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Effeney B, Pullar A, Burbery J, Hargrave C, Brady C. Dose to organs at risk for total body irradiation: Single-institution data using the modulated arc total body irradiation technique. Pediatr Blood Cancer 2024; 71:e31164. [PMID: 38953144 DOI: 10.1002/pbc.31164] [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: 03/04/2024] [Revised: 06/12/2024] [Accepted: 06/12/2024] [Indexed: 07/03/2024]
Abstract
BACKGROUND Organs at risk (OAR) dose reporting for total body irradiation (TBI) patients is limited, and standardly reported only as mean doses to the lungs and kidneys. Consequently, dose received and effects on other OAR remain unexplored. To remedy this gap, this study reports dose data on an extensive list of OAR for patients treated at a single institution using the modulated arc total body irradiation (MATBI) technique. METHOD An audit was undertaken of all patients treated with MATBI between January 2015 and March 2021 who had completed their course of treatment. OAR were contoured on MATBI patient treatment plans, with 12 Gy in six fraction prescription. OAR dose statistics and dose volume histogram data are reported for the whole body, lungs, kidneys, bones, brain, lens, heart, liver and bowel bag. RESULTS The OAR dose data for 29 patients are reported. Mean dose results are body 11.77 Gy, lungs 9.86 Gy, kidneys 11.84 Gy, bones 12.03 Gy, brain 12.12 Gy, right lens 12.31 Gy, left lens 12.64 Gy, heart 11.07 Gy, liver 11.81 Gy and bowel bag 12.06 Gy. Dose statistics at 1-Gy intervals of V6-V13 for lungs and V10-V13 for kidneys are also included. CONCLUSION This is the first time an extensive list of OAR data has been reported for any TBI technique. Due to the paucity of reporting, this information could be used by centres implementing the MATBI technique, in addition to aiding comparison between TBI techniques, with the potential for greater understanding of the relationship between dose volume data and toxicity.
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Affiliation(s)
- Beth Effeney
- Radiation Oncology Princess Alexandra Hospital - Raymond Terrace, South Brisbane, Queensland, Australia
| | - Andrew Pullar
- Radiation Oncology Princess Alexandra Hospital - Raymond Terrace, South Brisbane, Queensland, Australia
| | - Julie Burbery
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Cathy Hargrave
- Radiation Oncology Princess Alexandra Hospital - Raymond Terrace, South Brisbane, Queensland, Australia
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Carole Brady
- Radiation Oncology Princess Alexandra Hospital - Raymond Terrace, South Brisbane, Queensland, Australia
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2
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Takahashi T, Lake AJ, Wachter F, Calderon FA, Dandoy C, Keating AK. Effects of Total Body Irradiation on Hematopoietic Cell Transplantation Outcomes in Pediatric Acute Myeloid Leukemia with Prior Central Nervous System Involvement. Transplant Cell Ther 2024; 30:812.e1-812.e11. [PMID: 38763417 DOI: 10.1016/j.jtct.2024.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 05/02/2024] [Accepted: 05/13/2024] [Indexed: 05/21/2024]
Abstract
The implications of previous central nervous system (CNS) involvement in children with acute myeloid leukemia (AML) undergoing hematopoietic cell transplantation (HCT) remain inadequately understood. Patients with CNS disease require more upfront CNS-directed intrathecal therapy, but little is known about whether transplant conditioning regimens should be intensified or if previous CNS involvement impacts post-HCT outcomes. While total body irradiation (TBI) remains standard for pediatric acute lymphoblastic leukemia myeloablative conditioning, it has been largely replaced with chemotherapy-only myeloablation in pediatric AML, primarily due to toxicity and late effects associated with TBI. In the setting of previous CNS involvement, it has been suggested that TBI-based myeloablation may have advantages due to superior CNS tissue penetration and thus decreased rates of AML relapse post-HCT. We analyzed a publicly available dataset derived from the Center for International Blood and Marrow Transplantation Research (CIBMTR) registry to characterize the impact of TBI in HCT preparative regimens in pediatric AML patients with a history of CNS involvement. The study dataset was obtained from the CIBMTR data repository. The study cohort included patients aged ≤21 years who underwent initial allogeneic HCT with myeloablative conditioning for de novo AML in the first or second complete remission (CR) between 2008 and 2016, who provided consent for research. Patients with mismatched related donor transplants and noncalcineurin inhibitor graft-versus-host disease (GVHD) prophylaxis were excluded. The dataset was further modified by excluding patients with missing disease site data or those with non-CNS extramedullary disease. Patients were categorized as CNS-positive or -negative AML (AML-CNS(+) and AML-CNS(-), respectively) based on the disease status at diagnosis. The Cox regression model and Fine-Grey methods were employed to delineate the effects of TBI and CNS disease on key HCT outcomes. The study cohort comprised 550 pediatric AML patients, of which 25% (n = 136) were AML-CNS(+). CNS involvement was more prevalent in patients aged 0 to 3 years, patients who were in the second CR, and those with a mismatched unrelated donor or umbilical cord blood. AML-CNS(+) patients demonstrated a lower relapse rate (hazard ratio: 0.50, 95% confidence interval: 0.33 to 0.76) compared to AML-CNS(-) patients, with comparable disease-free survival (DFS) and overall survival (OS) (P = .10 and 0.20, respectively) in the two cohorts. The entire TBI-treated cohort showed an association with increased risks of grade 2 to 4 acute GVHD, bloodstream infections, and endocrine dysfunction. TBI use within the AML-CNS(+) cohort was associated with a lower relapse rate but increased risks of nonrelapse mortality and a trend of higher grade 3 to 4 acute GVHD. In this population-based analysis of pediatric patients with de novo AML undergoing HCT, TBI-based conditioning regimens did not confer an advantage in DFS or OS compared to non-TBI regimens, irrespective of CNS disease status. However, TBI use was associated with increased risks of short- and long-term comorbidities. These findings underscore the need for careful consideration of TBI in pediatric AML.
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Affiliation(s)
- Takuto Takahashi
- Pediatric Stem Cell Transplant, Boston Children's Hospital and Dana-Farber Cancer Institute, Boston, Massachusetts.
| | - Alexander J Lake
- Pediatric Stem Cell Transplant, Boston Children's Hospital and Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Franziska Wachter
- Pediatric Stem Cell Transplant, Boston Children's Hospital and Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Francesca Alvarez Calderon
- Pediatric Stem Cell Transplant, Boston Children's Hospital and Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Christopher Dandoy
- Pediatric Stem Cell Transplant, Boston Children's Hospital and Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Amy K Keating
- Pediatric Stem Cell Transplant, Boston Children's Hospital and Dana-Farber Cancer Institute, Boston, Massachusetts
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3
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Saultier P, Michel G. How I treat long-term survivors of childhood acute leukemia. Blood 2024; 143:1795-1806. [PMID: 38227937 DOI: 10.1182/blood.2023019804] [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: 06/01/2023] [Revised: 01/08/2024] [Accepted: 01/08/2024] [Indexed: 01/18/2024] Open
Abstract
ABSTRACT The population of survivors of childhood leukemia who reach adulthood is growing due to improved therapy. However, survivors are at risk of long-term complications. Comprehensive follow-up programs play a key role in childhood leukemia survivor care. The major determinant of long-term complications is the therapeutic burden accumulated over time. Relapse chemotherapy, central nervous system irradiation, hematopoietic stem cell transplantation, and total body irradiation are associated with greater risk of long-term complications. Other parameters include clinical characteristics such as age and sex as well as environmental, genetic, and socioeconomic factors, which can help stratify the risk of long-term complications and organize follow-up program. Early diagnosis improves the management of several late complications such as anthracycline-related cardiomyopathy, secondary cancers, metabolic syndrome, development defects, and infertility. Total body irradiation is the treatment associated with worse long-term toxicity profile with a wide range of complications. Patients treated with chemotherapy alone are at a lower risk of long-term complications, although the optimal long-term follow-up remains unclear. Novel immunotherapies and targeted therapy are generally associated with a better short-term safety profile but still require careful long-term toxicity monitoring. Advances in understanding genetic susceptibility to long-term complications could enable tailored therapeutic strategies for leukemia treatment and optimized follow-up programs.
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Affiliation(s)
- Paul Saultier
- Department of Pediatric Hematology, Immunology and Oncology, Aix Marseille Université, APHM, INSERM, INRAe, C2VN, La Timone Children's Hospital, Marseille, France
| | - Gérard Michel
- Department of Pediatric Hematology, Immunology and Oncology, Aix Marseille Université, APHM, CERESS, La Timone Children's Hospital, Marseille, France
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4
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Yamada S, Maruyama Y, Saito S, Komori K, Morokawa H, Okura E, Hirabayashi K, Furui Y, Kurata T, Nishioka M, Fukuyama T, Sakashita K, Nakazawa Y. Successful haploidentical bone marrow transplantation in Griscelli syndrome type 2 with non-busulfan-based regimen and post-transplantation cyclophosphamide: a case report and review of the literature. Pediatr Hematol Oncol 2024; 41:296-300. [PMID: 37906298 DOI: 10.1080/08880018.2023.2273880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 10/17/2023] [Indexed: 11/02/2023]
Affiliation(s)
- Saori Yamada
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
| | - Yuta Maruyama
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
| | - Shoji Saito
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
| | - Kazutoshi Komori
- Department of Hematology and Oncology, Nagano Children's Hospital, Azumino, Japan
| | - Hirokazu Morokawa
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
- Department of Hematology and Oncology, Nagano Children's Hospital, Azumino, Japan
| | - Eri Okura
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
| | - Koichi Hirabayashi
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
| | - Yu Furui
- Department of Hematology and Oncology, Nagano Children's Hospital, Azumino, Japan
| | - Takashi Kurata
- Department of Hematology and Oncology, Nagano Children's Hospital, Azumino, Japan
| | - Makoto Nishioka
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
| | - Tetsuhiro Fukuyama
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
| | - Kazuo Sakashita
- Department of Hematology and Oncology, Nagano Children's Hospital, Azumino, Japan
| | - Yozo Nakazawa
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
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5
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Zinter MS, Brazauskas R, Strom J, Chen S, Bo-Subait S, Sharma A, Beitinjaneh A, Dimitrova D, Guilcher G, Preussler J, Myers K, Bhatt NS, Ringden O, Hematti P, Hayashi RJ, Patel S, De Oliveira SN, Rotz S, Badawy SM, Nishihori T, Buchbinder D, Hamilton B, Savani B, Schoemans H, Sorror M, Winestone L, Duncan C, Phelan R, Dvorak CC. Intensive care risk and long-term outcomes in pediatric allogeneic hematopoietic cell transplant recipients. Blood Adv 2024; 8:1002-1017. [PMID: 38127268 PMCID: PMC10879681 DOI: 10.1182/bloodadvances.2023011002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 11/16/2023] [Accepted: 12/05/2023] [Indexed: 12/23/2023] Open
Abstract
ABSTRACT Allogeneic hematopoietic cell transplantation (HCT) can be complicated by life-threatening organ toxicity and infection necessitating intensive care. Epidemiologic data have been limited by single-center studies, poor database granularity, and a lack of long-term survivors. To identify contemporary trends in intensive care unit (ICU) use and long-term outcomes, we merged data from the Center for International Blood and Marrow Transplant Research and the Virtual Pediatric Systems databases. We identified 6995 pediatric patients with HCT aged ≤21 years who underwent first allogeneic HCT between 2008 and 2014 across 69 centers in the United States or Canada and followed patients until the year 2020. ICU admission was required for 1067 patients (8.3% by day +100, 12.8% by 1 year, and 15.3% by 5 years after HCT), and was linked to demographic background, pretransplant organ toxicity, allograft type and HLA-match, and the development of graft-versus-host disease or malignancy relapse. Survival to ICU discharge was 85.7%, but more than half of ICU survivors required ICU readmission, leading to 52.5% and 42.6% survival at 1- and 5-years post-ICU transfer, respectively. ICU survival was worse among patients with malignant disease, poor pretransplant organ function, and alloreactivity risk factors. Among 1-year HCT survivors, those who required ICU in the first year had 10% lower survival at 5 years and developed new dialysis-dependent renal failure at a greater rate (P<.001). Thus, although ICU management is common and survival to ICU discharge is high, ongoing complications necessitate recurrent ICU admission and lead to a poor 1-year outcome in select patients who are at high risk.
