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Wirk B. Acquired Aplastic Anemia Therapies: Immunosuppressive Therapy Versus Alternative Donor Hematopoietic Cell Transplantation. J Hematol 2024; 13:61-70. [PMID: 38993743 PMCID: PMC11236356 DOI: 10.14740/jh1264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 05/24/2024] [Indexed: 07/13/2024] Open
Abstract
Immunosuppressive therapy for acquired severe aplastic anemia improves pancytopenia but has a significant risk of relapse (40%) and clonal evolution to myeloid neoplasms (15%), especially in patients older than 40. Yet, current guidelines for newly diagnosed severe aplastic anemia patients over the age of 40 recommend immunosuppressive therapy instead of curative allogeneic stem cell transplantation. Upfront allogeneic stem cell transplants are restricted to the rare patient who is not only young but also has a matched sibling donor. This article will discuss practice-changing data on the recent advances in upfront alternative donor hematopoietic cell transplants that could rewrite current treatment algorithms.
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Affiliation(s)
- Baldeep Wirk
- Cellular Immunotherapies and Transplant Program, Massey Comprehensive Cancer Center, Virginia Commonwealth University, Richmond, VA 23219, USA.
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2
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Piekarska A, Pawelec K, Szmigielska-Kapłon A, Ussowicz M. The state of the art in the treatment of severe aplastic anemia: immunotherapy and hematopoietic cell transplantation in children and adults. Front Immunol 2024; 15:1378432. [PMID: 38646536 PMCID: PMC11026616 DOI: 10.3389/fimmu.2024.1378432] [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: 02/01/2024] [Accepted: 03/22/2024] [Indexed: 04/23/2024] Open
Abstract
Acquired aplastic anemia (AA) is an immune-mediated bone marrow (BM) failure where marrow disruption is driven by a cytotoxic T-cell-mediated autoimmune attack against hematopoietic stem cells. The key diagnostic challenge in children, but also in adults, is to exclude the possible underlying congenital condition and myelodysplasia. The choice of treatment options, either allogeneic hematopoietic cell transplantation (alloHCT) or immunosuppressive therapy (IST), depends on the patient's age, comorbidities, and access to a suitable donor and effective therapeutic agents. Since 2022, horse antithymocyte globulin (hATG) has been available again in Europe and is recommended for IST as a more effective option than rabbit ATG. Therefore, an update on immunosuppressive strategies is warranted. Despite an improved response to the new immunosuppression protocols with hATG and eltrombopag, some patients are not cured or remain at risk of aplasia relapse or clonal evolution and require postponed alloHCT. The transplantation field has evolved, becoming safer and more accessible. Upfront alloHCT from unrelated donors is becoming a tempting option. With the use of posttransplant cyclophosphamide, haploidentical HCT offers promising outcomes also in AA. In this paper, we present the state of the art in the management of severe AA for pediatric and adult patients based on the available guidelines and recently published studies.
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Affiliation(s)
- Agnieszka Piekarska
- Department of Hematology and Transplantology, Medical University of Gdansk, Gdansk, Poland
| | - Katarzyna Pawelec
- Department of Oncology, Pediatric Hematology, Clinical Transplantology and Pediatrics, Medical University of Warsaw, Warsaw, Poland
| | | | - Marek Ussowicz
- Department of Pediatric Bone Marrow Transplantation, Oncology and Hematology, Wroclaw Medical University, Wroclaw, Poland
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3
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Kulasekararaj A, Cavenagh J, Dokal I, Foukaneli T, Gandhi S, Garg M, Griffin M, Hillmen P, Ireland R, Killick S, Mansour S, Mufti G, Potter V, Snowden J, Stanworth S, Zuha R, Marsh J. Guidelines for the diagnosis and management of adult aplastic anaemia: A British Society for Haematology Guideline. Br J Haematol 2024; 204:784-804. [PMID: 38247114 DOI: 10.1111/bjh.19236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 10/26/2023] [Accepted: 11/20/2023] [Indexed: 01/23/2024]
Abstract
Pancytopenia with hypocellular bone marrow is the hallmark of aplastic anaemia (AA) and the diagnosis is confirmed after careful evaluation, following exclusion of alternate diagnosis including hypoplastic myelodysplastic syndromes. Emerging use of molecular cyto-genomics is helpful in delineating immune mediated AA from inherited bone marrow failures (IBMF). Camitta criteria is used to assess disease severity, which along with age and availability of human leucocyte antigen compatible donor are determinants for therapeutic decisions. Supportive care with blood and platelet transfusion support, along with anti-microbial prophylaxis and prompt management of opportunistic infections remain key throughout the disease course. The standard first-line treatment for newly diagnosed acquired severe/very severe AA patients is horse anti-thymocyte globulin and ciclosporin-based immunosuppressive therapy (IST) with eltrombopag or allogeneic haemopoietic stem cell transplant (HSCT) from a matched sibling donor. Unrelated donor HSCT in adults should be considered after lack of response to IST, and up front for young adults with severe infections and a readily available matched unrelated donor. Management of IBMF, AA in pregnancy and in elderly require special attention. In view of the rarity of AA and complexity of management, appropriate discussion in multidisciplinary meetings and involvement of expert centres is strongly recommended to improve patient outcomes.
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Affiliation(s)
- Austin Kulasekararaj
- King's College Hospital NHS Foundation Trust, London and King's College London, London, UK
| | - Jamie Cavenagh
- St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Inderjeet Dokal
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London and Barts Health NHS Trust, London, UK
| | - Theodora Foukaneli
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- NHS Blood and Transplant, Bristol, UK
| | - Shreyans Gandhi
- King's College Hospital NHS Foundation Trust, London and King's College London, London, UK
| | - Mamta Garg
- Leicester Royal Infirmary, Leicester, UK
- British Society Haematology Task Force Representative, London, UK
| | | | | | - Robin Ireland
- King's College Hospital NHS Foundation Trust, London and King's College London, London, UK
| | - Sally Killick
- University Hospitals Dorset NHS Foundation Trust, The Royal Bournemouth Hospital, Bournemouth, UK
| | - Sahar Mansour
- St George's Hospital/St George's University of London, London, UK
| | - Ghulam Mufti
- King's College Hospital NHS Foundation Trust, London and King's College London, London, UK
| | - Victoria Potter
- King's College Hospital NHS Foundation Trust, London and King's College London, London, UK
| | - John Snowden
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Simon Stanworth
- Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Radcliffe Department of Medicine, University of Oxford and NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Roslin Zuha
- James Paget University Hospitals NHS Foundation Trust, Great Yarmouth, Norfolk, England
| | - Judith Marsh
- King's College Hospital NHS Foundation Trust, London and King's College London, London, UK
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4
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Kricke S, Rao K, Adams S. The significance of mixed chimaerism and cell lineage chimaerism monitoring in paediatric patients post haematopoietic stem cell transplant. Br J Haematol 2022; 198:625-640. [PMID: 35421255 DOI: 10.1111/bjh.18190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 03/23/2022] [Accepted: 03/25/2022] [Indexed: 11/28/2022]
Abstract
Haematopoietic stem cell transplants (HSCTs) are carried out across the world to treat haematological and immunological diseases which would otherwise prove fatal. Certain diseases are predominantly encountered in paediatric patients, such severe primary immunodeficiencies (PID) and diseases of inborn errors of metabolism (IEM). Chimaerism testing for these disorders has different considerations compared to adult diseases. This review focuses on the importance of cell-lineage-specific chimaerism testing and examines the appropriate cell populations to be assessed in individual paediatric patient groups. By analysing disease-associated subpopulations, abnormalities are identified significantly earlier than in whole samples and targeted clinical decisions can be made. Chimaerism methods have evolved over time and lead to an ever-increasing level of sensitivity and biomarker arrays to distinguish between recipient and donor cells. Short tandem repeat (STR) is still the gold standard for routine chimaerism assessment, and hypersensitive methods such as quantitative and digital polymerase chain reaction (PCR) are leading the forefront of microchimaerism testing. The rise of molecular methods operating with minute DNA amounts has been hugely beneficial to chimaerism testing of paediatric samples. As HSCTs are becoming increasingly personalised and risk-adjusted towards a child's individual needs, chimaerism testing needs to adapt alongside these medical advances ensuring the best possible care.
