinical Trials Network (BMT CTN) 0402. We found that baseline EGF plasma concentrations were three-fold lower in HCT recipients compared to donors (24.3 vs 76.0 pg/mL, P<0.01). Ninety-one patients (43%) had a markedly low plasma EGF at pre-HCT baseline, defined as <2.7 pg/mL-an optimal cutpoint associated with development of grade III-IV aGvHD. Patients with these low EGF levels at pre-HCT baseline had a 2.9-fold increased risk of grade III-IV aGvHD by day +100. Patients with low EGF at day +28 after HCT had an increased risk of death (relative risk 2.3, P=0.02) by 1 year due to transplant-related toxicities, especially aGvHD. Our results suggest that very low plasma EGF early in the HCT process may predispose patients to an increased risk of death, potentially due to epithelial damage and limited repair capacity.
Collapse
|
30
|
McDonald GB, Tabellini L, Storer BE, Martin PJ, Lawler RL, Rosinski SL, Schoch HG, Hansen JA. Predictive Value of Clinical Findings and Plasma Biomarkers after Fourteen Days of Prednisone Treatment for Acute Graft-versus-host Disease. Biol Blood Marrow Transplant 2017; 23:1257-1263. [PMID: 28478120 DOI: 10.1016/j.bbmt.2017.04.029] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Accepted: 04/29/2017] [Indexed: 11/30/2022]
Abstract
We examined the hypothesis that plasma biomarkers and concomitant clinical findings after initial glucocorticoid therapy can accurately predict failure of graft-versus-host-disease (GVHD) treatment and mortality. We analyzed plasma samples and clinical data in 165 patients after 14 days of glucocorticoid therapy and used logistic regression and areas under receiver-operating characteristic curves (AUC) to evaluate associations with treatment failure and nonrelapse mortality (NRM). Initial treatment of GVHD was unsuccessful in 49 patients (30%). For predicting GVHD treatment failure, the best clinical combination (total serum bilirubin and skin GVHD stage: AUC, .70) was competitive with the best biomarker combination (T cell immunoglobulin and mucin domain 3 [TIM3] and [interleukin 1 receptor family encoded by the IL1RL1 gene, ST2]: AUC, .73). The combination of clinical features and biomarker results offered only a slight improvement (AUC, .75). For predicting NRM at 1 year, the best clinical predictor (total serum bilirubin: AUC, .81) was competitive with the best biomarker combination (TIM3 and soluble tumor necrosis factor receptor-1 [sTNFR1]: AUC, .85). The combination offered no improvement (AUC, .85). Infection was the proximate cause of death in virtually all patients. We conclude that after 14 days of glucocorticoid therapy, clinical findings (serum bilirubin, skin GVHD) and plasma biomarkers (TIM3, ST2, sTNFR1) can predict failure of GVHD treatment and NRM. These biomarkers reflect counter-regulatory mechanisms and provide insight into the pathophysiology of GVHD reactions after glucocorticoid treatment. The best predictive models, however, exhibit inadequate positive predictive values for identifying high-risk GVHD cohorts for investigational trials, as only a minority of patients with high-risk GVHD would be identified and most patients would be falsely predicted to have adverse outcomes.
Collapse
Affiliation(s)
- George B McDonald
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Laura Tabellini
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Barry E Storer
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Biostatistics, University of Washington School of Medicine, Seattle, Washington
| | - Paul J Martin
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Richard L Lawler
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Steven L Rosinski
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - H Gary Schoch
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - John A Hansen
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| |
Collapse
|
31
|
Ghimire S, Weber D, Mavin E, Wang XN, Dickinson AM, Holler E. Pathophysiology of GvHD and Other HSCT-Related Major Complications. Front Immunol 2017; 8:79. [PMID: 28373870 PMCID: PMC5357769 DOI: 10.3389/fimmu.2017.00079] [Citation(s) in RCA: 144] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Accepted: 01/17/2017] [Indexed: 12/13/2022] Open
Abstract
For over 60 years, hematopoietic stem cell transplantation has been the major curative therapy for several hematological and genetic disorders, but its efficacy is limited by the secondary disease called graft versus host disease (GvHD). Huge advances have been made in successful transplantation in order to improve patient quality of life, and yet, complete success is hard to achieve. This review assimilates recent updates on pathophysiology of GvHD, prophylaxis and treatment of GvHD-related complications, and advances in the potential treatment of GvHD.