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Affiliation(s)
- Matt S. Zinter
- Division of Critical Care Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, CA
- Division of Allergy, Immunology, and BMT, Department of Pediatrics, University of California, San Francisco, San Francisco, CA
| | | | | | | | | | | | | | - Dimana Dimitrova
- National Institutes of Health, National Cancer Institute, Bethesda, MD
| | | | | | - Kasiani Myers
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | | | - Olle Ringden
- Karolinska Institutet, Karolinska University Hospital, Huddinge, Sweden
| | | | | | - Sagar Patel
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | | | | | - Sherif M. Badawy
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | | | | | - Bipin Savani
- Vanderbilt University Medical Center, Nashville, TN
| | | | | | - Lena Winestone
- Division of Allergy, Immunology, and BMT, Department of Pediatrics, University of California, San Francisco, San Francisco, CA
| | | | | | - Christopher C. Dvorak
- Division of Allergy, Immunology, and BMT, Department of Pediatrics, University of California, San Francisco, San Francisco, CA
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6
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Bader P, Pötschger U, Dalle JH, Moser LM, Balduzzi A, Ansari M, Buechner J, Güngör T, Ifversen M, Krivan G, Pichler H, Renard M, Staciuk R, Sedlacek P, Stein J, Heusel JR, Truong T, Wachowiak J, Yesilipek A, Locatelli F, Peters C. Low rate of nonrelapse mortality in under-4-year-olds with ALL given chemotherapeutic conditioning for HSCT: a phase 3 FORUM study. Blood Adv 2024; 8:416-428. [PMID: 37738088 PMCID: PMC10827403 DOI: 10.1182/bloodadvances.2023010591] [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: 05/01/2023] [Revised: 09/05/2023] [Accepted: 09/08/2023] [Indexed: 09/23/2023] Open
Abstract
ABSTRACT Allogeneic hematopoietic stem cell transplantation (HSCT) is highly effective for treating pediatric high-risk or relapsed acute lymphoblastic leukemia (ALL). For young children, total body irradiation (TBI) is associated with severe late sequelae. In the FORUM study (NCT01949129), we assessed safety, event-free survival (EFS), and overall survival (OS) of 2 TBI-free conditioning regimens in children aged <4 years with ALL. Patients received fludarabine (Flu), thiotepa (Thio), and either busulfan (Bu) or treosulfan (Treo) before HSCT. From 2013 to 2021, 191 children received transplantation and were observed for ≥6 months (median follow-up: 3 years). The 3-year OS was 0.63 (95% confidence interval [95% CI], 0.52-0.72) and 0.76 (95% CI, 0.64-0.84) for Flu/Thio/Bu and Flu/Thio/Treo (P = .075), respectively. Three-year EFS was 0.52 (95% CI, 0.41-0.61) and 0.51 (95% CI, 0.39-0.62), respectively (P = .794). Cumulative incidence of nonrelapse mortality (NRM) and relapse at 3 years were 0.06 (95% CI, 0.02-0.12) vs 0.03 (95% CI: <0.01-0.09) (P = .406) and 0.42 (95% CI, 0.31-0.52) vs 0.45 (95% CI, 0.34-0.56) (P = .920), respectively. Grade >1 acute graft-versus-host disease (GVHD) occurred in 29% of patients receiving Flu/Thio/Bu and 17% of those receiving Flu/Thio/Treo (P = .049), whereas grade 3/4 occurred in 10% and 9%, respectively (P = .813). The 3-year incidence of chronic GVHD was 0.07 (95% CI, 0.03-0.13) vs 0.05 (95% CI, 0.02-0.11), respectively (P = .518). In conclusion, both chemotherapeutic conditioning regimens were well tolerated and NRM was low. However, relapse was the major cause of treatment failure. This trial was registered at www.clinicaltrials.gov as #NCT01949129.
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Affiliation(s)
- Peter Bader
- Goethe University, University Hospital, Department of Pediatrics, Division for Stem Cell Transplantation, Immunology and Intensive Care Medicine, Frankfurt, Germany
| | | | - Jean-Hugues Dalle
- Pediatric Hematology and Immunology Department, Robert Debré Hospital, Groupe Hospitalo-Universitaire Assistance Publique Hôpitaux de Paris (GHU AP-HP) Nord, Université Paris Cité, Paris, France
| | - Laura M. Moser
- Goethe University, University Hospital, Department of Pediatrics, Division for Stem Cell Transplantation, Immunology and Intensive Care Medicine, Frankfurt, Germany
| | - Adriana Balduzzi
- Università degli Studi di Milano-Fondazione, FONDAZIONE MONZA E BRIANZA PER IL BAMBINO E LA SUA MAMMA (MBBM), Department for Pediatric Hematology and Oncology, Monza, Italy
| | - Marc Ansari
- CANSEARCH Research Platform for Pediatric Oncology and Hematology, Faculty of Medicine, Department of Pediatrics, Gynecology and Obstetrics, University of Geneva, Switzerland
- Division of Pediatric Oncology and Hematology, Department of Women, Child and Adolescent, University Geneva Hospitals, Geneva, Switzerland
| | - Jochen Buechner
- Department of Pediatric Hematology and Oncology, Oslo University Hospital, Oslo, Norway
| | - Tayfun Güngör
- Department of Hematology/Oncology/Immunology, Gene Therapy, and Stem Cell Transplantation, University Children's Hospital Zürich, Eleonore Foundation & Children’s Research Center, Zürich, Switzerland
| | - Marianne Ifversen
- Copenhagen University Hospital Rigshospitalet, Department for Pediatric Hematology and Oncology, Copenhagen, Denmark
| | - Gergely Krivan
- Pediatric Hematology and Stem Cell Transplantation Department, Central Hospital of Southern Pest, National Institute of Hematology and Infectious Diseases, Budapest, Hungary
| | - Herbert Pichler
- St. Anna Children's Hospital, University Vienna, Vienna, Austria
| | - Marleen Renard
- Department of Paediatric Oncology, University Hospital Leuven, Leuven, Belgium
| | - Raquel Staciuk
- Hospital de Pediatría “Prof. Dr. Juan P. Garrahan,” Buenos Aires, Buenos Aires, Argentina
| | - Petr Sedlacek
- Department of Pediatric Hematology and Oncology, Motol University Hospital, Prague, Czech Republic
| | - Jerry Stein
- Schneider Children's Medical Center of Israel and Sackler Faculty of Medicine, Tel Aviv University, Petah Tikva, Israel
| | - Jan Robert Heusel
- Goethe University, University Hospital, Department of Pediatrics, Division for Stem Cell Transplantation, Immunology and Intensive Care Medicine, Frankfurt, Germany
| | - Tony Truong
- Division of Pediatric Oncology and Cellular Therapy, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Jacek Wachowiak
- Department of Pediatric Oncology, Hematology and Transplantology, Poznań University of Medical Sciences, Poznań, Poland
| | | | - Franco Locatelli
- Department of Pediatric Hematology and Oncology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale Pediatrico Bambino Gesù, Catholic University of the Sacred Heart, Rome, Italy
| | - Christina Peters
- St. Anna Children's Cancer Research Institute, Vienna, Austria
- St. Anna Children's Hospital, University Vienna, Vienna, Austria
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Snyder EJ, Sarma A, Poussaint TY, Krishnasarma R, Pruthi S. Complications of Cancer Therapy in Children: A Comprehensive Review of Neuroimaging Findings. J Comput Assist Tomogr 2023; 47:820-832. [PMID: 37707414 DOI: 10.1097/rct.0000000000001481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
ABSTRACT Complications of cancer therapy in children can result in a spectrum of neurologic toxicities that may occur at the initiation of therapy or months to years after treatment. Although childhood cancer remains rare, increasing survival rates mean that more children will be living longer after cancer treatment. Therefore, complications of cancer therapy will most likely occur with increasing frequency.At times, it is very difficult to differentiate between therapeutic complications and other entities such as tumor recurrence, development of secondary malignancy, and infection (among other conditions). Radiologists often play a key role in the diagnosis and evaluation of pediatric patients with malignancies, and thus, awareness of imaging findings of cancer complications and alternative diagnoses is essential in guiding management and avoiding misdiagnosis. The aim of this review article is to illustrate the typical neuroimaging findings of cancer therapy-related toxicities, including both early and late treatment effects, highlighting pearls that may aid in making the appropriate diagnosis.
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Affiliation(s)
- Elizabeth J Snyder
- From the Department of Radiology, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
| | - Asha Sarma
- From the Department of Radiology, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
| | | | - Rekha Krishnasarma
- From the Department of Radiology, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
| | - Sumit Pruthi
- From the Department of Radiology, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
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8
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Zinter MS, Brazauskas R, Strom J, Chen S, Bo-Subait S, Sharma A, Beitinjaneh A, Dimitrova D, Guilcher G, Preussler J, Myers K, Bhatt NS, Ringden O, Hematti P, Hayashi RJ, Patel S, De Oliveira SN, Rotz S, Badawy SM, Nishihori T, Buchbinder D, Hamilton B, Savani B, Schoemans H, Sorror M, Winestone L, Duncan C, Phelan R, Dvorak CC. Critical Illness Risk and Long-Term Outcomes Following Intensive Care in Pediatric Hematopoietic Cell Transplant Recipients. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.07.31.23293444. [PMID: 37577706 PMCID: PMC10418579 DOI: 10.1101/2023.07.31.23293444] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Abstract
Background Allogeneic hematopoietic cell transplantation (HCT) can be complicated by the development of organ toxicity and infection necessitating intensive care. Risk factors for intensive care admission are unclear due to heterogeneity across centers, and long-term outcome data after intensive care are sparse due to a historical paucity of survivors. Methods The Center for International Blood and Marrow Transplant Research (CIBMTR) was queried to identify patients age ≤21 years who underwent a 1st allogeneic HCT between 2008-2014 in the United States or Canada. Records were cross-referenced with the Virtual Pediatric Systems pediatric ICU database to identify intensive care admissions. CIBMTR follow-up data were collected through the year 2020. Result We identified 6,995 pediatric HCT patients from 69 HCT centers, of whom 1,067 required post-HCT intensive care. The cumulative incidence of PICU admission was 8.3% at day +100, 12.8% at 1 year, and 15.3% at 5 years post HCT. PICU admission was linked to younger age, lower median zip code income, Black or multiracial background, pre-transplant organ toxicity, pre-transplant CMV seropositivity, use of umbilical cord blood and/or HLA-mismatched allografts, and the development of post-HCT graft-versus-host disease or malignancy relapse. Among PICU patients, survival to ICU discharge was 85.7% but more than half of ICU survivors were readmitted to a PICU during the study interval. Overall survival from the time of 1st PICU admission was 52.5% at 1 year and 42.6% at 5 years. Long-term post-ICU survival was worse among patients with malignant disease (particularly if relapsed), as well as those with poor pre-transplant organ function and alloreactivity risk-factors. In a landmark analysis of all 1-year HCT survivors, those who required intensive care in the first year had 10% lower survival at 5 years (77.1% vs. 87.0%, p<0.001) and developed new dialysis-dependent renal failure at a greater rate (p<0.001). Conclusions Intensive care management is common in pediatric HCT patients. Survival to ICU discharge is high, but ongoing complications necessitate recurrent ICU admission and lead to a poor 1-year outcome in many patients. Together, these data suggest an ongoing burden of toxicity in pediatric HCT patients that continues to limit long-term survival.