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Affiliation(s)
- Susanne Kricke
- Specialist Integrated Haematology and Malignancy Diagnostic Service, Department of Haematology, Great Ormond Street Hospital for Children, London, UK
| | - Kanchan Rao
- Department of Blood and Marrow Transplantation, Great Ormond Street Hospital for Children, London, UK
| | - Stuart Adams
- Specialist Integrated Haematology and Malignancy Diagnostic Service, Department of Haematology, Great Ormond Street Hospital for Children, London, UK
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5
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Penter L, Gohil SH, Wu CJ. Natural Barcodes for Longitudinal Single Cell Tracking of Leukemic and Immune Cell Dynamics. Front Immunol 2022; 12:788891. [PMID: 35046946 PMCID: PMC8761982 DOI: 10.3389/fimmu.2021.788891] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 12/08/2021] [Indexed: 11/26/2022] Open
Abstract
Blood malignancies provide unique opportunities for longitudinal tracking of disease evolution following therapeutic bottlenecks and for the monitoring of changes in anti-tumor immunity. The expanding development of multi-modal single-cell sequencing technologies affords newer platforms to elucidate the mechanisms underlying these processes at unprecedented resolution. Furthermore, the identification of molecular events that can serve as in-vivo barcodes now facilitate the tracking of the trajectories of malignant and of immune cell populations over time within primary human samples, as these permit unambiguous identification of the clonal lineage of cell populations within heterogeneous phenotypes. Here, we provide an overview of the potential for chromosomal copy number changes, somatic nuclear and mitochondrial DNA mutations, single nucleotide polymorphisms, and T and B cell receptor sequences to serve as personal natural barcodes and review technical implementations in single-cell analysis workflows. Applications of these methodologies include the study of acquired therapeutic resistance and the dissection of donor- and host cellular interactions in the context of allogeneic hematopoietic stem cell transplantation.
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Affiliation(s)
- Livius Penter
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
- Broad Institute of Massachusetts Institute of Technology and Harvard University, Cambridge, MA, United States
- Harvard Medical School, Boston, MA, United States
- Department of Hematology, Oncology, and Tumorimmunology, Campus Virchow Klinikum, Berlin, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Satyen H. Gohil
- Department of Academic Haematology, University College London Cancer Institute, London, United Kingdom
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Catherine J. Wu
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
- Broad Institute of Massachusetts Institute of Technology and Harvard University, Cambridge, MA, United States
- Harvard Medical School, Boston, MA, United States
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA, United States
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6
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Ruhnke L, Stölzel F, Oelschlägel U, von Bonin M, Sockel K, Middeke JM, Röllig C, Jöhrens K, Schetelig J, Thiede C, Bornhäuser M. Long-Term Mixed Chimerism After Ex Vivo/In Vivo T Cell-Depleted Allogeneic Hematopoietic Cell Transplantation in Patients With Myeloid Neoplasms. Front Oncol 2021; 11:776946. [PMID: 34950586 PMCID: PMC8688843 DOI: 10.3389/fonc.2021.776946] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 11/08/2021] [Indexed: 01/06/2023] Open
Abstract
In patients who have undergone allogeneic hematopoietic cell transplantation (HCT), myeloid mixed donor chimerism (MC) is a risk factor for disease relapse. In contrast, several studies found favorable outcome in patients with lymphoid MC. Thus far, most studies evaluating MC focused on a short-term follow-up period. Here, we report the first case series of long-term survivors with MC. We screened 1,346 patients having undergone HCT for myeloid neoplasms at our center from 1996 to 2016; 443 patients with data on total peripheral blood mononuclear cells (PBMC)/CD4+/CD34+ short tandem repeat (STR) donor chimerism (DC) and follow-up ≥24 months post-HCT were included. We identified 10 patients with long-term MC (PBMC DC <95% at ≥12 months post-HCT). Median follow-up was 11 years. All patients had received combined ex vivo/in vivo T cell-depleted (TCD) peripheral blood stem cells; none experienced ≥grade 2 acute graft-versus-host disease (GVHD). The mean total PBMC, CD4+, and CD34+ DC of all patients were 95.88%, 85.84%, and 90.15%, respectively. Reduced-intensity conditioning (RIC) was associated with a trend to lower mean total DC. Of note, two patients who experienced relapse had lower CD34+ DC but higher CD4+ DC as compared with patients in continuous remission. Bone marrow evaluation revealed increased CD4+/FOXP3+ cells in patients with MC, which might indicate expansion of regulatory T cells (Tregs). Our results support known predictive factors associated with MC such as RIC and TCD, promote the value of CD34+ MC as a potential predictor of relapse, highlight the potential association of CD4+ MC with reduced risk of GVHD, and indicate a possible role of Tregs in the maintenance of immune tolerance post-HCT.