Collapse
Affiliation(s)
- Sakhila Ghimire
- Department of Internal Medicine III, University Medical Centre , Regensburg , Germany
| | - Daniela Weber
- Department of Internal Medicine III, University Medical Centre , Regensburg , Germany
| | - Emily Mavin
- Hematological Sciences, Institute of Cellular Medicine, Newcastle University , Newcastle , UK
| | - Xiao Nong Wang
- Hematological Sciences, Institute of Cellular Medicine, Newcastle University , Newcastle , UK
| | - Anne Mary Dickinson
- Hematological Sciences, Institute of Cellular Medicine, Newcastle University , Newcastle , UK
| | - Ernst Holler
- Department of Internal Medicine III, University Medical Centre , Regensburg , Germany
| |
Collapse
|
32
|
Kanakry CG, Bakoyannis G, Perkins SM, McCurdy SR, Vulic A, Warren EH, Daguindau E, Olmsted T, Mumaw C, Towlerton AMH, Cooke KR, O'Donnell PV, Symons HJ, Paczesny S, Luznik L. Plasma-derived proteomic biomarkers in human leukocyte antigen-haploidentical or human leukocyte antigen-matched bone marrow transplantation using post-transplantation cyclophosphamide. Haematologica 2017; 102:932-940. [PMID: 28126963 PMCID: PMC5477612 DOI: 10.3324/haematol.2016.152322] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 01/20/2017] [Indexed: 01/13/2023] Open
Abstract
Recent studies have suggested that plasma-derived proteins may be potential biomarkers relevant for graft-versus-host disease and/or non-relapse mortality occurring after allogeneic blood or marrow transplantation. However, none of these putative biomarkers have been assessed in patients treated either with human leukocyte antigen-haploidentical blood or marrow transplantation or with post-transplantation cyclophosphamide, which has been repeatedly associated with low rates of severe acute graft-versus-host disease, chronic graft-versus-host disease, and non-relapse mortality. We explored whether seven of these plasma-derived proteins, as measured by enzyme-linked immunosorbent assays, were predictive of clinical outcomes in post-transplantation cyclophosphamide-treated patients using plasma samples collected at serial predetermined timepoints from patients treated on prospective clinical studies of human leukocyte antigen-haploidentical (n=58; clinicaltrials.gov Identifier: 00796562) or human leukocyte antigen-matched-related or -unrelated (n=100; clinicaltrials.gov Identifiers: 00134017 and 00809276) T-cell-replete bone marrow transplantation. Day 30 levels of interleukin-2 receptor α, tumor necrosis factor receptor 1, serum STimulation-2 (IL1RL1 gene product), and regenerating islet-derived 3-α all had high areas under the curve of 0.74–0.97 for predicting non-relapse mortality occurrence by 3 months post-transplant in both the human leukocyte antigen-matched and human leukocyte antigen-haploidentical cohorts. In both cohorts, all four of these proteins were also predictive of subsequent non-relapse mortality occurring by 6, 9, or 12 months post-transplant and were significantly associated with non-relapse mortality in univariable analyses. Furthermore, day 30 elevations of interleukin-2 receptor α were associated with grade II–IV and III–IV acute graft-versus-host disease occurring after day 30 in both cohorts. These data confirm that plasma-derived proteins previously assessed in other transplantation platforms appear to retain prognostic and predictive utility in patients treated with post-transplantation cyclophosphamide.