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Affiliation(s)
- Matt S Zinter
- Department of Pediatrics, Division of Critical Care Medicine, University of California, San Francisco, San Francisco, CA, USA
- Department of Pediatrics, Division of Allergy, Immunology, and BMT, University of California, San Francisco, San Francisco, CA, USA
| | | | - Joelle Strom
- Medical College of Wisconsin, Milwaukee, WI, USA
| | - Stella Chen
- Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Akshay Sharma
- St. Jude Children's Research Hospital, Memphis, TN, USA
| | | | - Dimana Dimitrova
- National Institutes of Health, National Cancer Institute, Bethesda, MD, USA
| | | | - Jaime Preussler
- National Marrow Donor Program/Be The Match, Minneapolis, MN, USA
| | - Kasiani Myers
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Olle Ringden
- Karolinska Institutet, Karolinska University Hospital, Huddinge, The Netherlands
| | | | | | - Sagar Patel
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | | | - Seth Rotz
- Cleveland Clinic, Cleveland, OH, USA
| | - Sherif M Badawy
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | | | - Bipin Savani
- Vanderbilt University Medical Center, Nashville, TN, USA
| | | | | | - Lena Winestone
- Department of Pediatrics, Division of Allergy, Immunology, and BMT, University of California, San Francisco, San Francisco, CA, USA
| | | | | | - Christopher C Dvorak
- Department of Pediatrics, Division of Allergy, Immunology, and BMT, University of California, San Francisco, San Francisco, CA, USA
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9
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Siemaszko J, Ussowicz M, Rybka B, Ryczan-Krawczyk R, Kałwak K, Bogunia-Kubik K. The impact of NKG2A and NKG2D receptors and HLA-E and MICA ligands polymorphisms on post-transplant complications after paediatric allogeneic HSCT: a single-centre experience. Front Genet 2023; 14:1186123. [PMID: 37351346 PMCID: PMC10282657 DOI: 10.3389/fgene.2023.1186123] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 05/16/2023] [Indexed: 06/24/2023] Open
Abstract
Introduction: Natural Killer cells are the first subpopulation of lymphocytes that reconstitute after allogeneic haematopoietic stem cell transplantation (HSCT). Their activity is regulated by various receptor-ligand interactions, including stimulation of the activating NKG2D receptor by the MICA molecule, and inhibitory NKG2A receptor interacting with the HLA-E. In this study the research effort focused on the effect of selected NKG2A and NKG2D receptors and their ligands (HLA-E and MICA molecules) polymorphisms that may affect the pathomechanisms of post-transplant complications after HSCT in children. Methods: One hundred donor-recipient pairs from a single paediatric transplantation centre were investigated. Altogether six single nucleotide substitutions (NKG2A rs7301582; NKG2D rs1049174, rs1154831; HLA-E rs1264457; MICA rs1051792, rs1063635) were genotyped, and the influence of polymorphisms was analysed on acute and chronic graft-versus-host disease (GvHD), cytomegalovirus (CMV) infection incidence, disease relapse and survival. Results: The distribution of the evaluated polymorphisms did not differ between patients and their donors. The results showed a significant influence of HLA-E rs1264457 polymorphism in patients' HLA-E*01:01 allele, which was associated with increased risk of CMV infection (p = 0.050), especially in children positive for CMV IgG before transplantation (p = 0.001). Furthermore, the effect of HLA-E*01:01 allele on CMV infections was more evident in children above the age of 7 years (p = 0.031). Strong tendencies (0.05 < p < 0.10) towards association with the risk of acute GvHD were also observed for the NKG2A or MICA polymorphisms of the recipients. In addition, NKG2D rs1154831 AA and MICA rs1063635 GG might play a protective role as they were not present in any recipient who died after transplantation. Conclusion: In summary, there is emerging evidence that genotyping results of NKG2 receptors and their ligands, may have prognostic value for the outcome of paediatric allogeneic HSCT, but more extensive studies performed on larger groups of donors and transplant recipients are required to confirm these observations.
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Affiliation(s)
- Jagoda Siemaszko
- Laboratory of Clinical Immunogenetics and Pharmacogenetics, Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, Wroclaw, Poland
| | - Marek Ussowicz
- Department and Clinic of Paediatric Bone Marrow Transplantation, Oncology and Haematology, Wroclaw Medical University, Wroclaw, Poland
| | - Blanka Rybka
- Department and Clinic of Paediatric Bone Marrow Transplantation, Oncology and Haematology, Wroclaw Medical University, Wroclaw, Poland
| | - Renata Ryczan-Krawczyk
- Department and Clinic of Paediatric Bone Marrow Transplantation, Oncology and Haematology, Wroclaw Medical University, Wroclaw, Poland
| | - Krzysztof Kałwak
- Department and Clinic of Paediatric Bone Marrow Transplantation, Oncology and Haematology, Wroclaw Medical University, Wroclaw, Poland
| | - Katarzyna Bogunia-Kubik
- Laboratory of Clinical Immunogenetics and Pharmacogenetics, Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, Wroclaw, Poland
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10
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Kelkar AH, Antin JH, Shapiro RM. Long-term health outcomes of allogeneic hematopoietic stem cell transplantation. Front Oncol 2023; 13:1175794. [PMID: 37124489 PMCID: PMC10130410 DOI: 10.3389/fonc.2023.1175794] [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: 02/28/2023] [Accepted: 03/29/2023] [Indexed: 05/02/2023] Open
Abstract
Background Fifty years of hematopoietic cell transplantation (HCT) has ushered in an exciting era of cellular therapy and has led to enormous progress in improving the outcomes of patients with both malignant and non-malignant hematologic disease. As the survival of transplanted patients has increased, so has the recognition of long-term complications related to this therapy. Purpose The goal of this review is to highlight some of the most common long-term complications of HCT. Data sources To this end, we have conducted a review of the published literature on the long-term complications of HCT encompassing the past 50 years. Study selection We have endeavored to include long-term complications reported in research articles, case series and case reports, reviews, and abstracts. We have focused primarily on adult allogeneic HCT, but have included some data from studies of pediatric allogeneic HCT as well. We have also prioritized the literature published in the last 15 years. Data extraction Key data supporting the onset and prevalence of the most common long-term complications was extracted. Limitations While the list of long-term complications extracted and reported was comprehensive, it was not exhaustive. Conclusions We have endeavored to highlight some of the most common long-term complications of HCT, the recognition and management of which constitutes an important part of HCT survivorship care.
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Affiliation(s)
- Amar H. Kelkar
- Division of Stem Cell Transplantation and Cellular Therapies, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
- Department of Medicine, Harvard Medical School, Boston, MA, United States
| | - Joseph H. Antin
- Division of Stem Cell Transplantation and Cellular Therapies, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
- Department of Medicine, Harvard Medical School, Boston, MA, United States
| | - Roman M. Shapiro
- Division of Stem Cell Transplantation and Cellular Therapies, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
- Department of Medicine, Harvard Medical School, Boston, MA, United States
- *Correspondence: Roman M. Shapiro,
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11
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Lee CJ, Wang T, Chen K, Arora M, Brazauskas R, Spellman SR, Kitko C, MacMillan ML, Pidala JA, Auletta JJ, Badawy SM, Bhatt N, Bhatt VR, Cahn JY, DeFilipp Z, Diaz MA, Farhadfar N, Gadalla S, Gale RP, Hashem H, Hashmi S, Hematti P, Hong S, Hossain NM, Inamoto Y, Lekakis LJ, Modi D, Patel S, Sharma A, Solomon S, Couriel DR. Association of Chronic Graft-versus-Host Disease with Late Effects following Allogeneic Hematopoietic Cell Transplantation for Children with Hematologic Malignancy. Transplant Cell Ther 2022; 28:712.e1-712.e8. [PMID: 35863740 PMCID: PMC9547959 DOI: 10.1016/j.jtct.2022.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 06/15/2022] [Accepted: 07/12/2022] [Indexed: 10/17/2022]
Abstract
Chronic graft-versus-host disease (cGVHD) occurs in up to 25% of children following allogeneic hematopoietic cell transplantation (HCT) and continues to be a major cause of late morbidity and poor quality of life among long-term survivors of pediatric HCT. Late effects (LEs) of HCT are well documented in this population, and cGVHD has been identified as a risk factor for subsequent neoplasms (SNs) and several nonmalignant LEs (NM-LEs); however, the reported correlation between cGVHD and LEs varies among studies. We compared LEs occurring ≥2 years following childhood HCT for a hematologic malignancy in 2-year disease-free survivors with and without cGVHD and further evaluated the association of cGVHD features on the development of LEs. This systematic retrospective analysis used data from the Center of International Blood and Marrow Transplant Research (CIBMTR) on a large, representative cohort of 1260 survivors of pediatric HCT for hematologic malignancy to compare first malignant LEs and NM-LEs in those with a diagnosis of cGVHD and those who never developed cGVHD. The cumulative incidences of any first LE, SN, and NM-LE were estimated at 10 years after HCT, with death as a competing risk for patients with cGVHD versus no cGVHD. Cox proportional hazards models were used to evaluate the impact of cGVHD and its related characteristics on the development of first LEs. The estimated 10-year cumulative incidence of any LE in patients with and without cGVHD was 43% (95% CI, 38% to 48.2%) versus 32% (95% confidence interval [CI], 28.5% to 36.3%) (P < .001), respectively. The development of cGVHD by 2 years post-HCT was independently associated with any LE (hazard ratio [HR], 1.38; 95% CI, 1.13 to 1.68; P = .001) and NM-LE (HR, 1.37; 95% CI, 1.10 to 1.70; P = .006), but not SN (HR, 1.30; 95% CI, .73 to 2.31; P = .38). cGVHD-related factors linked with the development of an NM-LE included having extensive grade cGVHD (HR, 1.60; 95% CI, 1.23 to 2.08; P = .0005), severe cGVHD (HR, 2.25; 95% CI, 1.60 to 3.17; P < .0001), interrupted onset type (HR, 1.57; 95% CI, 1.21 to 2.05; P = .0008), and both mucocutaneous and visceral organ involvement (HR, 1.59; 95% CI, 1.24 to 2.03; P = .0002). No significant association between cGVHD-specific variables and SN was identified. Finally, the duration of cGVHD treatment of cGVHD with systemic immunosuppression was not significantly associated with SNs or NM-LEs. cGVHD was more closely associated with NM-LEs than with SNs among survivors of pediatric HCT for hematologic malignancy. In this analysis, the development of SNs was strongly associated with the use of myeloablative total body irradiation. cGVHD-related characteristics consistent with a state of greater immune dysregulation were more closely linked to NM-LEs.