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Affiliation(s)
- Leo Ruhnke
- Department of Internal Medicine I, University Hospital Dresden, TU Dresden, Dresden, Germany
- *Correspondence: Leo Ruhnke,
| | - Friedrich Stölzel
- Department of Internal Medicine I, University Hospital Dresden, TU Dresden, Dresden, Germany
- German Cancer Consortium (DKTK) partner site Dresden, Dresden, Germany
| | - Uta Oelschlägel
- Department of Internal Medicine I, University Hospital Dresden, TU Dresden, Dresden, Germany
| | - Malte von Bonin
- Department of Internal Medicine I, University Hospital Dresden, TU Dresden, Dresden, Germany
- German Cancer Consortium (DKTK) partner site Dresden, Dresden, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Katja Sockel
- Department of Internal Medicine I, University Hospital Dresden, TU Dresden, Dresden, Germany
| | - Jan Moritz Middeke
- Department of Internal Medicine I, University Hospital Dresden, TU Dresden, Dresden, Germany
- German Cancer Consortium (DKTK) partner site Dresden, Dresden, Germany
| | - Christoph Röllig
- Department of Internal Medicine I, University Hospital Dresden, TU Dresden, Dresden, Germany
| | - Korinna Jöhrens
- Institute of Pathology, University Hospital Dresden, TU Dresden, Dresden, Germany
| | - Johannes Schetelig
- Department of Internal Medicine I, University Hospital Dresden, TU Dresden, Dresden, Germany
- DKMS Clinical Trials Unit, Dresden, Germany
| | - Christian Thiede
- Department of Internal Medicine I, University Hospital Dresden, TU Dresden, Dresden, Germany
- AgenDix GmbH, Dresden, Germany
| | - Martin Bornhäuser
- Department of Internal Medicine I, University Hospital Dresden, TU Dresden, Dresden, Germany
- German Cancer Consortium (DKTK) partner site Dresden, Dresden, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- National Center for Tumor Diseases (NCT) Dresden, Dresden, Germany
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7
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Wright M, Rangarajan H, Abu-Arja R, Auletta JJ, Lee D, Polishchuk V, Pai V, Taylor K, Bajwa RPS. Use of belatacept as alternative graft vs host disease prophylaxis in pediatric allogeneic hematopoietic stem cell transplantation. Pediatr Transplant 2021; 25:e14041. [PMID: 34014014 DOI: 10.1111/petr.14041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 03/13/2021] [Accepted: 04/28/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Immunosuppressive prophylaxis is usually given to decrease the development of acute graft versus host disease (GvHD) after allogeneic hematopoietic stem cell transplantation (HSCT). Belatacept is a Cytotoxic T-lymphocyte-associated protein 4, blocking agent, an immunosuppressive agent used for organ rejection prevention in adult renal transplant recipients. METHODS We describe two children in whom belatacept was successfully used for GvHD prophylaxis. Case 1 was noncompliant with prior immunosuppressive therapy for aplastic anemia, and Case 2 developed severe thrombotic microangiopathy (TMA) precluding the use of calcineurin inhibitors (CNI) or mTOR inhibitors. RESULTS AND CONCLUSION Belatacept was found to be a safe alternative in preventing GvHD in 2 patients in whom traditional prophylactic therapies were not possible to use.
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Affiliation(s)
- Mariah Wright
- Department of Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, OH, USA
| | - Hemalatha Rangarajan
- Department of Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, OH, USA
| | - Rolla Abu-Arja
- Department of Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, OH, USA
| | - Jeffery J Auletta
- Department of Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, OH, USA
| | - Dean Lee
- Department of Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, OH, USA
| | - Veronika Polishchuk
- Department of Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, OH, USA
| | - Vinita Pai
- Department of Clinical Pharmacy, Nationwide Children's Hospital, Columbus, OH, USA
| | - Kimberly Taylor
- Department of Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, OH, USA
| | - Rajinder P S Bajwa
- Department of Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, OH, USA
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8
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Bacigalupo A, Benintende G. Bone marrow transplantation for acquired aplastic anemia: What's new. Best Pract Res Clin Haematol 2021; 34:101284. [PMID: 34404530 DOI: 10.1016/j.beha.2021.101284] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 07/02/2021] [Accepted: 07/02/2021] [Indexed: 11/19/2022]
Abstract
Bone marrow transplantation is a major therapeutic option for patients with acquired severe aplastic anaemia: improved survival has been achieved in younger patients, thanks to better donor selection, conditioning regimens and graft versus host disease prophylaxis, together with improved supportive care, including diagnosis and treatment of opportunistic infections. This has not been the case for older patients over the age of 40 years. We will discuss transplantation platforms as used for different donor types and we will analyse major breakthroughs of the last years: the combination of Fludarabine and cyclophosphamide as a conditioning regimen, the use of alternative donors including HLA haploidentical related donors and new strategies to prevent acute and chronic graft versus host disease, including post transplantation Cyclophosphamide. These changes extend the option of a bone marrow transplantation for patients who lack an HLA matched donor and appear to improve engraftment and reduce graft versus host disease: whether this will be true for all age groups is currently being investigated.
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Affiliation(s)
- Andrea Bacigalupo
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Roma, Italy.
| | - Giulia Benintende
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Roma, Italy.
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9
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Postvaccination graft dysfunction/aplastic anemia relapse with massive clonal expansion of autologous CD8+ lymphocytes. Blood Adv 2021; 4:1378-1382. [PMID: 32267929 DOI: 10.1182/bloodadvances.2019000853] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 02/22/2020] [Indexed: 11/20/2022] Open
Abstract
Key Points
Acquired aplastic anemia is a T-cell–mediated autoimmune bone marrow aplasia, without a known etiologic trigger. Clonal expansion of CD8+ effector T lymphocytes can occur following vaccination and accompany graft dysfunction or aplastic anemia relapse.
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10
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Iftikhar R, Chaudhry QUN, Anwer F, Neupane K, Rafae A, Mahmood SK, Ghafoor T, Shahbaz N, Khan MA, Khattak TA, Shamshad GU, Rehman J, Farhan M, Khan M, Ansar I, Ashraf R, Marsh J, Satti TM, Ahmed P. Allogeneic hematopoietic stem cell transplantation in aplastic anemia: current indications and transplant strategies. Blood Rev 2020; 47:100772. [PMID: 33187812 DOI: 10.1016/j.blre.2020.100772] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 09/12/2020] [Accepted: 10/15/2020] [Indexed: 12/18/2022]
Abstract
Treatment options for newly diagnosed aplastic anemia (AA) patient includes upfront allogeneic hematopoietic stem cell transplant (HSCT) or immunosuppressive therapy (IST). With recent advances in supportive care, conditioning regimens and post-transplant immunosuppression the overall survival for HSCT approaches 70-90%. Transplant eligibility needs to be assessed considering age, comorbidities, donor availability and probability of response to immunosuppressive therapy (IST). Upfront HSCT should be offered to children and young adults with matched related donor (MRD). Upfront HSCT may also be offered to children and young adults with rapidly available matched unrelated donor (MUD) who require urgent HSCT. Bone marrow (BM) graft source and cyclosporine (CsA) plus methotrexate (MTX) as graft versus host disease (GVHD) prophylaxis are preferable when using anti-thymocyte globulin (ATG) based conditioning regimens. Alemtuzumab is an acceptable alternative to ATG and is used with CsA alone and with either BM or peripheral blood stem cells (PBSC). Cyclophosphamide (CY) plus ATG conditioning is preferable for patients receiving MRD transplant, while Fludarabine (Flu) based conditioning is reserved for older adults, those with risk factors of graft failure and those receiving MUD HSCT. For haploidentical transplant, use of low dose radiotherapy and post-transplant cyclophosphamide has resulted in a marked reduction in graft failure and GVHD.