Collapse
Affiliation(s)
- Christopher G Kanakry
- Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Giorgos Bakoyannis
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN
| | - Susan M Perkins
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN
| | - Shannon R McCurdy
- Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ante Vulic
- Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Edus H Warren
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Etienne Daguindau
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN.,Department of Immunology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Taylor Olmsted
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN.,Department of Immunology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Christen Mumaw
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN.,Department of Immunology, Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Kenneth R Cooke
- Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Paul V O'Donnell
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Heather J Symons
- Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sophie Paczesny
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN .,Department of Immunology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Leo Luznik
- Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University School of Medicine, Baltimore, MD
| |
Collapse
|
33
|
Initiation of acute graft-versus-host disease by angiogenesis. Blood 2017; 129:2021-2032. [PMID: 28096092 DOI: 10.1182/blood-2016-08-736314] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 01/08/2017] [Indexed: 01/06/2023] Open
Abstract
The inhibition of inflammation-associated angiogenesis ameliorates inflammatory diseases by reducing the recruitment of tissue-infiltrating leukocytes. However, it is not known if angiogenesis has an active role during the initiation of inflammation or if it is merely a secondary effect occurring in response to stimuli by tissue-infiltrating leukocytes. Here, we show that angiogenesis precedes leukocyte infiltration in experimental models of inflammatory bowel disease and acute graft-versus-host disease (GVHD). We found that angiogenesis occurred as early as day+2 after allogeneic transplantation mainly in GVHD typical target organs skin, liver, and intestines, whereas no angiogenic changes appeared due to conditioning or syngeneic transplantation. The initiation phase of angiogenesis was not associated with classical endothelial cell (EC) activation signs, such as Vegfa/VEGFR1+2 upregulation or increased adhesion molecule expression. During early GVHD at day+2, we found significant metabolic and cytoskeleton changes in target organ ECs in gene array and proteomic analyses. These modifications have significant functional consequences as indicated by profoundly higher deformation in real-time deformability cytometry. Our results demonstrate that metabolic changes trigger alterations in cell mechanics, leading to enhanced migratory and proliferative potential of ECs during the initiation of inflammation. Our study adds evidence to the hypothesis that angiogenesis is involved in the initiation of tissue inflammation during GVHD.
Collapse
|
34
|
Profile of Inflammation-Associated Proteins in Early Post-Transplant Samples of Patients After Allogeneic Hematopoietic Stem Cell Transplantation: a Preliminary Study. Arch Immunol Ther Exp (Warsz) 2017; 64:55-61. [DOI: 10.1007/s00005-016-0446-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 12/01/2016] [Indexed: 01/19/2023]
|
35
|
Newell LF, Holtan SG. Placental growth factor: What hematologists need to know. Blood Rev 2017; 31:57-62. [PMID: 27608972 PMCID: PMC5916812 DOI: 10.1016/j.blre.2016.08.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 08/19/2016] [Accepted: 08/23/2016] [Indexed: 12/16/2022]
Abstract
Although first identified in placenta, the angiogenic factor known as placental growth factor (PlGF) can be widely expressed in ischemic or damaged tissues. Recent studies have indicated that PlGF is a relevant factor in the pathobiology of blood diseases including hemoglobinopathies and hematologic malignancies. Therapies for such blood diseases may one day be based upon these and ongoing investigations into the role of PlGF in sickle cell disease, acute and chronic leukemias, and complications related to hematopoietic cell transplantation. In this review, we summarize recent studies regarding the potential role of PlGF in blood disorders and suggest avenues for future research.
Collapse
Affiliation(s)
- Laura F Newell
- Oregon Health and Science University, Center for Hematologic Malignancies, Portland, OR, USA.
| | - Shernan G Holtan
- University of Minnesota, Blood and Marrow Transplant Program, Minneapolis, MN, USA.
| |
Collapse
|
36
|
Politikos I, T Kim H, Karantanos T, Brown J, McDonough S, Li L, Cutler C, Antin JH, Ballen KK, Ritz J, Boussiotis VA. Angiogenic Factors Correlate with T Cell Immune Reconstitution and Clinical Outcomes after Double-Unit Umbilical Cord Blood Transplantation in Adults. Biol Blood Marrow Transplant 2017; 23:103-112. [PMID: 27777141 PMCID: PMC5489056 DOI: 10.1016/j.bbmt.2016.10.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 10/15/2016] [Indexed: 11/18/2022]
Abstract
Umbilical cord blood (UCB) is a valuable graft source for allogeneic hematopoietic stem cell transplantation (HSCT) in patients who lack adult donors. UCB transplantation (UCBT) in adults results in delayed immune reconstitution, leading to high infection-related morbidity and mortality. Angiogenic factors and markers of endothelial dysfunction have biologic and prognostic significance in conventional HSCT, but their role in UCBT has not been investigated. Furthermore, the interplay between angiogenesis and immune reconstitution has not been studied. Here we examined whether angiogenic cytokines, angiopoietin-1 (ANG-1) and vascular endothelial growth factor (VEGF), or markers of endothelial injury, thrombomodulin (TM) and angiopoietin-2 (ANG-2), associate with thymic regeneration as determined by T cell receptor excision circle (TREC) values and recovery of T cell subsets, as well as clinical outcomes in adult recipients of UCBT. We found that plasma levels of ANG-1 significantly correlated with the reconstitution of naive CD4+CD45RA+ and CD8+CD45RA+ T cell subsets, whereas plasma levels of VEGF displayed a positive correlation with CD4+CD45RO+ T cells and regulatory T cells and a weak correlation with TRECs. Assessment of TM and ANG-2 revealed a strong inverse correlation of both factors with naive T cells and TRECs. The angiogenic capacity of each patient's plasma, as determined by an in vitro angiogenesis assay, positively correlated with VEGF levels and with reconstitution of CD4+ T cell subsets. Higher VEGF levels were associated with worse progression-free survival and higher risk of relapse, whereas higher levels of TM were associated with chronic graft-versus-host disease and nonrelapse mortality. Thus, angiogenic factors may serve as valuable markers associated with T cell reconstitution and clinical outcomes after UCBT.