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Affiliation(s)
- Catherine J Lee
- The University of Utah Transplant and Cellular Therapy Program, Salt Lake City, Utah.
| | - Tao Wang
- Division of Biostatistics, Institute for Heath and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin; Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Karen Chen
- Division of Biostatistics, Institute for Heath and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin; Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Mukta Arora
- Division of Hematology, Oncology and Transplant, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Ruta Brazauskas
- Division of Biostatistics, Institute for Heath and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin; Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Stephen R Spellman
- Center for International Blood and Marrow Transplant Research, National Marrow Donor Program, Minneapolis, Minnesota
| | - Carrie Kitko
- Department of Pediatrics, Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Margaret L MacMillan
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota; Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Joseph A Pidala
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Jeffery J Auletta
- Department of Hematology/Oncology/BMT and Infectious Diseases, Nationwide Children's Hospital, Ohio State University, Columbus, Ohio
| | - Sherif M Badawy
- Hematology, Oncology and Stem Cell Transplantation, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Evanston, Illinois
| | - Neel Bhatt
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Vijaya R Bhatt
- Section of Hematology, University of Nebraska, Omaha, Nebraska
| | - Jean-Yves Cahn
- Department of Hematology, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Zachariah DeFilipp
- Blood and Marrow Transplant Program, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Nosha Farhadfar
- Division of Hematology/Oncology, University of Florida College of Medicine, Gainesville, Florida
| | - Shahinaz Gadalla
- Clinical Genetics Branch, National Cancer Institute, Rockville, Maryland
| | - Robert P Gale
- Haematology Section, Division of Experimental Medicine, Department of Medicine, Imperial College London, London, United Kingdom
| | - Hasan Hashem
- Department of Pediatrics, Pediatric Bone Marrow Transplantation, King Hussein Cancer Center, Amman, Jordan
| | - Shahrukh Hashmi
- Department of Internal Medicine, Mayo Clinic, Minnesota; Department of Medicine, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
| | - Peiman Hematti
- Section of Hematology/Oncology, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin
| | - Sanghee Hong
- Department of Hematology and Oncology, University Hospitals, Case Western Reserve University, Cleveland, Ohio
| | - Nasheed M Hossain
- Loyola University Chicago-Stritch School of Medicine, Maywood, Illinois
| | - Yoshihiro Inamoto
- Division of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | | | - Dipenkumar Modi
- Department of Oncology, Barbara Ann Karmanos Cancer Institute, Wayne State University, Detroit, Michigan
| | - Sager Patel
- The University of Utah Transplant and Cellular Therapy Program, Salt Lake City, Utah
| | - Akshay Sharma
- Department of Bone Marrow Transplantation and Cellular Therapy, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Scott Solomon
- Northside Hospital Cancer Institute, Atlanta, Georgia
| | - Daniel R Couriel
- The University of Utah Transplant and Cellular Therapy Program, Salt Lake City, Utah
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12
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Hoeben BAW, Pazos M, Seravalli E, Bosman ME, Losert C, Albert MH, Boterberg T, Ospovat I, Mico Milla S, Demiroz Abakay C, Engellau J, Jóhannesson V, Kos G, Supiot S, Llagostera C, Bierings M, Scarzello G, Seiersen K, Smith E, Ocanto A, Ferrer C, Bentzen SM, Kobyzeva DA, Loginova AA, Janssens GO. ESTRO ACROP and SIOPE recommendations for myeloablative Total Body Irradiation in children. Radiother Oncol 2022; 173:119-133. [PMID: 35661674 DOI: 10.1016/j.radonc.2022.05.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 05/26/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND PURPOSE Myeloablative Total Body Irradiation (TBI) is an important modality in conditioning for allogeneic hematopoietic stem cell transplantation (HSCT), especially in children with high-risk acute lymphoblastic leukemia (ALL). TBI practices are heterogeneous and institution-specific. Since TBI is associated with multiple late adverse effects, recommendations may help to standardize practices and improve the outcome versus toxicity ratio for children. MATERIAL AND METHODS The European Society for Paediatric Oncology (SIOPE) Radiotherapy TBI Working Group together with ESTRO experts conducted a literature search and evaluation regarding myeloablative TBI techniques and toxicities in children. Findings were discussed in bimonthly virtual meetings and consensus recommendations were established. RESULTS Myeloablative TBI in HSCT conditioning is mostly performed for high-risk ALL patients or patients with recurring hematologic malignancies. TBI is discouraged in children <3-4 years old because of increased toxicity risk. Publications regarding TBI are mostly retrospective studies with level III-IV evidence. Preferential TBI dose in children is 12-14.4 Gy in 1.6-2 Gy fractions b.i.d. Dose reduction should be considered for the lungs to <8 Gy, for the kidneys to ≤10 Gy, and for the lenses to <12 Gy, for dose rates ≥6 cGy/min. Highly conformal techniques i.e. TomoTherapy and VMAT TBI or Total Marrow (and/or Lymphoid) Irradiation as implemented in several centers, improve dose homogeneity and organ sparing, and should be evaluated in studies. CONCLUSIONS These ESTRO ACROP SIOPE recommendations provide expert consensus for conventional and highly conformal myeloablative TBI in children, as well as a supporting literature overview of TBI techniques and toxicities.
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Affiliation(s)
- Bianca A W Hoeben
- Dept. of Radiation Oncology, University Medical Center Utrecht, The Netherlands; Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.
| | - Montserrat Pazos
- Dept. of Radiation Oncology, University Hospital, LMU Munich, Germany
| | - Enrica Seravalli
- Dept. of Radiation Oncology, University Medical Center Utrecht, The Netherlands
| | - Mirjam E Bosman
- Dept. of Radiation Oncology, University Medical Center Utrecht, The Netherlands
| | - Christoph Losert
- Dept. of Radiation Oncology, University Hospital, LMU Munich, Germany
| | - Michael H Albert
- Dept. of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Germany
| | - Tom Boterberg
- Dept. of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Inna Ospovat
- Dept. of Radiation Oncology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Soraya Mico Milla
- Dept. of Radiation Oncology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Candan Demiroz Abakay
- Dept. of Radiation Oncology, Uludag University Faculty of Medicine Hospital, Bursa, Turkey
| | - Jacob Engellau
- Dept. of Radiation Oncology, Skåne University Hospital, Lund, Sweden
| | | | - Gregor Kos
- Dept. of Radiation Oncology, Institute of Oncology Ljubljana, Slovenia
| | - Stéphane Supiot
- Dept. of Radiation Oncology, Institut de Cancérologie de l'Ouest, Nantes St. Herblain, France
| | - Camille Llagostera
- Dept. of Medical Physics, Institut de Cancérologie de l'Ouest, Nantes St. Herblain, France
| | - Marc Bierings
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Giovanni Scarzello
- Dept. of Radiation Oncology, Veneto Institute of Oncology-IRCCS, Padua, Italy
| | | | - Ed Smith
- Dept. of Radiation Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Abrahams Ocanto
- Dept. of Radiation Oncology, La Paz University Hospital, Madrid, Spain
| | - Carlos Ferrer
- Dept. of Medical Physics and Radiation Protection, La Paz University Hospital, Madrid, Spain
| | - Søren M Bentzen
- Dept. of Epidemiology and Public Health, Division of Biostatistics and Bioinformatics, University of Maryland School of Medicine, Baltimore, United States
| | - Daria A Kobyzeva
- Dept. of Radiation Oncology, Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Anna A Loginova
- Dept. of Radiation Oncology, Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Geert O Janssens
- Dept. of Radiation Oncology, University Medical Center Utrecht, The Netherlands; Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
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13
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Marsh RA, Hebert K, Kim S, Dvorak CC, Aquino VM, Baker KS, Chellapandian D, Saldaña BD, Duncan CN, Eckrich MJ, Georges GE, Olson TS, Pulsipher MA, Shenoy S, Stenger E, Lugt MV, Yu LC, Gennery AR, Eapen M. Comparison of hematopoietic cell transplant conditioning regimens for hemophagocytic lymphohistiocytosis disorders. J Allergy Clin Immunol 2022; 149:1097-1104.e2. [PMID: 34375618 PMCID: PMC8821728 DOI: 10.1016/j.jaci.2021.07.031] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 07/29/2021] [Accepted: 07/30/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Allogeneic hematopoietic cell transplantation for hemophagocytic lymphohistiocytosis (HLH) disorders is associated with substantial morbidity and mortality. OBJECTIVE The effect of conditioning regimen groups of varying intensity on outcomes after transplantation was examined to identify an optimal regimen or regimens for HLH disorders. METHODS We studied 261 patients with HLH disorders transplanted between 2005 and 2018. Risk factors for transplantation outcomes by conditioning regimen groups were studied by Cox regression models. RESULTS Four regimen groups were studied: (1) fludarabine (Flu) and melphalan (Mel) in 123 subjects; (2) Flu, Mel, and thiotepa (TT) in 28 subjects; (3) Flu and busulfan (Bu) in 14 subjects; and (4) Bu and cyclophosphamide (Cy) in 96 subjects. The day 100 incidence of veno-occlusive disease was lower with Flu/Mel (4%) and Flu/Mel/TT (0%) compared to Flu/Bu (14%) and Bu/Cy (22%) (P < .001). The 6-month incidence of viral infections was highest after Flu/Mel (72%) and Flu/Mel/TT (64%) compared to Flu/Bu (39%) and Bu/Cy (38%) (P < .001). Five-year event-free survival (alive and engrafted without additional cell product administration) was lower with Flu/Mel (44%) compared to Flu/Mel/TT (70%), Flu/Bu (79%), and Bu/Cy (61%) (P = .002). The corresponding 5-year overall survival values were 68%, 75%, 86%, and 64%, and did not differ by conditioning regimen (P = .19). Low event-free survival with Flu/Mel is attributed to high graft failure (42%) compared to Flu/Mel/TT (15%), Flu/Bu (7%), and Bu/Cy (18%) (P < .001). CONCLUSIONS Given the high rate of graft failure with Flu/Mel and the high rate of veno-occlusive disease with Bu/Cy and Flu/Bu, Flu/Mel/TT may be preferred for HLH disorders. Prospective studies are warranted.
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Affiliation(s)
- Rebecca A. Marsh
- University of Cincinnati, and Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Kyle Hebert
- Center for International Blood and Marrow Transplant Research, Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Soyoung Kim
- Center for International Blood and Marrow Transplant Research, Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Christopher C. Dvorak
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplantation, University of California San Francisco, Benioff Children’s Hospital, San Francisco, CA
| | | | | | - Deepak Chellapandian
- Center for Cell and Gene Therapy for Non-Malignant Conditions, Johns Hopkins All Children’s Hospital, St Petersburg, FL
| | | | | | - Michael J. Eckrich
- Sarah Cannon Pediatric Transplant and Cellular Therapy Program, Methodist Children’s Hospital, San Antonio, TX
| | | | - Timothy S. Olson
- Department of Pediatrics, Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | - Shalini Shenoy
- Department of Pediatrics, Washington University School of Medicine, Saint Louis, MO
| | | | | | | | | | - Mary Eapen
- Center for International Blood and Marrow Transplant Research, Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
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14
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Andolina JR, Fries C, Boulware R, Vargas A, Fraint E, Barth M, Ambrusko S, Comito M, Monteleone P. Successful Bone Marrow Transplantation With Intensive Post-transplant Intrathecal Chemotherapy for CNS Relapsed AML in 2 Infants. J Pediatr Hematol Oncol 2022; 44:e264-e267. [PMID: 33843815 DOI: 10.1097/mph.0000000000002151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 02/15/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Infant acute myeloid leukemia is a rare but aggressive form of leukemia. OBSERVATION We report 2 children who presented with hyperleukocytosis, subsequently diagnosed with infant acute myeloid leukemia, and both developed isolated central nervous system relapse while on chemotherapy. Both infants underwent successful bone marrow transplantation with myeloablative conditioning (thiotepa, busulfan, and cyclophosphamide) without radiation, followed by 12 empiric post-transplant lumbar punctures with intrathecal cytarabine. Both patients tolerated these therapies well, and are without infections, chronic graft-versus-host disease, or any post-transplant sequelae. CONCLUSION Nonradiation-based conditioning followed by empiric central nervous system-directed intrathecal chemotherapy may be considered for high-risk infants with leukemia.