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Affiliation(s)
- Raheel Iftikhar
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan.
| | - Qamar Un Nisa Chaudhry
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Faiz Anwer
- Department of Hematology, Medical Oncology, Tausig Cancer Center, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Karun Neupane
- Department of Internal Medicine, Manipal College of Medical Sciences, Pokhara 33700, Nepal
| | - Abdul Rafae
- Department of Internal Medicine, McLaren Flint Michigan State University, United States
| | - Syed Kamran Mahmood
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Tariq Ghafoor
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Nighat Shahbaz
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Mehreen Ali Khan
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Tariq Azam Khattak
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Ghassan Umair Shamshad
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Jahanzeb Rehman
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Muhammad Farhan
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Maryam Khan
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Iqraa Ansar
- Shifa College of Medicine, Islamabad 44000, Pakistan
| | - Rabia Ashraf
- King Edward Medical University, Lahore 54000, Pakistan
| | - Judith Marsh
- Department of Hematological Medicine, King's College Hospital, Denmark Hill, London SE59RS, UK
| | | | - Parvez Ahmed
- Department of Hematology Oncology and Stem Cell Transplant, Quaid-e-Azam International Hospital, Islamabad 44000, Pakistan
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11
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Similar outcomes of alemtuzumab-based hematopoietic cell transplantation for SAA patients older or younger than 50 years. Blood Adv 2020; 3:3070-3079. [PMID: 31648330 DOI: 10.1182/bloodadvances.2019000480] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 08/27/2019] [Indexed: 12/11/2022] Open
Abstract
Survival after allogeneic hematopoietic cell transplantation (HSCT) for severe aplastic anemia (SAA) among older patients remains poor and associated with increased risk for graft-versus-host disease (GVHD). In this retrospective study of 65 consecutive patients with acquired SAA who were transplanted using fludarabine, low-dose cyclophosphamide, and alemtuzumab (FCC), outcomes of 27 patients aged at least 50 years were compared with those of 38 patients younger than 50 years. The median age of the older cohort was 61 years (range, 51-71 years); 21 (78%) patients were transplanted from unrelated donors (3 of 21 from HLA 9/10 mismatch donors) and 6 from matched sibling donors. One-year GVHD-free, relapse-free survival (GRFS) was comparable to that of patients younger than 50 years (84% vs 94%, respectively; P = .23). Both groups showed low rates of acute (5% vs 4%) and chronic (18% vs 14%) GVHD, with no cases of severe GVHD among matched donor transplants, and similar 1-year transplant-related mortality (14% vs 5.4%, older vs younger; P = .23). HSCT comorbidity index (HTC-CI) scores were similar between the groups, but overall survival with an HCT-CI of at least 3 was lower compared with a score less than 3 (76% vs 98%; P = .005). Median donor T-cell chimerism among older patients was 64% and 60% at 1 and 3 years, respectively, and was similar to that of younger patients. Increased B regulatory cells potentially contributed to low alloreactivity and mutual donor-recipient tolerance in older patients. Effect of comorbidities rather than age alone may be a more important determinant of suitability for FCC HSCT in older patients.
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12
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Fludarabine, Campath, and Low-Dose Cyclophosphamide (FCC low) with or without TBI Conditioning Results in Excellent Transplant Outcomes in Children with Severe Aplastic Anemia. Biol Blood Marrow Transplant 2020; 26:1900-1905. [PMID: 32640311 DOI: 10.1016/j.bbmt.2020.06.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 05/24/2020] [Accepted: 06/28/2020] [Indexed: 11/22/2022]
Abstract
Various reduced-intensity conditioning regimens are in use for allogeneic hematopoietic cell transplant (HSCT) in patients with idiopathic severe aplastic anemia (SAA). We describe the use of fludarabine, Campath, and low-dose cyclophosphamide (FCClow) conditioning in 15 children undergoing related or unrelated donor transplants. Total body irradiation (TBI) of 2 Gy was added for unrelated donor HSCT. At a median follow-up of 2.3 years, the failure-free survival was 100%, with low rates of infection and toxicity. There was no occurrence of grade III to IV acute graft-versus-host disease (GVHD). All patients had full donor myeloid chimerism post-HSCT, even with mixed chimerism in the T cell lineage. The absence of chronic GVHD and long-term stable mixed donor T cell chimerism confirms immune tolerance following FCClow (± TBI) conditioned transplantation in children with SAA.
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Shaw A, Passweg JR, De La Fuente J, Bajwa R, Stein J, Al-Zaben A, Halkes CJ, Norton A, Cummins M, Moppett JP, Shanap MA, Steward CG. Relapse of Aplastic Anemia with Majority Donor Chimerism (Donor-Type Aplasia) Occurring Late after Bone Marrow Transplantation. Biol Blood Marrow Transplant 2020; 26:480-485. [DOI: 10.1016/j.bbmt.2019.11.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 11/02/2019] [Accepted: 11/08/2019] [Indexed: 01/30/2023]
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14
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Miller PDE, Snowden JA, De Latour RP, Iacobelli S, Eikema DJ, Knol C, Marsh JCW, Rice C, Koh M, Fagioli F, Chaganti S, Finke J, Duarte RF, Bader P, Farge D, Passweg JR, Madrigal JA, Dufour C. Autoimmune cytopenias (AIC) following allogeneic haematopoietic stem cell transplant for acquired aplastic anaemia: a joint study of the Autoimmune Diseases and Severe Aplastic Anaemia Working Parties (ADWP/SAAWP) of the European Society for Blood and Marrow Transplantation (EBMT). Bone Marrow Transplant 2020; 55:441-451. [PMID: 31554929 PMCID: PMC6995778 DOI: 10.1038/s41409-019-0680-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 07/06/2019] [Accepted: 07/20/2019] [Indexed: 12/03/2022]
Abstract
This retrospective study explored the incidence of autoimmune cytopenia (AIC) in 530 paediatric and adult patients with acquired aplastic anaemia (aAA) who underwent first allogeneic HSCT between 2002 and 2012. AIC was a rare complication with a cumulative incidence of AIC at 1, 3, 5 and 10 years post HSCT of 2.5% (1.2-3.9 95% CI), 4.4% (2.6-6.2 95% CI), 4.6% (2.8-6.5 95% CI) and 5.1% (3.1-7.2 95% CI). Overall survival at 5 years after diagnosis of AIC was 85.9% (71-100 95% CI). Twenty-five patients were diagnosed with AIC at a median of 10.6 (2.6-91.5) months post HSCT. Eight (32%) patients were diagnosed with immune thrombocytopenia (ITP), seven (28%) with autoimmune haemolytic anaemia (AIHA), seven (24%) with Evans syndrome and four (16%) with autoimmune neutropenia (AIN). Treatment strategies were heterogeneous. Complete responses were seen in 12 of 25 patients, with death in three patients. In multivariable Cox analysis of a subgroup of 475 patients, peripheral blood stem cell (PBSC) transplant was associated with higher risk of AIC compared with bone marrow (BM) when conditioning regimens contained fludarabine and/or alemtuzumab (2.81 [1.06-7.49 95% CI]; p = 0.038), or anti-thymocyte globulin (ATG) (2.86 [1.11-7.37 95% CI]; p = 0.029). Myeloablative conditioning was associated with a lower risk of AIC compared with reduced intensity conditioning (RIC) in fludarabine and/or alemtuzumab (0.34 [0.12-0.98 95% CI]; p = 0.046) and ATG containing regimens (0.34 [0.12-0.95 95% CI]; p = 0.04). These findings provide clinically useful information regarding the incidence of a rare and potentially life-threatening complication of allogeneic HSCT for aAA, and further support for BM as the preferred stem cell source for transplant of patients with aAA.