Collapse
Affiliation(s)
- Ioannis Politikos
- Hematology-Oncology and Cancer Biology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Haesook T Kim
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Theodoros Karantanos
- Hematology-Oncology and Cancer Biology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Julia Brown
- Hematology-Oncology and Cancer Biology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Sean McDonough
- Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Lequn Li
- Hematology-Oncology and Cancer Biology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Corey Cutler
- Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Joseph H Antin
- Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Karen K Ballen
- Bone Marrow Transplant Unit, Massachusetts General Hospital, Boston, Massachusetts
| | - Jerome Ritz
- Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Vassiliki A Boussiotis
- Hematology-Oncology and Cancer Biology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
| |
Collapse
|
37
|
Mohammadi Najafabadi M, Shamsasenjan K, Akbarzadehalaleh P. Angiogenesis Status in Patients with Acute Myeloid Leukemia: From Diagnosis to Post-hematopoietic Stem Cell Transplantation. Int J Organ Transplant Med 2017; 8:57-67. [PMID: 28828165 PMCID: PMC5549002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
As already proven in solid tumors, increased angiogenesis leads to increased number of blood vessels, resulting in unfavorable outcomes and resistance to chemotherapy. It was previously thought that angiogenesis plays no role in the pathogenesis of acute myeloid leukemia (AML), due to the fact that AML is a liquid tumor. However, many studies have suggested that increased angiogenesis has important roles in patients with AML, including increased numbers of vessels in bone marrow and pro-angiogenic factors, as well as decreased anti-angiogenic factors. Also a large number of studies demonstrated that a two-way communication is established between leukemic and endothelial cells, as a component of the vessel wall, in the bone marrow of patients with AML. These two cells support the survival and proliferation of each other through a paracrine pathway, resulting in resistance to chemotherapy. In addition, It is well-established that increased angiogenesis is associated with unfavorable prognosis, lower survival rate, resistance to chemotherapy, and relapse. Furthermore, increased angiogenesis affects the response to treatment, hematopoietic stem cell transplantation (HSCT) outcome and graft versus host disease (GVHD) occurrence. In this regard, this review will address vascular endothelial growth factor (VEGF) and angiopoietin (Ang), two of the most important angiogenic factors, in patients with AML before and after HSCT. By increasing our understanding of the role of endothelial cells and angiogenic factors in patients with AML from diagnosis to post-HSCT, new therapeutic strategies can be developed to reduce angiogenesis, improve patients' survival and reduce complications.