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Affiliation(s)
- Jeffrey R Andolina
- Department of Pediatrics, Golisano Children's Hospital, University of Rochester Medical Center, Rochester
| | - Carol Fries
- Department of Pediatrics, Golisano Children's Hospital, University of Rochester Medical Center, Rochester
| | - Renee Boulware
- Department of Pediatrics, Golisano Children's Hospital, University of Rochester Medical Center, Rochester
| | - Alyssa Vargas
- Department of Pediatrics, Golisano Children's Hospital, University of Rochester Medical Center, Rochester
| | - Ellen Fraint
- Department of Pediatrics, Children's Hospital at Montefiore, New York
| | - Matthew Barth
- Department of Pediatrics, Oshei Children's Hospital, Roswell Park Cancer Institute, Buffalo
| | - Steven Ambrusko
- Department of Pediatrics, Oshei Children's Hospital, Roswell Park Cancer Institute, Buffalo
| | - Melanie Comito
- Department of Pediatrics, Upstate Golisano Children's Hospital, Syracuse, NY
| | - Philip Monteleone
- Department of Pediatrics, Upstate Golisano Children's Hospital, Syracuse, NY
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15
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Sobkowiak-Sobierajska A, Lindemans C, Sykora T, Wachowiak J, Dalle JH, Bonig H, Gennery A, Lawitschka A. Management of Chronic Graft-vs.-Host Disease in Children and Adolescents With ALL: Present Status and Model for a Personalised Management Plan. Front Pediatr 2022; 10:808103. [PMID: 35252060 PMCID: PMC8894895 DOI: 10.3389/fped.2022.808103] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 01/24/2022] [Indexed: 12/18/2022] Open
Abstract
Herein we review current practice regarding the management of chronic graft-vs.-host disease (cGvHD) in paediatric patients after allogeneic haematopoietic stem cell transplantation (HSCT) for acute lymphoblastic leukaemia (ALL). Topics covered include: (i) the epidemiology of cGvHD; (ii) an overview of advances in our understanding cGvHD pathogenesis; (iii) current knowledge regarding risk factors for cGvHD and prevention strategies complemented by biomarkers; (iii) the paediatric aspects of the 2014 National Institutes for Health-defined diagnosis and grading of cGvHD; and (iv) current options for cGvHD treatment. We cover topical therapy and newly approved tyrosine kinase inhibitors, emphasising the use of immunomodulatory approaches in the context of the delicate counterbalance between immunosuppression and immune reconstitution as well as risks of relapse and infectious complications. We examine real-world approaches of response assessment and tapering schedules of treatment. Furthermore, we report on the optimal timepoints for therapeutic interventions and changes in relation to immune reconstitution and risk of relapse/infection. Additionally, we review the different options for anti-infectious prophylaxis. Finally, we put forth a theory of a holistic view of paediatric cGvHD and its associated manifestations and propose a checklist for individualised risk evaluation with aggregated considerations including site-specific cGvHD evaluation with attention to each individual's GvHD history, previous medical history, comorbidities, and personal tolerance and psychosocial circumstances. To complement this checklist, we present a treatment algorithm using representative patients to inform the personalised management plans for patients with cGvHD after HSCT for ALL who are at high risk of relapse.
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Affiliation(s)
| | - Caroline Lindemans
- Department of Pediatrics, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands.,Pediatric Blood and Bone Marrow Transplantation, Princess Máxima Center, Utrecht, Netherlands
| | - Tomas Sykora
- Department of Pediatric Hematology and Oncology - Haematopoietic Stem Cell Transplantation Unit, National Institute of Children's Diseases and Medical Faculty, Comenius University, Bratislava, Slovakia
| | - Jacek Wachowiak
- Department of Pediatric Oncology, Hematology and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Jean-Hugues Dalle
- Hematology and Immunology Department, Robert-Debré Hospital, Assistance Publique-Hôpitaux de Paris and University of Paris, Paris, France
| | - Halvard Bonig
- Goethe University Medical Center, Institute of Transfusion Medicine and Immunohematology, and German Red Cross Blood Center Frankfurt, Frankfurt, Germany
| | - Andrew Gennery
- Medical School, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Anita Lawitschka
- Stem Cell Transplantation Unit, St. Anna Children's Hospital, Medical University Vienna, Vienna, Austria.,St. Anna Children's Cancer Research Institute, Vienna, Austria
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16
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Balduzzi A, Buechner J, Ifversen M, Dalle JH, Colita AM, Bierings M. Acute Lymphoblastic Leukaemia in the Youngest: Haematopoietic Stem Cell Transplantation and Beyond. Front Pediatr 2022; 10:807992. [PMID: 35281233 PMCID: PMC8911028 DOI: 10.3389/fped.2022.807992] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 01/13/2022] [Indexed: 12/14/2022] Open
Abstract
The ALL SCTped 2012 FORUM (For Omitting Radiation Under Majority age) trial compared outcomes for children ≥4 years of age transplanted for acute lymphoblastic leukaemia (ALL) who were randomised to myeloablation with a total body irradiation (TBI)-based or chemotherapy-based conditioning regimen. The TBI-based preparation was associated with a lower rate of relapse compared with chemoconditioning. Nevertheless, the age considered suitable for TBI was progressively raised over time to spare the most fragile youngest patients from irradiation-related complications. The best approach to use for children <4 years of age remains unclear. Children diagnosed with ALL in their first year of life, defined as infants, have a remarkably poorer prognosis compared with older children. This is largely explained by the biology of their ALL, with infants often carrying a KMT2A gene rearrangement, as well as by their fragility. In contrast, the clinical presentations and biological features of ALL in children >1 year but <4 years often resemble those presented by older children. In this review, we explore the state of the art regarding haematopoietic stem cell transplantation (HSCT) in children <4 years, the preparative regimens available, and new developments in the field that may influence treatment decisions.
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Affiliation(s)
- Adriana Balduzzi
- Clinica Pediatrica Università degli Studi di Milano-Bicocca, Fondazione Monza e Brianza per il Bambino e la sua Mamma, Monza, Italy
| | - Jochen Buechner
- Department of Pediatric Hematology and Oncology, Oslo University Hospital, Oslo, Norway
| | | | - Jean-Hugues Dalle
- Hôpital Robert Debré, GH AP-HP. Nord Université de Paris, Paris, France
| | - Anca M Colita
- Department of Pediatric Hematology and BMT, Fundeni Clinical Institute, "Carol Davila" University of Medicine, Bucharest, Romania
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17
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Hoeben BAW, Wong JYC, Fog LS, Losert C, Filippi AR, Bentzen SM, Balduzzi A, Specht L. Total Body Irradiation in Haematopoietic Stem Cell Transplantation for Paediatric Acute Lymphoblastic Leukaemia: Review of the Literature and Future Directions. Front Pediatr 2021; 9:774348. [PMID: 34926349 PMCID: PMC8678472 DOI: 10.3389/fped.2021.774348] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 11/03/2021] [Indexed: 12/13/2022] Open
Abstract
Total body irradiation (TBI) has been a pivotal component of the conditioning regimen for allogeneic myeloablative haematopoietic stem cell transplantation (HSCT) in very-high-risk acute lymphoblastic leukaemia (ALL) for decades, especially in children and young adults. The myeloablative conditioning regimen has two aims: (1) to eradicate leukaemic cells, and (2) to prevent rejection of the graft through suppression of the recipient's immune system. Radiotherapy has the advantage of achieving an adequate dose effect in sanctuary sites and in areas with poor blood supply. However, radiotherapy is subject to radiobiological trade-offs between ALL cell destruction, immune and haematopoietic stem cell survival, and various adverse effects in normal tissue. To diminish toxicity, a shift from single-fraction to fractionated TBI has taken place. However, HSCT and TBI are still associated with multiple late sequelae, leaving room for improvement. This review discusses the past developments of TBI and considerations for dose, fractionation and dose-rate, as well as issues regarding TBI setup performance, limitations and possibilities for improvement. TBI is typically delivered using conventional irradiation techniques and centres have locally developed heterogeneous treatment methods and ways to achieve reduced doses in several organs. There are, however, limitations in options to shield organs at risk without compromising the anti-leukaemic and immunosuppressive effects of conventional TBI. Technological improvements in radiotherapy planning and delivery with highly conformal TBI or total marrow irradiation (TMI), and total marrow and lymphoid irradiation (TMLI) have opened the way to investigate the potential reduction of radiotherapy-related toxicities without jeopardising efficacy. The demonstration of the superiority of TBI compared with chemotherapy-only conditioning regimens for event-free and overall survival in the randomised For Omitting Radiation Under Majority age (FORUM) trial in children with high-risk ALL makes exploration of the optimal use of TBI delivery mandatory. Standardisation and comprehensive reporting of conventional TBI techniques as well as cooperation between radiotherapy centres may help to increase the ratio between treatment outcomes and toxicity, and future studies must determine potential added benefit of innovative conformal techniques to ultimately improve quality of life for paediatric ALL patients receiving TBI-conditioned HSCT.
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Affiliation(s)
- Bianca A. W. Hoeben
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, Netherlands
- Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
| | - Jeffrey Y. C. Wong
- Department of Radiation Oncology, City of Hope National Medical Center and Beckman Research Institute, Duarte, CA, United States
| | - Lotte S. Fog
- Alfred Health Radiation Oncology, The Alfred Hospital, Melbourne, VIC, Australia
| | - Christoph Losert
- Department of Radiation Oncology, University Hospital, Ludwig Maximilian University of Munich, Munich, Germany
| | - Andrea R. Filippi
- Department of Radiation Oncology, Fondazione IRCCS Policlinico San Matteo and University of Pavia, Pavia, Italy
| | - Søren M. Bentzen
- Division of Biostatistics and Bioinformatics, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Adriana Balduzzi
- Stem Cell Transplantation Unit, Clinica Paediatrica Università degli Studi di Milano Bicocca, Monza, Italy
| | - Lena Specht
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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18
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Dandoy CE, Davies SM, Woo Ahn K, He Y, Kolb AE, Levine J, Bo-Subait S, Abdel-Azim H, Bhatt N, Chewning J, Gadalla S, Gloude N, Hayashi R, Lalefar NR, Law J, MacMillan M, O'Brien T, Prestidge T, Sharma A, Shaw P, Winestone L, Eapen M. Comparison of total body irradiation versus non-total body irradiation containing regimens for de novo acute myeloid leukemia in children. Haematologica 2021; 106:1839-1845. [PMID: 32554562 PMCID: PMC8252927 DOI: 10.3324/haematol.2020.249458] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Indexed: 12/13/2022] Open
Abstract
With limited data comparing hematopoietic cell transplant outcomes between myeloablative total body irradiation (TBI) containing and non-TBI regimens in children with de novo acute myeloid leukemia, the aim of this study was to compare transplant-outcomes between these regimens. Cox regression models were used to compare transplant-outcomes after TBI and non-TBI regimens in 624 children transplanted between 2008 and 2016. Thirty two percent (n=199) received TBI regimens whereas 68% (n=425) received non-TBI regimens. Five-year non-relapse mortality was higher with TBI regimens (22% vs. 11%, P<0.0001) but relapse was lower (23% vs. 37%, P<0.0001) compared to non-TBI regimens. Consequently, overall (62% vs. 60%, P=1.00) and leukemia-free survival (55% vs. 52%, P=0.42) did not differ between treatment groups. Grade 2-3 acute graft versus host disease was higher with TBI regimens (56% vs. 27%, P<0.0001) but not chronic graft versus host disease. The 3-year incidence of gonadal or growth hormone deficiency was higher with TBI regimens (24% vs. 8%, P<0.001) but there were no differences in late pulmonary, cardiac or renal impairment. In the absence of a survival advantage, the choice of TBI or non-TBI regimen merits careful consideration with the data favoring non-TBI regimens to limit the burden of morbidity associated with endocrine dysfunction.