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Affiliation(s)
| | - John A Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | - Simona Iacobelli
- Department of Biology, University of Rome Tor Vergata, Rome, Italy
| | | | - Cora Knol
- EBMT Data Office, Leiden, Netherlands
| | - Judith C W Marsh
- Department of Haematological Medicine, Kings College Hospital, London, UK
| | - Carmel Rice
- Department of Haematological Medicine, Kings College Hospital, London, UK
| | - Mickey Koh
- Department of Haematology, St George's Hospital NHS Foundation Trust, London, UK
| | - Franca Fagioli
- Pediatric Onco-Hematology, Stem Cell Transplantation and Cellular Therapy Division, Regina Margherita Children's Hospital, Torino, Italy
| | - Sridhar Chaganti
- Centre for Clinical Haematology, University Hospital Birmingham, Birmingham, UK
| | - Jürgen Finke
- Department of Hematology and Oncology, University Medical Center, Freiburg, Germany
| | - Rafael F Duarte
- Department of Hematology, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Peter Bader
- University Children's Hospital Frankfurt, Frankfurt, Germany
| | - Dominique Farge
- Department of Autoimmune Diseases and Vascular Pathology, Hopital Saint-Louis, Paris, France
| | - Jakob R Passweg
- Division of Hematology, University Hospital of Santander, Basel, Switzerland
| | | | - Carlo Dufour
- Hematology Unit, G. Gaslini Children's Hospital, Genova, Italy
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Sheth V, Kennedy V, de Lavallade H, Mclornan D, Potter V, Engelhardt BG, Savani B, Chinratanalab W, Goodman S, Greer J, Kassim A, York S, Kenyon M, Gandhi S, Kulasekararaj A, Marsh J, Mufti G, Pagliuca A, Jagasia M, Raj K. Differential Interaction of Peripheral Blood Lymphocyte Counts (ALC) With Different in vivo Depletion Strategies in Predicting Outcomes of Allogeneic Transplant: An International 2 Center Experience. Front Oncol 2019; 9:623. [PMID: 31355140 PMCID: PMC6636242 DOI: 10.3389/fonc.2019.00623] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 06/24/2019] [Indexed: 11/17/2022] Open
Abstract
Dosing regimens for antithymocyte globulin (ATG) and anti-CD52 antibody (alemtuzumab) for graft vs. host disease prophylaxis (GVHD) are empiric or weight-based, and do not account for individual patient factors. Recently, it has been shown that recipient peripheral blood absolute lymphocyte count (ALC) on the day of ATG administration interacts with the dose of ATG administered to predict transplantation outcome. Similarly, we wanted to analyze if the recipient ALC interacts with alemtuzumab dosing to predict outcomes. We retrospectively compared 364 patients, 124 patients receiving ATG (anti-thymocyte globulin) for GVHD prophylaxis, and undergoing unrelated first allogeneic transplant for myeloid and lymphoid malignancies (group 1) to 240 patients receiving alemtuzumab (group 2), in similar time period. There was no difference in survival or acute and chronic GVHD between 60 and 100 mg of alemtuzumab dosing. Unlike ATG (where the pre-transplant recipient ALC interacted with ATG dose on day of its administration (day 1) to predict OS and DFS (p = 0.05), within alemtuzumab group, the recipient ALC on second day of alemtuzumab administration (day 2) and its interaction with alemtuzumab dose strongly predicted OS, DFS and relapse (p = 0.05, HR-1.81, 1.1–3.3; p = 0.002, HR-2.41, CI, 1.3–4.2; and p = 0.003, HR-2.78, CI, 1.4–5.2), respectively. ALC (day 2) of 0.08 × 109/lit or higher, had a specificity of 96% in predicting inferior DFS. Like ATG, there is definite but differential interaction between the recipient peripheral blood ALC and alemtuzumab dose to predict OS, DFS, and relapses.