Collapse
Affiliation(s)
| | - K. Shamsasenjan
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran,Correspondence: Karim Shamsasenjan, PhD of Hematology and Blood Banking. Assistant Professor of Hematology Department, Medicine Faculty, Tabriz University of Medical Sciences, PO Box: 51335, Tabriz, Iran, Tel: +98-411-287-1515, Fax: +98-411-287-1515, E-mail:
| | - P. Akbarzadehalaleh
- Department of Pharmaceutical Biotechnology, Faculty of Pharmacy, Tabriz University of Medical Sciences, Tabriz, Iran
| |
Collapse
|
38
|
Ali AM, DiPersio JF, Schroeder MA. A proposed biology- and biomarker-based algorithm for management of acute GvHD. Bone Marrow Transplant 2016; 52:337-340. [PMID: 27869807 DOI: 10.1038/bmt.2016.289] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- A M Ali
- Bone Marrow Transplantation and Leukemia Section, Division of Oncology, Washington University School of Medicine, St Louis, MO, USA
| | - J F DiPersio
- Bone Marrow Transplantation and Leukemia Section, Division of Oncology, Washington University School of Medicine, St Louis, MO, USA
| | - M A Schroeder
- Bone Marrow Transplantation and Leukemia Section, Division of Oncology, Washington University School of Medicine, St Louis, MO, USA
| |
Collapse
|
39
|
He F, Verneris MR, Cooley S, Blazar BR, MacMillan ML, Newell LF, Panoskaltsis-Mortari A, DeFor T, Weisdorf DJ, Holtan SG. Low day +100 serum epidermal growth factor levels are associated with acute GvHD after allogeneic hematopoietic cell transplantation. Bone Marrow Transplant 2016; 52:301-303. [PMID: 27869812 DOI: 10.1038/bmt.2016.261] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- F He
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - M R Verneris
- Blood and Marrow Transplant Program, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - S Cooley
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - B R Blazar
- Blood and Marrow Transplant Program, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - M L MacMillan
- Blood and Marrow Transplant Program, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - L F Newell
- Center for Hematologic Malignancies, Oregon Health and Science University, Portland, OR, USA
| | - A Panoskaltsis-Mortari
- Blood and Marrow Transplant Program, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - T DeFor
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - D J Weisdorf
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - S G Holtan
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| |
Collapse
|
40
|
|
41
|
Steering Committee Of The Blood And Marrow Transplant Clinical Trials Network. The Blood and Marrow Transplant Clinical Trials Network: An Effective Infrastructure for Addressing Important Issues in Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2016; 22:1747-1757. [PMID: 27418009 PMCID: PMC5027144 DOI: 10.1016/j.bbmt.2016.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 07/08/2016] [Indexed: 12/01/2022]
Abstract
Hematopoietic cell transplantation (HCT) is a rapidly evolving field with active preclinical and clinical development of new strategies for patient assessment, graft selection and manipulation, and pre- and post-transplantation drug and cell therapy. New strategies require evaluation in definitive clinical trials; however, HCT trials face unique challenges, including the relatively small number of transplantations performed at any single center, the diverse indications for HCT requiring dissimilar approaches, the complex nature of the intervention itself, the risk of multiple complications in the immediate post-transplantation period, and the risk of important, though infrequent, late effects. The Blood and Marrow Transplant Clinical Trials Network (BMT CTN) was established by the US National Heart Lung and Blood Institute and the National Cancer Institute to meet these challenges. In its 15 years as a network, the BMT CTN has proven to be a successful infrastructure for planning, implementing, and completing such trials and for providing definitive answers to questions leading to improvements in the understanding and practice of HCT. It has opened 37 trials, about one-half phase 2 and one-half phase 3, enrolled more than 8000 patients, and published 57 papers addressing important issues in the treatment of patients with life-threatening malignant and nonmalignant blood disorders. This review describes the network's accomplishments, key components of its success, lessons learned over the past 15 years, and challenges for the future.
Collapse
|
42
|
Late acute graft-versus-host disease: a prospective analysis of clinical outcomes and circulating angiogenic factors. Blood 2016; 128:2350-2358. [PMID: 27625357 DOI: 10.1182/blood-2015-09-669846] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 08/17/2016] [Indexed: 01/09/2023] Open
Abstract
Late acute (LA) graft-versus-host disease (GVHD) is persistent, recurrent, or new-onset acute GVHD symptoms occurring >100 days after allogeneic hematopoietic cell transplantation (HCT). The aim of this analysis is to describe the onset, course, morbidity, and mortality of and examine angiogenic factors associated with LA GVHD. A prospective cohort of patients (n = 909) was enrolled as part of an observational study within the Chronic GVHD Consortium. Eighty-three patients (11%) developed LA GVHD at a median of 160 (interquartile range, 128-204) days after HCT. Although 51 out of 83 (61%) achieved complete or partial response to initial therapy by 28 days, median failure-free survival was only 7.1 months (95% confidence interval, 3.4-19.1 months), and estimated overall survival (OS) at 2 years was 56%. Given recently described alterations of circulating angiogenic factors in classic acute GVHD, we examined whether alterations in such factors could be identified in LA GVHD. We first tested cases (n = 55) and controls (n = 50) from the Chronic GVHD Consortium and then validated the findings in 37 cases from Mount Sinai Acute GVHD International Consortium. Plasma amphiregulin (AREG; an epidermal growth factor [EGF] receptor ligand) was elevated, and an AREG/EGF ratio at or above the median was associated with inferior OS and increased nonrelapse mortality in both cohorts. Elevation of AREG was detected in classic acute GVHD, but not chronic GVHD. These prospective data characterize the clinical course of LA GVHD and demonstrate alterations in angiogenic factors that make LA GVHD biologically distinct from chronic GVHD.