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Affiliation(s)
| | - Stella M Davies
- Cincinnati Children Hospital Medical Center, Cincinnati, OH, USA
| | - Kwang Woo Ahn
- Division of Biostatics, Institute for Heath and Equity, Medical College of Wisconsin, Milwaukee, USA
| | - Yizeng He
- Division of Biostatics, Institute for Heath and Equity, Medical College of Wisconsin, Milwaukee, USA
| | - Anders E Kolb
- Division of Hematology-Oncology, Alfred I. duPont Hospital for Children, Wilmington, USA
| | - John Levine
- Blood and Marrow Transplant Program, Icahn School of Medicine at Mount Sinai, New York, USA
| | | | - Hisham Abdel-Azim
- Children Hospital Los Angeles, University of Southern California Keck School of Medicine, USA
| | - Neel Bhatt
- Department of Data Abstraction, Fred Hutchinson Cancer Research Center, Seattle, USA
| | - Joseph Chewning
- Division of Hematology-Oncology, University of Alabama at Birmingham, Birmingham, USA
| | - Shahinaz Gadalla
- Division of Cancer Epidemiology and Genetics, NIH-NCI Clinical Genetics Branch, Rockville, MD, USA
| | - Nicholas Gloude
- Division of Hematology-Oncology, Rady Children Hospital San Diego, San Diego, USA
| | - Robert Hayashi
- Department of Pediatrics, Washington University School of Medicine in St. Louis, USA
| | - Nahal R Lalefar
- Division of Hematology-Oncology, Children Hospital and Research Center Oakland, CA, USA
| | - Jason Law
- Division of Pediatric Hematology-Oncology, Tufts Medical Center, Boston, MA, USA
| | | | - Tracy O'Brien
- Kids Cancer Centre, Sydney Children Hospital, Sydney, Australia
| | - Timothy Prestidge
- Blood and Cancer Centre, Starship Children Hospital, Auckland, New Zealand
| | - Akshay Sharma
- St. Jude Children Research Hospital, Memphis, TN, USA
| | - Peter Shaw
- The Children Hospital at Westmead; Westmead, Australia
| | - Lena Winestone
- Department of Pediatrics, Children Hospital of Philadelphia, Philadelphia, PA, USA
| | - Mary Eapen
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
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19
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Late effects after ablative allogeneic stem cell transplantation for adolescent and young adult acute myeloid leukemia. Blood Adv 2021; 4:983-992. [PMID: 32168378 DOI: 10.1182/bloodadvances.2019001126] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 02/02/2020] [Indexed: 12/13/2022] Open
Abstract
There is marked paucity of data regarding late effects in adolescents and young adults (AYAs) who undergo myeloablative conditioning (MAC) allogeneic hematopoietic cell transplantation (HCT) for acute myeloid leukemia (AML). We evaluated late effects and survival in 826 1-year disease-free survivors of MAC HCT for AYA AML, with an additional focus on comparing late effects based upon MAC type (total body irradiation [TBI] vs high-dose chemotherapy only). The estimated 10-year cumulative incidence of subsequent neoplasms was 4% (95% confidence interval [CI], 2%-6%); 10-year cumulative incidence of nonmalignant late effects included gonadal dysfunction (10%; 95% CI, 8%-13%), cataracts (10%; 95% CI, 7%-13%), avascular necrosis (8%; 95% CI, 5%-10%), diabetes mellitus (5%; 95% CI, 3%-7%), and hypothyroidism (3%; 95% CI, 2%-5%). Receipt of TBI was independently associated with a higher risk of cataracts only (hazard ratio [HR], 4.98; P < .0001) whereas chronic graft-versus-host disease (cGVHD) was associated with an increased risk of cataracts (HR, 3.22; P = .0006), avascular necrosis (HR, 2.49; P = .006), and diabetes mellitus (HR, 3.36; P = .03). Estimated 10-year overall survival and leukemia-free survival were 73% and 70%, respectively, and did not differ on the basis of conditioning type. In conclusion, late effects among survivors of MAC HCT for AYA AML are frequent and are more closely linked to cGVHD than type of conditioning.
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20
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Hematopoietic cell transplantation in chronic granulomatous disease: a study of 712 children and adults. Blood 2021; 136:1201-1211. [PMID: 32614953 DOI: 10.1182/blood.2020005590] [Citation(s) in RCA: 81] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 06/24/2020] [Indexed: 11/20/2022] Open
Abstract
Chronic granulomatous disease (CGD) is a primary immunodeficiency resulting in life-threatening infections and inflammatory complications. Allogeneic hematopoietic cell transplantation (allo-HCT) can cure the disease, but the indication to transplant remains controversial. We performed a retrospective multicenter study of 712 patients with CGD who underwent allo-HCT transplantation from March 1993 through December 2018. We studied 635 children (aged <18 years) and 77 adults. Median follow-up was 45 months. Median age at transplantation was 7 years (range, 0.1-48.6). Kaplan-Meier estimates of overall survival (OS) and event-free survival (EFS) at 3 years were 85.7% and 75.8%, respectively. In multivariate analysis, older age was associated with reduced survival and increased chronic graft-versus-host disease. Nevertheless, OS and EFS at 3 years for patients ≥18 years were 76% and 69%, respectively. Use of 1-antigen-mismatched donors was associated with reduced OS and EFS . No significant difference was found in OS, but a significantly reduced EFS was noted in the small group of patients who received a transplant from a donor with a >1 antigen mismatch. Choice of conditioning regimen did not influence OS or EFS. In summary, we report an excellent outcome after allo-HCT in CGD, with low incidence of graft failure and mortality in all ages. Older patients and recipients of 1-antigen-mismatched grafts had a less favorable outcome. Transplantation should be strongly considered at a younger age and particularly in the presence of a well-matched donor.
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21
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Abstract
PURPOSE OF THE REVIEW Infant leukemia is a rare, distinct subgroup of pediatric acute leukemias diagnosed in children under 1 year of age and characterized by unique, aggressive biology. Here, we review its clinical presentation, underlying molecular biology, current treatment strategies, and novel therapeutic approaches. RECENT FINDINGS Infant leukemias are associated with high-risk molecular features and high rates of chemotherapy resistance. International collaborative clinical trials have led to better understanding of the underlying molecular biology, refined risk-based stratification, and investigated the use of hematopoietic stem cell transplantation. However, intensification of chemotherapy has failed to improve outcomes, and current regimens are associated with significant treatment-related and long-term toxicities. Infants with leukemia remain a challenging group to treat. We must continue collaborative efforts to move beyond traditional cytotoxic chemotherapy, incorporate molecularly targeted strategies and immunotherapy, and increase access to clinical trials to improve outcomes for this high-risk group of patients.
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22
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Gabriel M, Hoeben BAW, Uhlving HH, Zajac-Spychala O, Lawitschka A, Bresters D, Ifversen M. A Review of Acute and Long-Term Neurological Complications Following Haematopoietic Stem Cell Transplant for Paediatric Acute Lymphoblastic Leukaemia. Front Pediatr 2021; 9:774853. [PMID: 35004543 PMCID: PMC8734594 DOI: 10.3389/fped.2021.774853] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 12/02/2021] [Indexed: 12/02/2022] Open
Abstract
Despite advances in haematopoietic stem cell transplant (HSCT) techniques, the risk of serious side effects and complications still exists. Neurological complications, both acute and long term, are common following HSCT and contribute to significant morbidity and mortality. The aetiology of neurotoxicity includes infections and a wide variety of non-infectious causes such as drug toxicities, metabolic abnormalities, irradiation, vascular and immunologic events and the leukaemia itself. The majority of the literature on this subject is focussed on adults. The impact of the combination of neurotoxic drugs given before and during HSCT, radiotherapy and neurological complications on the developing and vulnerable paediatric and adolescent brain remains unclear. Moreover, the age-related sensitivity of the nervous system to toxic insults is still being investigated. In this article, we review current evidence regarding neurotoxicity following HSCT for acute lymphoblastic leukaemia in childhood. We focus on acute and long-term impacts. Understanding the aetiology and long-term sequelae of neurological complications in children is particularly important in the current era of immunotherapy for acute lymphoblastic leukaemia (such as chimeric antigen receptor T cells and bi-specific T-cell engager antibodies), which have well-known and common neurological side effects and may represent a future treatment modality for at least a fraction of HSCT-recipients.
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Affiliation(s)
- Melissa Gabriel
- Cancer Centre for Children, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Bianca A W Hoeben
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, Netherlands.,Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
| | - Hilde Hylland Uhlving
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Olga Zajac-Spychala
- Department of Pediatric Oncology, Hematology and Transplantology, Poznan University of Medical Sciences, Poznań, Poland
| | - Anita Lawitschka
- Haematopoietic Stem Cell Transplant Unit, St. Anna Children's Hospital, Medical University Vienna, Vienna, Austria
| | - Dorine Bresters
- Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
| | - Marianne Ifversen
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
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23
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Diesch-Furlanetto T, Gabriel M, Zajac-Spychala O, Cattoni A, Hoeben BAW, Balduzzi A. Late Effects After Haematopoietic Stem Cell Transplantation in ALL, Long-Term Follow-Up and Transition: A Step Into Adult Life. Front Pediatr 2021; 9:773895. [PMID: 34900873 PMCID: PMC8652149 DOI: 10.3389/fped.2021.773895] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 10/19/2021] [Indexed: 12/13/2022] Open
Abstract
Haematopoietic stem cell transplant (HSCT) can be a curative treatment for children and adolescents with very-high-risk acute lymphoblastic leukaemia (ALL). Improvements in supportive care and transplant techniques have led to increasing numbers of long-term survivors worldwide. However, conditioning regimens as well as transplant-related complications are associated with severe sequelae, impacting patients' quality of life. It is widely recognised that paediatric HSCT survivors must have timely access to life-long care and surveillance in order to prevent, ameliorate and manage all possible adverse late effects of HSCT. This is fundamentally important because it can both prevent ill health and optimise the quality and experience of survival following HSCT. Furthermore, it reduces the impact of preventable chronic illness on already under-resourced health services. In addition to late effects, survivors of paediatric ALL also have to deal with unique challenges associated with transition to adult services. In this review, we: (1) provide an overview of the potential late effects following HSCT for ALL in childhood and adolescence; (2) focus on the unique challenges of transition from paediatric care to adult services; and (3) provide a framework for long-term surveillance and medical care for survivors of paediatric ALL who have undergone HSCT.