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Affiliation(s)
- Vipul Sheth
- Department of Haematology and Stem Cell Transplantation, Kings College Hospital, London, United Kingdom
| | - Vanessa Kennedy
- Department of Haematology and Stem Cell Transplant, Stanford University, Stanford, CA, United States
| | - Hugues de Lavallade
- Department of Haematology and Stem Cell Transplantation, Kings College Hospital, London, United Kingdom
| | - Donal Mclornan
- Department of Haematology and Stem Cell Transplantation, Kings College Hospital, London, United Kingdom
| | - Victoria Potter
- Department of Haematology and Stem Cell Transplantation, Kings College Hospital, London, United Kingdom
| | - Brian G Engelhardt
- Department of Haematology and Stem Cell Transplant, Vanderbilt University, Nashville, TN, United States
| | - Bipin Savani
- Department of Haematology and Stem Cell Transplant, Vanderbilt University, Nashville, TN, United States
| | - Wichai Chinratanalab
- Department of Haematology and Stem Cell Transplant, Vanderbilt University, Nashville, TN, United States
| | - Stacey Goodman
- Department of Haematology and Stem Cell Transplant, Vanderbilt University, Nashville, TN, United States
| | - John Greer
- Department of Haematology and Stem Cell Transplant, Vanderbilt University, Nashville, TN, United States
| | - Adetola Kassim
- Department of Haematology and Stem Cell Transplant, Vanderbilt University, Nashville, TN, United States
| | - Sally York
- Department of Haematology and Stem Cell Transplant, Vanderbilt University, Nashville, TN, United States
| | - Michelle Kenyon
- Department of Haematology and Stem Cell Transplantation, Kings College Hospital, London, United Kingdom
| | - Shreyans Gandhi
- Department of Haematology and Stem Cell Transplantation, Kings College Hospital, London, United Kingdom
| | - Austin Kulasekararaj
- Department of Haematology and Stem Cell Transplantation, Kings College Hospital, London, United Kingdom
| | - Judith Marsh
- Department of Haematology and Stem Cell Transplantation, Kings College Hospital, London, United Kingdom
| | - Ghulam Mufti
- Department of Haematology and Stem Cell Transplantation, Kings College Hospital, London, United Kingdom
| | - Antonio Pagliuca
- Department of Haematology and Stem Cell Transplantation, Kings College Hospital, London, United Kingdom
| | - Madan Jagasia
- Department of Haematology and Stem Cell Transplant, Vanderbilt University, Nashville, TN, United States
| | - Kavita Raj
- Department of Haematology and Stem Cell Transplantation, Kings College Hospital, London, United Kingdom
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Marsh JCW, Risitano AM, Mufti GJ. The Case for Upfront HLA-Matched Unrelated Donor Hematopoietic Stem Cell Transplantation as a Curative Option for Adult Acquired Severe Aplastic Anemia. Biol Blood Marrow Transplant 2019; 25:e277-e284. [PMID: 31129354 DOI: 10.1016/j.bbmt.2019.05.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 05/07/2019] [Accepted: 05/16/2019] [Indexed: 12/20/2022]
Abstract
The improved success of HLA-matched unrelated donor (MUD) hematopoietic stem cell transplantation (HSCT) for severe aplastic anemia (SAA) in recent decades has had an impact on the indications for and timing of this treatment modality. In the absence of a matched sibling donor (MSD), historically MUD HSCT was reserved as an option after failure to respond to at least 2 courses of immunosuppressive therapy (IST) in adults with SAA, but with improved outcomes over time, it is now considered following failure to respond to 1 course of IST. Recent national and international studies and guidelines now recommend upfront MUD HSCT as an option for children for whom an MUD is readily available, because outcomes are similar to those for MSD HSCT. Fludarabine-based conditioning and the use of in vivo T cell depletion with antithymocyte globulin or alemtuzumab has been associated with a reported overall survival (OS) of >85% in adult patients undergoing MUD HSCT. However, the recent introduction of eltrombopag for patients with SAA has transformed the treatment landscape, and there is currently much interest in its use with IST as upfront treatment, which showed a high response rate in an early-phase study. The risks of HSCT, especially graft-versus-host disease (GVHD), need to be carefully balanced against the concerns of IST, namely relapse and later clonal evolution to myelodysplastic syndrome (MDS)/acute myelogenous leukemia (AML). In the absence of a current prospective randomized trial comparing these 2 approaches, in this review we examine the evidence supporting consideration of early MUD HSCT in adults with SAA who would have been considered for MSD HSCT but who lack a MSD and for whom an MUD is readily available, especially using an irradiation-free conditioning regimen, with a low risk of GVHD, as another treatment option. This option may be offered to patients to provide them with an informed choice, with the aim of curing disease rather than achieving freedom from disease, relapse-free survival, or OS. Furthermore, understanding the immune signature for the response to IST and the immunologic responses to somatic mutations and clonal progression to MDS/AML may help define the future indications for upfront HSCT and a more precise medical approach to therapy.
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Affiliation(s)
- Judith C W Marsh
- Department of Haematological Medicine, King's College Hospital/King's College London, London, UK.
| | | | - Ghulam J Mufti
- Department of Haematological Medicine, King's College Hospital/King's College London, London, UK
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Samarasinghe S, Clesham K, Iacobelli S, Sbianchi G, Knol C, Hamladji RM, Socié G, Aljurf M, Koh M, Sengeloev H, Dalle JH, Robinson S, Van Lint MT, Halkes CJM, Beelen D, Mufti GJ, Snowden J, Blaise D, de Latour RP, Marsh J, Dufour C, Risitano AM. Impact of T-cell depletion strategies on outcomes following hematopoietic stem cell transplantation for idiopathic aplastic anemia: A study on behalf of the European blood and marrow transplant severe aplastic anemia working party. Am J Hematol 2019; 94:80-86. [PMID: 30328134 DOI: 10.1002/ajh.25314] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 10/02/2018] [Accepted: 10/15/2018] [Indexed: 12/11/2022]
Abstract
We retrospectively analyzed the outcomes of 1837 adults and children with severe aplastic anemia (SAA) who underwent matched sibling donor (MSD) and matched unrelated donor (MUD) hemopoietic stem cell transplantation (HSCT) between 2000 and 2013. Patients were grouped by transplant conditioning containing either anti-thymocyte globulin (ATG) (n = 1283), alemtuzumab (n = 261), or no serotherapy (NS) (n = 293). The risks of chronic GvHD were significantly reduced when ATG or alemtuzumab were compared with NS (P = .021 and .003, respectively). Acute GVHD was significantly reduced in favor of alemtuzumab compared with ATG (P = .012) and NS (P < .001). By multivariate analysis, when compared with ATG, alemtuzumab was associated with a lower risk of developing acute (OR 0.262; 95% CI 0.14-0.47; P < .001) and chronic GVHD (HR 0.58; 95% CI 0.35-0.94; P = .027). OS was significantly better in ATG and alemtuzumab patients compared with NS (P = .010 and .025). Our data shows inclusion of serotherapy in MSD and MUD HSCT for patients with SAA reduces chronic GVHD and provides a survival advantage over patients not receiving serotherapy. Notably, alemtuzumab reduced the risk of acute and chronic GvHD compared with ATG and indicates that alemtuzumab might be the serotherapy of choice for MSD and MUD transplants for SAA.