Collapse
|
43
|
Tatekawa S, Kohno A, Ozeki K, Watamoto K, Ueda N, Yamaguchi Y, Kobayashi T, Yokota I, Teramukai S, Taniwaki M, Kuroda J, Morishita Y. A Novel Diagnostic and Prognostic Biomarker Panel for Endothelial Cell Damage-Related Complications in Allogeneic Transplantation. Biol Blood Marrow Transplant 2016; 22:1573-1581. [PMID: 27246373 DOI: 10.1016/j.bbmt.2016.05.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 05/20/2016] [Indexed: 12/28/2022]
Abstract
Noninfectious transplantation-related complications (TRCs), such as graft-versus-host disease or TRC with endothelial cell damage (TRC-EC), remain as the major obstacle for successful allogeneic hematopoietic cell transplantation (allo-HCT). However, the diagnosis and prognosis for the emergence of these complications are difficult to define during the early post allo-HCT period. Here, we tried to generate a novel diagnostic system for TRC-EC by analyzing 188 adult patients who received allo-HCT. Our study found that the peripheral blood levels of angiopoietin 2 (ANG2), C-reactive protein (CRP), D-dimer, and thrombomodulin (TM) at the onset of TRCs were significantly associated with the development of TRC-EC. We next developed a composite biomarker panel incorporating the risk values of ANG2, CRP, D-dimer, and TM at the onset of TRCs, which classified these patients into 3 risk groups: low, intermediate, and high risk. As a result, the panel was useful not only for the diagnosis of TRC-EC with high specificity and sensitivity, but also for the prediction of the patients' long-term outcome. The 5-year overall survival (OS) rates of patients in the low-, intermediate-, and high-risk groups since the occurrence from TRCs were 76.2%, 54.9%, and 26.9%, respectively, and the high-risk score was significantly associated with both poor OS (hazard ratio [HR], 5.60; 95% confidence interval [CI], 2.81 to 11.20; P < .01) and frequent nonrelapse mortality (HR, 19.75; 95% CI, 5.59 to 69.77; P < .01). Thus, the composite panel proposed in this study provides a powerful tool for the diagnosis of TRC-EC and for the prediction of survival for patients with TRC-EC after allo-HCT.
Collapse
Affiliation(s)
- Shotaro Tatekawa
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan; Division of Hematology and Oncology, JA Aichi Konan Kosei Hospital, Aichi, Japan
| | - Akio Kohno
- Division of Hematology and Oncology, JA Aichi Konan Kosei Hospital, Aichi, Japan
| | - Kazutaka Ozeki
- Division of Hematology and Oncology, JA Aichi Konan Kosei Hospital, Aichi, Japan
| | - Koichi Watamoto
- Division of Hematology and Oncology, JA Aichi Konan Kosei Hospital, Aichi, Japan; Department of Hematology, Komaki City Hospital, Aichi, Japan
| | - Norihiro Ueda
- Division of Hematology and Oncology, JA Aichi Konan Kosei Hospital, Aichi, Japan; Department of Hematology and Oncology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Yohei Yamaguchi
- Division of Hematology and Oncology, JA Aichi Konan Kosei Hospital, Aichi, Japan; Department of Hematology and Oncology, Japanese Red Cross Nagoya Daini Hospital, Aichi, Japan
| | - Tsutomu Kobayashi
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Isao Yokota
- Department of Biostatistics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Satoshi Teramukai
- Department of Biostatistics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masafumi Taniwaki
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Junya Kuroda
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan.