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Affiliation(s)
- Tamara Diesch-Furlanetto
- Division of Pediatric Oncology/Hematology, University Children's Hospital Basel (UKB), University of Basel, Basel, Switzerland
| | - Melissa Gabriel
- Cancer Centre for Children, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Olga Zajac-Spychala
- Department of Pediatric Oncology, Hematology and Transplantology, University of Medical Sciences, Poznań, Poland
| | - Alessandro Cattoni
- Clinica Pediatrica, University degli Studi di Milano-Bicocca, Fondazione Monza e Brianza per il Bambino e la sua Mamma (MBBM), San Gerardo Hospital, Monza, Italy
| | - Bianca A W Hoeben
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, Netherlands.,Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
| | - Adriana Balduzzi
- Clinica Pediatrica, University degli Studi di Milano-Bicocca, Fondazione Monza e Brianza per il Bambino e la sua Mamma (MBBM), San Gerardo Hospital, Monza, Italy
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24
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The influence of stem cell source on transplant outcomes for pediatric patients with acute myeloid leukemia. Blood Adv 2020; 3:1118-1128. [PMID: 30952678 DOI: 10.1182/bloodadvances.2018025908] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 01/14/2019] [Indexed: 12/18/2022] Open
Abstract
When hematopoietic stem cell transplant (HSCT) is necessary for children with acute myeloid leukemia (AML), there remains debate about the best stem cell source. Post-HSCT relapse is a common cause of mortality, and complications such as chronic graft versus host disease (cGVHD) are debilitating and life-threatening. To compare post-HSCT outcomes of different donor sources, we retrospectively analyzed consecutive transplants performed in several international centers from 2005 to 2015. A total of 317 patients were studied: 19% matched sibling donor (MSD), 23% matched unrelated donor (MUD), 39% umbilical cord blood (UCB), and 19% double UCB (dUCB) recipients. The median age at transplant was 10 years (range, 0.42-21 years), and median follow-up was 4.74 years (range, 4.02-5.39 years). Comparisons were made while controlling for patient, transplant, and disease characteristics. There were no differences in relapse, leukemia-free survival, or nonrelapse mortality. dUCB recipients had inferior survival compared with matched sibling recipients, but all other comparisons showed similar overall survival. Despite the majority of UCB transplants being HLA mismatched, the rates of cGVHD were low, especially compared with the well-matched MUD recipients (hazard ratio, 0.3; 95% confidence interval, 0.14-0.67; P = .02). The composite measure of cGVHD and leukemia-free survival (cGVHD-LFS), which represents both the quality of life and risk for mortality, was significantly better in the UCB compared with the MUD recipients (HR, 0.56; 95% confidence interval, 0.34-1; P = .03). In summary, the use of UCB is an excellent donor choice for pediatric patients with AML when a matched sibling cannot be identified.
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25
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Marinho DH, Ribeiro LL, Nichele S, Loth G, Koliski A, Mousquer RTG, Funke VAM, Page K, Fasth A, Pasquini R, Boguszewski MCDS, Bonfim C. The challenge of long-term follow-up of survivors of childhood acute leukemia after hematopoietic stem cell transplantation in resource-limited countries: A single-center report from Brazil. Pediatr Transplant 2020; 24:e13691. [PMID: 32246550 DOI: 10.1111/petr.13691] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 01/30/2020] [Accepted: 02/18/2020] [Indexed: 11/28/2022]
Abstract
With the number of long-term HSCT survivors steadily increasing, attention needs to be focused on the late complications and quality of life. We therefore analyzed the outcome of 101 pediatric patients (<18 years old at the time of HSCT) transplanted for acute leukemia between 1981 and 2015 at Complexo Hospital de Clínicas, Federal University of Paraná, Brazil, and who survived at least two years after HSCT. The median follow-up was 5.9 years (2.0-29.0); median age at follow-up was 17.5 years (2.98-39.0). The 5-year cumulative incidence of relapse was 27.5% (95% CI 18.6%-36.4%). Two-year cumulative incidence of chronic GVHD was 21.8% (95% CI 13.7%-29.8%). Of the 101 patients, 72 patients (71.3%) presented with late effects. Those surviving longer after HSCT experienced more complications. Patients who received TBI-based regimen developed more late effects (P = .013) and more endocrinological complications (P = .024). Endocrinological complications were the most common late sequelae found in this study. For childhood survivors, quality of life was not influenced by age (at HSCT or at last visit), time from HSCT, gender, donor, or GVHD. For survivors that no longer were children, only age at last visit impacted financial domain measures, irrespective of gender, donor, or GVHD. The current study confirms the high burden late complications after pediatric HSCT have on the survivors and underlines the importance of extended follow-up.
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Affiliation(s)
| | | | - Samantha Nichele
- Bone Marrow Transplantation Unit, Federal University of Paraná, Curitiba, Brazil
| | - Gisele Loth
- Bone Marrow Transplantation Unit, Federal University of Paraná, Curitiba, Brazil
| | - Adriana Koliski
- Bone Marrow Transplantation Unit, Federal University of Paraná, Curitiba, Brazil
| | | | | | - Kristin Page
- Pediatric Transplant and Cellular Therapy, Duke University, Durham, NC, USA
| | - Anders Fasth
- Department of Pediatrics, Institute of Clinical Sciencies at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ricardo Pasquini
- Bone Marrow Transplantation Unit, Federal University of Paraná, Curitiba, Brazil
| | | | - Carmem Bonfim
- Bone Marrow Transplantation Unit, Federal University of Paraná, Curitiba, Brazil
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26
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Giaccone L, Felicetti F, Butera S, Faraci D, Cerrano M, Dionisi Vici M, Brunello L, Fortunati N, Brignardello E, Bruno B. Optimal Delivery of Follow-Up Care After Allogeneic Hematopoietic Stem-Cell Transplant: Improving Patient Outcomes with a Multidisciplinary Approach. J Blood Med 2020; 11:141-162. [PMID: 32523389 PMCID: PMC7237112 DOI: 10.2147/jbm.s206027] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 05/02/2020] [Indexed: 01/05/2023] Open
Abstract
The increasing indications for allogeneic stem-cell transplant in patients with hematologic malignancies and non-malignant diseases combined with improved clinical outcomes have contributed to increase the number of long-term survivors. However, survivors are at increased risk of developing a unique set of complications and late effects, besides graft-versus-host disease and disease relapse. In this setting, the management capacity of a single health-care provider can easily be overwhelmed. Thus, to provide appropriate survivorship care, a multidisciplinary approach for the long-term follow-up is essential. This review aims at summarizing the most relevant information that a health-care provider should know to establish a follow-up care plan, in the light of individual exposures and risk factors, that includes all organ systems and considers the psychological burden of these patients.
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Affiliation(s)
- Luisa Giaccone
- Division of Hematology, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy.,Dipartimento di Biotecnologie Molecolari e Scienze per la Salute, University of Torino, Torino, Italy
| | - Francesco Felicetti
- Transition Unit for Childhood Cancer Survivors, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - Sara Butera
- Division of Hematology, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy.,Dipartimento di Biotecnologie Molecolari e Scienze per la Salute, University of Torino, Torino, Italy
| | - Danilo Faraci
- Division of Hematology, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy.,Dipartimento di Biotecnologie Molecolari e Scienze per la Salute, University of Torino, Torino, Italy
| | - Marco Cerrano
- Division of Hematology, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy.,Dipartimento di Biotecnologie Molecolari e Scienze per la Salute, University of Torino, Torino, Italy
| | - Margherita Dionisi Vici
- Transition Unit for Childhood Cancer Survivors, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - Lucia Brunello
- Division of Hematology, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy.,Dipartimento di Biotecnologie Molecolari e Scienze per la Salute, University of Torino, Torino, Italy
| | - Nicoletta Fortunati
- Transition Unit for Childhood Cancer Survivors, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - Enrico Brignardello
- Transition Unit for Childhood Cancer Survivors, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - Benedetto Bruno
- Division of Hematology, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy.,Dipartimento di Biotecnologie Molecolari e Scienze per la Salute, University of Torino, Torino, Italy
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27
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Development of Secondary Osteosarcoma After TBI and Allogeneic Bone Marrow Transplant: A Case Series of 3 Patients. J Pediatr Hematol Oncol 2020; 42:e100-e103. [PMID: 30807391 DOI: 10.1097/mph.0000000000001442] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Osteosarcoma can rarely occur as a subsequent malignant neoplasm after cancer therapy. Children who underwent treatment for cancer and received an allogeneic hematopoietic cell transplant are at a higher risk to develop secondary malignancies. Radiation is also a known risk factor, but estimating the quantitative risk is difficult due to the rarity of the condition and long latency period between primary and secondary cancer. In this report, we present 3 patients diagnosed with leukemia as young children who received hematopoietic cell transplants with total body irradiation as part of the conditioning regimen, and later went on to develop secondary osteosarcoma.
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28
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Occurrence of long-term effects after hematopoietic stem cell transplantation in children affected by acute leukemia receiving either busulfan or total body irradiation: results of an AIEOP (Associazione Italiana Ematologia Oncologia Pediatrica) retrospective study. Bone Marrow Transplant 2020; 55:1918-1927. [DOI: 10.1038/s41409-020-0806-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 12/13/2019] [Accepted: 01/20/2020] [Indexed: 12/21/2022]
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Summers C, Sheth VS, Bleakley M. Minor Histocompatibility Antigen-Specific T Cells. Front Pediatr 2020; 8:284. [PMID: 32582592 PMCID: PMC7283489 DOI: 10.3389/fped.2020.00284] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 05/06/2020] [Indexed: 01/05/2023] Open
Abstract
Minor Histocompatibility (H) antigens are major histocompatibility complex (MHC)/Human Leukocyte Antigen (HLA)-bound peptides that differ between allogeneic hematopoietic stem cell transplantation (HCT) recipients and their donors as a result of genetic polymorphisms. Some minor H antigens can be used as therapeutic T cell targets to augment the graft-vs.-leukemia (GVL) effect in order to prevent or manage leukemia relapse after HCT. Graft engineering and post-HCT immunotherapies are being developed to optimize delivery of T cells specific for selected minor H antigens. These strategies have the potential to reduce relapse risk and thereby permit implementation of HCT approaches that are associated with less toxicity and fewer late effects, which is particularly important in the growing and developing pediatric patient. Most minor H antigens are expressed ubiquitously, including on epithelial tissues, and can be recognized by donor T cells following HCT, leading to graft-vs.-host disease (GVHD) as well as GVL. However, those minor H antigens that are expressed predominantly on hematopoietic cells can be targeted for selective GVL. Once full donor hematopoietic chimerism is achieved after HCT, hematopoietic-restricted minor H antigens are present only on residual recipient malignant hematopoietic cells, and these minor H antigens serve as tumor-specific antigens for donor T cells. Minor H antigen-specific T cells that are delivered as part of the donor hematopoietic stem cell graft at the time of HCT contribute to relapse prevention. However, in some cases the minor H antigen-specific T cells delivered with the graft may be quantitatively insufficient or become functionally impaired over time, leading to leukemia relapse. Following HCT, adoptive T cell immunotherapy can be used to treat or prevent relapse by delivering large numbers of donor T cells targeting hematopoietic-restricted minor H antigens. In this review, we discuss minor H antigens as T cell targets for augmenting the GVL effect in engineered HCT grafts and for post-HCT immunotherapy. We will highlight the importance of these developments for pediatric HCT.