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Affiliation(s)
| | - Katherine Clesham
- UCL Great Ormond Street Hospital for Children; London United Kingdom
| | - Simona Iacobelli
- Dipartimento di Biologia; Tor Vergata Università di Roma; Rome Italy
| | - Giulia Sbianchi
- Dipartimento di Biologia; Tor Vergata Università di Roma; Rome Italy
| | - Cora Knol
- EBMT Data Office; Leiden The Netherlands
| | | | | | - Mahmoud Aljurf
- King Faisal Hospital & Research Centre; Riyadh Saudi Arabia
| | - Mickey Koh
- St. George's Hospital; London United Kingdom
| | | | | | | | | | | | | | - Ghulam J. Mufti
- King's College Hospital/King's College London; London United Kingdom
| | - John Snowden
- Sheffield Teaching Hospitals NHS Foundation Trust; Sheffield United Kingdom
| | | | | | - Judith Marsh
- King's College Hospital/King's College London; London United Kingdom
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Dvorak CC, Higham C, Shimano KA. Transplant-Associated Thrombotic Microangiopathy in Pediatric Hematopoietic Cell Transplant Recipients: A Practical Approach to Diagnosis and Management. Front Pediatr 2019; 7:133. [PMID: 31024873 PMCID: PMC6465621 DOI: 10.3389/fped.2019.00133] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 03/21/2019] [Indexed: 01/04/2023] Open
Abstract
Transplant-associated thrombotic microangiopathy (TA-TMA) is an endothelial damage syndrome that is increasingly identified as a complication of both autologous and allogeneic hematopoietic cell transplantation (HCT) in children. If not promptly diagnosed and treated, TA-TMA can lead to significant morbidity (e.g., permanent renal injury) or mortality. However, as the recognition of the early stages of TA-TMA may be difficult, we propose a TA-TMA "triad" of hypertension, thrombocytopenia (or platelet transfusion refractoriness), and elevated lactate dehydrogenase (LDH). While not diagnostic, this triad should prompt further evaluation for TA-TMA. There is increased understanding of the risk factors for the development of TA-TMA, including those which are inherent (e.g., race, genetics), transplant approach-related (e.g., second HCT, use of HLA-mismatched donors), and related to post-transplant events (e.g., receipt of calcineurin inhibitors, development of graft-vs. -host-disease, or certain infections). This understanding should lead to enhanced screening for TA-TMA signs and symptoms in high-risk patients. The pathophysiology of TA-TMA is complex, resulting from a cycle of activation of endothelial cells to produce a pro-coagulant state, along with activation of antigen-presenting cells and lymphocytes, as well as activation of the complement cascade and microthrombi formation. This has led to the formulation of a "Three-Hit Hypothesis" in which patients with either an underlying predisposition to complement activation or pre-existing endothelial injury (Hit 1) undergo a toxic conditioning regimen causing endothelial injury (Hit 2), and then additional insults are triggered by medications, alloreactivity, infections, and/or antibodies (Hit 3). Understanding this cycle of injury permits the development of a specific TA-TMA treatment algorithm designed to treat both the triggers and the drivers of the endothelial injury. Finally, several intriguing approaches to TA-TMA prophylaxis have been identified. Future work on the development of a single diagnostic test with high specificity and sensitivity, and the development of a robust risk-scoring system, will further improve the management of this serious post-transplant complication.
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Affiliation(s)
- Christopher C Dvorak
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, United States
| | - Christine Higham
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, United States
| | - Kristin A Shimano
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, United States
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Robin M, Raj K, Chevret S, Gauthier J, de Lavallade H, Michonneau D, McLornan D, Peffault de Latour R, Potter V, Kulasekararaj A, Sicre de Fontbrune F, Pagliuca A, Yakoub-Agha I, Socié G, Mufti GJ. Alemtuzumab vs anti-thymocyte globulin in patients transplanted from an unrelated donor after a reduced intensity conditioning. Eur J Haematol 2018; 101:466-474. [PMID: 29714032 DOI: 10.1111/ejh.13085] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Relapse and graft-vs-host disease (GVHD) are still the main complications after allogeneic hematopoietic stem cell transplantation, especially in the setting of reduced intensity regimen (RIC) and unrelated donor. We compared here anti-thymocyte globulin (ATG) or alemtuzumab as GVHD prophylaxis in patients with myeloid disease transplanted after RIC and from an unrelated donor. METHOD ATG and alemtuzumab patients have been matched by age, gender, HLA matching, comorbidities and cytogenetics risk (119 patients in each group). RESULTS After matching, we found that ATG decreased the risk of relapse (HR: 0.55, P = .0049) and improved relapse-free survival (RFS, HR: 0.70, P = .042). The improved RFS with ATG was more pronounced in CMV-positive patients but was not influenced by disease risk. Regarding overall survival, GVHD-free relapse-free survival and transplant-related mortality, the risk was similar using ATG or alemtuzumab. CONCLUSION Even if GVHD risk is lowered by alemtuzumab use, it does not translate in better outcome due to higher risk of relapse.
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Affiliation(s)
- Marie Robin
- Service d'hématologie greffe, Hôpital Saint-Louis, APHP, Paris, France.,INSERM 1131 Université Paris 7, Paris, France
| | - Kavita Raj
- Department of Haematological Medicine, Kings College Hospital and Kings College London, London, UK
| | - Sylvie Chevret
- Service de biostatistique, Hôpital Saint-Louis, APHP, Université Paris 7, Paris, France
| | - Jordan Gauthier
- CHU de Lille, LIRIC INSERM U955, Université Lille2, Paris, France
| | - Hugues de Lavallade
- Department of Haematological Medicine, Kings College Hospital and Kings College London, London, UK
| | - David Michonneau
- Service d'hématologie greffe, Hôpital Saint-Louis, APHP, Paris, France.,INSERM 1160 Université Paris 7, Paris, France
| | - Donal McLornan
- Department of Haematological Medicine, Kings College Hospital and Kings College London, London, UK
| | | | - Victoria Potter
- Department of Haematological Medicine, Kings College Hospital and Kings College London, London, UK
| | - Austin Kulasekararaj
- Department of Haematological Medicine, Kings College Hospital and Kings College London, London, UK
| | | | - Antonio Pagliuca
- Department of Haematological Medicine, Kings College Hospital and Kings College London, London, UK
| | - Ibrahim Yakoub-Agha
- Service de biostatistique, Hôpital Saint-Louis, APHP, Université Paris 7, Paris, France
| | - Gérard Socié
- Service d'hématologie greffe, Hôpital Saint-Louis, APHP, Paris, France.,INSERM 1160 Université Paris 7, Paris, France
| | - Ghulam J Mufti
- Department of Haematological Medicine, Kings College Hospital and Kings College London, London, UK
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van der Heiden P, Marijt E, Falkenburg F, Jedema I. Control of Cytomegalovirus Viremia after Allogeneic Stem Cell Transplantation: A Review on CMV-Specific T Cell Reconstitution. Biol Blood Marrow Transplant 2018; 24:1776-1782. [DOI: 10.1016/j.bbmt.2018.03.028] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 03/29/2018] [Indexed: 12/20/2022]
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21
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Guilcher GMT, Shah R, Shenoy S. Principles of alemtuzumab immunoablation in hematopoietic cell transplantation for non-malignant diseases in children: A review. Pediatr Transplant 2018; 22. [PMID: 29352515 DOI: 10.1111/petr.13142] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/29/2017] [Indexed: 12/19/2022]
Abstract
Alemtuzumab is a humanized mAb targeted to CD52. Alemtuzumab is highly immunosuppressive with the ability to deplete T and B cells (in addition to other immune cell lines). A growing understanding of the PKs, dosing, and timing of administration of alemtuzumab has allowed for the study of its use as a conditioning agent for allogeneic HCT. The highly immunosuppressive properties of the drug are particularly appealing in the setting of non-malignant HCT, where GVHD provides no clinical benefit and relapse of malignancy is not applicable. In addition, the degree of immune suppression achieved with alemtuzumab has allowed for a reduction in the intensity of myeloablative cytotoxic agents included in some HCT conditioning regimens, allowing for fewer acute and late toxicities. This review paper will provide a comprehensive summary of the mechanism of action, PKs, dosing, and timing of alemtuzumab, a brief description of its use in various allogeneic HCT protocols for non-malignant conditions and a summary of the data regarding its use for GVHD therapy. The goal of this review was to provide an understanding as to how alemtuzumab might be safely incorporated into HCT conditioning regimens for children with non-malignant disease, allowing for expanded access to curative HCT therapy.