| | - Yoshihisa Morishita
- Division of Hematology and Oncology, JA Aichi Konan Kosei Hospital, Aichi, Japan; Department of Internal Medicine, Seirei Hospital, Nagoya, Aichi, Japan
| |
Collapse
|
44
|
Rashidi A, DiPersio JF, Sandmaier BM, Colditz GA, Weisdorf DJ. Steroids Versus Steroids Plus Additional Agent in Frontline Treatment of Acute Graft-versus-Host Disease: A Systematic Review and Meta-Analysis of Randomized Trials. Biol Blood Marrow Transplant 2016; 22:1133-1137. [PMID: 26970383 DOI: 10.1016/j.bbmt.2016.02.021] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 02/19/2016] [Indexed: 12/15/2022]
Abstract
Despite extensive research in the last few decades, progress in treatment of acute graft-versus-host disease (aGVHD), a common complication of allogeneic hematopoietic cell transplantation (HCT), has been limited and steroids continue to be the standard frontline treatment. Randomized clinical trials (RCTs) have failed to find a beneficial effect of escalating immunosuppression using additional agents. Considering the small number of RCTs, limited sample sizes, and frequent early termination because of anticipated futility, we conducted a systematic review and an aggregate data meta-analysis to explore whether a true efficacy signal has been missed because of the limitations of individual RCTs. Seven reports met our inclusion criteria. The control arm in all studies was 2 mg/kg/day prednisone (or equivalent). The additional agent(s) used in the experimental arm(s) were higher-dose steroids, antithymocyte globulin, infliximab, anti-interleukin-2 receptor antibody (daclizumab and BT563), CD5-specific immunotoxin, and mycophenolate mofetil. Random effects meta-analysis revealed no efficacy signal in pooled response rates at various times points. Overall survival at 100 days was significantly worse in the experimental arm (relative risk [RR], .83; 95% confidence interval [CI], .74 to .94; P = .004, data from 3 studies) and showed a similar trend (albeit not statistically significantly) at 1 year as well (RR, .86; 95% CI, .68 to 1.09; P = .21, data from 5 studies). In conclusion, these results argue against the value of augmented generic immunosuppression beyond steroids for frontline treatment of aGVHD and emphasize the importance of developing alternative strategies. Novel forms of immunomodulation and targeted therapies against non-immune-related pathways may enhance the efficacy of steroids in this setting, and early predictive and prognostic biomarkers can help identify the subgroup of patients who would likely need treatments other than (or in addition to) generic immunosuppression.
Collapse
Affiliation(s)
- Armin Rashidi
- Section of Bone Marrow Transplantation and Leukemia, Division of Oncology, Washington University School of Medicine, St. Louis, Missouri.
| | - John F DiPersio
- Section of Bone Marrow Transplantation and Leukemia, Division of Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Brenda M Sandmaier
- Clinical Research Division, Fred Hutchinson Cancer Research Center and University of Washington School of Medicine, Seattle, Washington
| | - Graham A Colditz
- Division of Public Health Sciences, Washington University School of Medicine, St. Louis, Missouri
| | - Daniel J Weisdorf
- The Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| |
Collapse
|
45
|
How I treat acute graft-versus-host disease of the gastrointestinal tract and the liver. Blood 2016; 127:1544-50. [PMID: 26729898 DOI: 10.1182/blood-2015-10-612747] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 12/19/2015] [Indexed: 12/15/2022] Open
Abstract
Treatment of acute graft-versus-host disease (GVHD) has evolved from a one-size-fits-all approach to a more nuanced strategy based on predicted outcomes. Lower and time-limited doses of immune suppression for patients predicted to have low-risk GVHD are safe and effective. In more severe GVHD, prolonged exposure to immunosuppressive therapies, failure to achieve tolerance, and inadequate clinical responses are the proximate causes of GVHD-related deaths. This article presents acute GVHD-related scenarios representing, respectively, certainty of diagnosis, multiple causes of symptoms, jaundice, an initial therapy algorithm, secondary therapy, and defining futility of treatment.