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Affiliation(s)
- Corinne Summers
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States.,Department of Pediatrics, University of Washington, Seattle, WA, United States
| | - Vipul S Sheth
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States
| | - Marie Bleakley
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States.,Department of Pediatrics, University of Washington, Seattle, WA, United States
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30
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Gertson K, Hayashi SS, Trinkaus K, Wan F, Hayashi RJ. Prevalence of Ototoxicity Following Hematopoietic Stem Cell Transplantation in Pediatric Patients. Biol Blood Marrow Transplant 2019; 26:107-113. [PMID: 31494228 DOI: 10.1016/j.bbmt.2019.08.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 08/29/2019] [Accepted: 08/29/2019] [Indexed: 02/07/2023]
Abstract
The use of hematopoietic stem cell transplantation (HSCT) is increasing for a variety of diseases. Ototoxicity from this procedure has not been extensively studied. A retrospective chart review examined 275 patients from this institution who underwent HSCT between January 1, 2007, and April 30, 2017. Data extracted included therapy before HSCT and the subsequent course of transplantation. Evaluable patients had complete medical records and interpretable audiograms available. Ototoxicity constituted significant threshold changes from baseline or changes in International Society of Pediatric Oncology/Boston Ototoxicity Grading Scale (SIOP) grade comparing audiogram results just before HSCT with those following the transplantation procedure. A total of 147 patients were evaluable. Ototoxicity was observed in 10.2% of the patients. Higher SIOP grade before HSCT was significantly associated with a higher risk of post-transplantation ototoxicity (P < .01). Previous cisplatin treatment (P < .0001), but not carboplatin or radiation treatment, was also associated with ototoxicity. Patients with a solid tumor or brain tumor (P < .0001) and those who received an autologous transplant (P = .0002) were also at increased risk. No post-transplantation event was significantly associated with ototoxicity. Ototoxicity affects a significant percentage of patients undergoing HSCT, and careful monitoring is needed to identify patients impacted by this procedure.
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Affiliation(s)
- Kristen Gertson
- Program in Audiology and Communication Sciences, Washington University School of Medicine, St Louis, Missouri
| | - Susan S Hayashi
- Audiology Division, St Louis Children's Hospital, St Louis, Missouri
| | - Kathryn Trinkaus
- Biostatistics Shared Resource, Siteman Cancer Center, Washington University School of Medicine, St Louis, Missouri
| | - Fei Wan
- Biostatistics Shared Resource, Siteman Cancer Center, Washington University School of Medicine, St Louis, Missouri
| | - Robert J Hayashi
- Siteman Cancer Center, Washington University School of Medicine, St. Louis Children's Hospital, St Louis, Missouri.
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31
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Gebauer J, Higham C, Langer T, Denzer C, Brabant G. Long-Term Endocrine and Metabolic Consequences of Cancer Treatment: A Systematic Review. Endocr Rev 2019; 40:711-767. [PMID: 30476004 DOI: 10.1210/er.2018-00092] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 06/21/2018] [Indexed: 02/08/2023]
Abstract
The number of patients surviving ≥5 years after initial cancer diagnosis has significantly increased during the last decades due to considerable improvements in the treatment of many cancer entities. A negative consequence of this is that the emergence of long-term sequelae and endocrine disorders account for a high proportion of these. These late effects can occur decades after cancer treatment and affect up to 50% of childhood cancer survivors. Multiple predisposing factors for endocrine late effects have been identified, including radiation, sex, and age at the time of diagnosis. A systematic literature search has been conducted using the PubMed database to offer a detailed overview of the spectrum of late endocrine disorders following oncological treatment. Most data are based on late effects of treatment in former childhood cancer patients for whom specific guidelines and recommendations already exist, whereas current knowledge concerning late effects in adult-onset cancer survivors is much less clear. Endocrine sequelae of cancer therapy include functional alterations in hypothalamic-pituitary, thyroid, parathyroid, adrenal, and gonadal regulation as well as bone and metabolic complications. Surgery, radiotherapy, chemotherapy, and immunotherapy all contribute to these sequelae. Following irradiation, endocrine organs such as the thyroid are also at risk for subsequent malignancies. Although diagnosis and management of functional and neoplastic long-term consequences of cancer therapy are comparable to other causes of endocrine disorders, cancer survivors need individually structured follow-up care in specialized surveillance centers to improve care for this rapidly growing group of patients.
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Affiliation(s)
- Judith Gebauer
- Experimental and Clinical Endocrinology, University Hospital of Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - Claire Higham
- Department of Endocrinology, Christie Hospital NHS Foundation Trust, Manchester, United Kingdom.,Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Thorsten Langer
- Division of Pediatric Hematology and Oncology, University Hospital of Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - Christian Denzer
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Endocrinology and Diabetes, Ulm University Medical Center, Ulm, Germany
| | - Georg Brabant
- Experimental and Clinical Endocrinology, University Hospital of Schleswig-Holstein, Campus Luebeck, Luebeck, Germany.,Department of Endocrinology, Christie Hospital NHS Foundation Trust, Manchester, United Kingdom
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32
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Jiang L, Malik N, Acedo P, Zawacka-Pankau J. Protoporphyrin IX is a dual inhibitor of p53/MDM2 and p53/MDM4 interactions and induces apoptosis in B-cell chronic lymphocytic leukemia cells. Cell Death Discov 2019; 5:77. [PMID: 30886745 PMCID: PMC6412042 DOI: 10.1038/s41420-019-0157-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 02/16/2019] [Indexed: 12/20/2022] Open
Abstract
p53 is a tumor suppressor, which belongs to the p53 family of proteins. The family consists of p53, p63 and p73 proteins, which share similar structure and function. Activation of wild-type p53 or TAp73 in tumors leads to tumor regression, and small molecules restoring the p53 pathway are in clinical development. Protoporphyrin IX (PpIX), a metabolite of aminolevulinic acid, is a clinically approved drug applied in photodynamic diagnosis and therapy. PpIX induces p53-dependent and TAp73-dependent apoptosis and inhibits TAp73/MDM2 and TAp73/MDM4 interactions. Here we demonstrate that PpIX is a dual inhibitor of p53/MDM2 and p53/MDM4 interactions and activates apoptosis in B-cell chronic lymphocytic leukemia cells without illumination and without affecting normal cells. PpIX stabilizes p53 and TAp73 proteins, induces p53-downstream apoptotic targets and provokes cancer cell death at doses non-toxic to normal cells. Our findings open up new opportunities for repurposing PpIX for treating lymphoblastic leukemia with wild-type TP53.
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Affiliation(s)
- Liren Jiang
- 1Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Solnavägen 9, 171 65 Stockholm, Sweden.,2Department of Immunology, Genetics and Pathology, Medical Faculty, Uppsala University, Box 256, 75105 Uppsala, Sweden.,3Present Address: Department of Pathology Center, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, No. 100 Haining Road, Hongkou District, 200080 Shanghai, China
| | - Natasha Malik
- 1Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Solnavägen 9, 171 65 Stockholm, Sweden
| | - Pilar Acedo
- 1Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Solnavägen 9, 171 65 Stockholm, Sweden
| | - Joanna Zawacka-Pankau
- 1Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Solnavägen 9, 171 65 Stockholm, Sweden
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33
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Freycon F, Casagranda L, Trombert-Paviot B. The impact of severe late-effects after 12 Gy fractionated total body irradiation and allogeneic stem cell transplantation for childhood leukemia (1988-2010). Pediatr Hematol Oncol 2019; 36:86-102. [PMID: 30978121 DOI: 10.1080/08880018.2019.1591549] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
This study consists of a retrospective study including 71 childhood leukemia survivors (36 females) treated with allo-HSCT 12 Gy fractionated total body irradiation (fTBI) conditioning, with a median age of 25.0 y at time of follow-up and a median delay of 14.8 y since the graft. The recovery ratio was 90%. The number of severe late-effects was specified for each patient: 21 with growth deficiency (final height <162.5 cm for 12/35 men and <152.0 cm for 9/36 women - Growth deficiency was correlated to young age at the time of the allograft); 5 with sclerodermic chronic graft vs. host disease; 9 with osteonecrosis; risk of impaired fertility for 25 women and 28 men (only 2 women had a child); 8 with diabetes; 5 with pulmonary late-effects including 1 death; 5 with chronic renal insufficiency including 1 death; 2 with cardiac late-effects; 2 with arterial high blood pressure; 11 (8 women) declared 14 subsequent cancers (7 with thyroid carcinomas, 3 with multiple squamous cell carcinomas, 2 with epidermoïdis carcinomas of the tongue or the lip, 1 with bone sarcoma, and 1 with carcinoma of the breast); 6 with chelating treatments of hemochromatosis; 14 with important educational underachievement; 11 with depression at adult age; 1 with hepatitis B virus infection; 4 with other severe late-effects, including 2 with blindness. The average number of severe late-effects was 2.3 with a positive correlation according to delay from fTBI (p < 0.0002). Two-thirds had at least 2 late-effects. These results emphasize the urgent abandonment of conditioning by TBI in children.
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Affiliation(s)
- Fernand Freycon
- a Childhood Cancer Registry of the Rhône-Alpes Region, University of Saint-Etienne , Saint-Etienne , France
| | - Léonie Casagranda
- a Childhood Cancer Registry of the Rhône-Alpes Region, University of Saint-Etienne , Saint-Etienne , France.,b Department of Pediatric Hematology and Oncology Unit , University Hospital of Saint-Etienne , Saint-Etienne , France.,c Host Research Team EA4607 SNA-EPIS, PRES Lyon, Jean Monnet University, University Hospital , Saint-Etienne , France
| | - Béatrice Trombert-Paviot
- c Host Research Team EA4607 SNA-EPIS, PRES Lyon, Jean Monnet University, University Hospital , Saint-Etienne , France.,d Department of Public Health and Medical Informatics , University of Saint-Etienne , Saint-Etienne , France
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34
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Long-term Effects of Myeloablative Allogeneic Hematopoietic Stem Cell Transplantation in Pediatric Patients with Acute Lymphoblastic Leukemia. Curr Oncol Rep 2018; 20:74. [DOI: 10.1007/s11912-018-0719-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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35
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Jackson TJ, Mostoufi-Moab S, Hill-Kayser C, Balamuth NJ, Arkader A. Musculoskeletal complications following total body irradiation in hematopoietic stem cell transplant patients. Pediatr Blood Cancer 2018; 65. [PMID: 29286549 DOI: 10.1002/pbc.26905] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 10/31/2017] [Accepted: 10/31/2017] [Indexed: 01/13/2023]
Abstract
Total body irradiation (TBI) is commonly used in conditioning regimens for allogeneic hematopoietic stem cell transplantation (HSCT) to treat benign and malignant disease. Though life-saving, these therapies place patients at risk for important side effects, including musculoskeletal complications such as short stature, osteonecrosis, slipped capital femoral epiphysis, and the development of benign and malignant bone tumors. With an increasing number of HSCT survivors, there is a growing need for awareness of the musculoskeletal complications of HSCT and TBI.
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Affiliation(s)
- Taylor J Jackson
- Division of Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sogol Mostoufi-Moab
- Department of Pediatric Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatric Endocrinology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Christine Hill-Kayser
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Naomi J Balamuth
- Department of Pediatric Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Alexandre Arkader
- Division of Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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36
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Killinger JS, Hurley C, Wasserman E, McArthur J. Complications of Emerging Oncology Therapies Requiring Treatment in the Pediatric Intensive Care Unit. CURRENT PEDIATRICS REPORTS 2017. [DOI: 10.1007/s40124-017-0145-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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37
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Turcotte LM. Taking the Good with the Bad: Survival and Late Toxicity among Young Hematopoietic Cell Transplantation Survivors. Biol Blood Marrow Transplant 2017; 23:1225-1226. [PMID: 28619667 DOI: 10.1016/j.bbmt.2017.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 06/08/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Lucie M Turcotte
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota.
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