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Affiliation(s)
- Gregory M T Guilcher
- Section of Paediatric Oncology/BMT, Departments of Oncology and Paediatrics, University of Calgary, Calgary, AB, Canada
| | - Ravi Shah
- Department of Paediatric Haematology/BMT, Great Ormond Street Hospital, NHS Foundation Trust, London, UK
| | - Shalini Shenoy
- Division of Pediatric Hematology/Oncology, Washington University School of Medicine, St. Louis, MO, USA
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Loeff FC, Falkenburg JHF, Hageman L, Huisman W, Veld SAJ, van Egmond HME, van de Meent M, von dem Borne PA, Veelken H, Halkes CJM, Jedema I. High Mutation Frequency of thePIGAGene in T Cells Results in Reconstitution of GPI Anchor−/CD52−T Cells That Can Give Early Immune Protection after Alemtuzumab-Based T Cell–Depleted Allogeneic Stem Cell Transplantation. THE JOURNAL OF IMMUNOLOGY 2018; 200:2199-2208. [DOI: 10.4049/jimmunol.1701018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 01/09/2018] [Indexed: 12/30/2022]
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Abstract
OPINION STATEMENT Acquired aplastic anemia (AA) is a rare, life-threatening bone marrow failure (BMF) disorder that affects patients of all ages and is caused by lymphocyte destruction of early hematopoietic cells. Diagnosis of AA requires a comprehensive approach with prompt evaluation for inherited and secondary causes of bone marrow aplasia, while providing aggressive supportive care. The choice of frontline therapy is determined by a number of factors including AA severity, age of the patient, donor availability, and access to optimal therapies. For newly diagnosed severe aplastic anemia, bone marrow transplant should be pursued in all pediatric patients and in younger adult patients when a matched sibling donor is available. Frontline therapy in older adult patients and in all patients lacking a matched sibling donor involves immunosuppressive therapy (IST) with horse antithymocyte globulin and cyclosporine A. Recent improvements in upfront therapy include encouraging results with closely matched unrelated donor transplants in younger patients and the emerging benefits of eltrombopag combined with initial IST, with randomized studies underway. In the refractory setting, several therapeutic options exist, with improving outcomes of matched unrelated donor and haploidentical bone marrow transplantation as well as the addition of eltrombopag to the non-transplant AA armamentarium. With the recent appreciation of frequent clonal hematopoiesis in AA patients and with the growing use of next-generation sequencing in the clinic, utmost caution should be exercised in interpreting the significance of somatic mutations in AA. Future longitudinal studies of large numbers of patients are needed to determine the prognostic significance of somatic mutations and to guide optimal surveillance and treatment approaches to prevent long-term clonal complications.
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Affiliation(s)
- Scott A Peslak
- Division of Hematology and Oncology, Department of Medicine, Hospital of the University of Pennsylvania, Perelman Center for Advanced Medicine, 12 South, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Timothy Olson
- Comprehensive Bone Marrow Failure Center, Children's Hospital of Philadelphia, 3615 Civic Center Boulevard, Philadelphia, PA, 19104, USA
- Division of Oncology, Department of Pediatrics, Children's Hospital of Philadelphia, 3615 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Daria V Babushok
- Division of Hematology and Oncology, Department of Medicine, Hospital of the University of Pennsylvania, Perelman Center for Advanced Medicine, 12 South, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA.
- Comprehensive Bone Marrow Failure Center, Children's Hospital of Philadelphia, 3615 Civic Center Boulevard, Philadelphia, PA, 19104, USA.
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24
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Ogonek J, Varanasi P, Luther S, Schweier P, Kühnau W, Göhring G, Dammann E, Stadler M, Ganser A, Borchers S, Koehl U, Weissinger EM, Hambach L. Possible Impact of Cytomegalovirus-Specific CD8 + T Cells on Immune Reconstitution and Conversion to Complete Donor Chimerism after Allogeneic Stem Cell Transplantation. Biol Blood Marrow Transplant 2017; 23:1046-1053. [PMID: 28344058 DOI: 10.1016/j.bbmt.2017.03.027] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 03/17/2017] [Indexed: 12/22/2022]
Abstract
Complete donor chimerism is strongly associated with complete remission after allogeneic stem cell transplantation (allo-SCT) in patients with hematologic malignancies. Donor-derived allo-immune responses eliminate the residual host hematopoiesis and thereby mediate the conversion to complete donor chimerism. Recently, cytomegalovirus (CMV) reactivation was described to enhance overall T cell reconstitution, to increase graft-versus-host disease incidence, and to reduce the leukemia relapse risk. However, the link between CMV and allo-immune responses is still unclear. Here, we studied the relationship between CMV-specific immunity, overall T cell reconstitution, and residual host chimerism in 106 CMV-seropositive patients transplanted after reduced-intensity conditioning including antithymocyte globulin. In accordance with previous reports, the recovery of CMV-specific cytotoxic T cells (CMV-CTLs) was more frequent in CMV-seropositive recipients (R) transplanted from CMV-seropositive than from seronegative donors (D). However, once CMV-CTLs were detectable, the reconstitution of CMV-specific CTLs was comparable in CMV R+/D- and R+/D+ patients. CD3+ and CD8+ T cell reconstitution was significantly faster in patients with CMV-CTLs than in patients without CMV-CTLs both in the CMV R+/D- and R+/D+ setting. Moreover, CMV-CTL numbers correlated with CD3+ and CD8+ T cell numbers in both settings. Finally, presence of CMV-CTLs was associated with low host chimerism levels 3 months after allo-SCT. In conclusion, our data provide a first indication that CMV-CTLs in CMV-seropositive patients might trigger the reconstitution of T cells and allo-immune responses reflected by the conversion to complete donor chimerism.
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Affiliation(s)
- Justyna Ogonek
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Pavankumar Varanasi
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany; German Center for Infection Research (DZIF), Partner Site Hannover-Braunschweig, Germany
| | - Susanne Luther
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Patrick Schweier
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Wolfgang Kühnau
- Department Human Genetics, Hannover Medical School, Hannover, Germany
| | - Gudrun Göhring
- Department Human Genetics, Hannover Medical School, Hannover, Germany
| | - Elke Dammann
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Michael Stadler
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Arnold Ganser
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | | | - Ulrike Koehl
- Institute of Cellular Therapeutics, Hannover Medical School, Hannover, Germany
| | - Eva M Weissinger
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany; German Center for Infection Research (DZIF), Partner Site Hannover-Braunschweig, Germany
| | - Lothar Hambach
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany.
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