Collapse
|
46
|
Holtan SG, Arora M. Angiogenic factors and inflammation in steroid-refractory acute graft-vs-host disease. Transl Res 2016; 167:80-7. [PMID: 26117290 PMCID: PMC5747967 DOI: 10.1016/j.trsl.2015.06.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Revised: 05/25/2015] [Accepted: 06/01/2015] [Indexed: 01/29/2023]
Abstract
Steroid-refractory acute graft-vs-host disease (aGVHD) remains a frequent and often fatal complication of allogeneic hematopoietic cell transplantation. Recent evidence suggests that angiogenic factors-growth factors that contribute to blood vessel development-may be involved in tissue healing and restitution after inflammatory insults such as aGVHD. However, some angiogenic factors may also be involved in inflammation and worsen clinical outcomes. In this review, we summarize the data relevant to angiogenic factors that may contribute to healing after aGVHD (epidermal growth factor and vascular endothelial growth factor A) and angiogenic factors that may promote inflammation after aGVHD (placental growth factor and follistatin). It is currently unknown whether changes in these factors are a cause or a consequence of aGVHD. Mechanistic studies in the coming years will clarify their roles and identify new pathways for improving outcomes in steroid-refractory aGVHD.
Collapse
Affiliation(s)
- Shernan G Holtan
- Department of Medicine, Division of Hematology, Oncology, and Transplantation, Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minn.
| | - Mukta Arora
- Department of Medicine, Division of Hematology, Oncology, and Transplantation, Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minn
| |
Collapse
|
47
|
Holtan SG, MacMillan ML. A risk-adapted approach to acute GVHD treatment: are we there yet? Bone Marrow Transplant 2015; 51:172-5. [PMID: 26551780 DOI: 10.1038/bmt.2015.261] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 09/23/2015] [Accepted: 09/26/2015] [Indexed: 01/21/2023]
Abstract
Acute GVHD (aGVHD) is an immunologic complication of allogeneic hematopoietic cell transplantation (HCT) that can range from mild to life-threatening. Models to predict patients at risk of poor outcomes have been developed using both clinical and laboratory data, and the time to test these models in clinical trials has arrived. However, each modeling method has its potential advantages and limitations. In this mini-review, we summarize recent refinements to these models. We also suggest avenues for improving risk stratification through further studies of a patient's healing capacity and predisposition to endothelial damage, two factors that impact aGVHD outcomes but are absent from the current risk stratification models.
Collapse
Affiliation(s)
- S G Holtan
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, MN, USA.,Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - M L MacMillan
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, MN, USA.,Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| |
Collapse
|
48
|
Holtan SG, Panoskaltsis-Mortari A. Urinary-derived human chorionic gonadotropin to induce tolerance and promote healing in steroid-refractory GvHD. Bone Marrow Transplant 2015; 51:142-3. [PMID: 26389834 DOI: 10.1038/bmt.2015.220] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- S G Holtan
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - A Panoskaltsis-Mortari
- Blood and Marrow Transplant Program, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| |
Collapse
|
49
|
Plasma biomarkers of acute GVHD and nonrelapse mortality: predictive value of measurements before GVHD onset and treatment. Blood 2015; 126:113-20. [PMID: 25987657 DOI: 10.1182/blood-2015-03-636753] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 05/06/2015] [Indexed: 12/12/2022] Open
Abstract
We identified plasma biomarkers that presaged outcomes in patients with gastrointestinal graft-versus-host disease (GVHD) by measuring 23 biomarkers in samples collected before initiation of treatment. Six analytes with the greatest accuracy in predicting grade 3-4 GVHD in the first cohort (74 patients) were then tested in a second cohort (76 patients). The same 6 analytes were also tested in samples collected at day 14 ± 3 from 167 patients free of GVHD at the time. Logistic regression and calculation of an area under a receiver-operating characteristic (ROC) curve for each analyte were used to determine associations with outcome. Best models in the GVHD onset and landmark analyses were determined by forward selection. In samples from the second cohort, collected a median of 4 days before start of treatment, levels of TIM3, IL6, and sTNFR1 had utility in predicting development of peak grade 3-4 GVHD (area under ROC curve, 0.88). Plasma ST2 and sTNFR1 predicted nonrelapse mortality within 1 year after transplantation (area under ROC curve, 0.90). In the landmark analysis, plasma TIM3 predicted subsequent grade 3-4 GVHD (area under ROC curve, 0.76). We conclude that plasma levels of TIM3, sTNFR1, ST2, and IL6 are informative in predicting more severe GVHD and nonrelapse mortality.
Collapse
|