1
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Meade MG, Bolaños-Meade J. The history of haploidentical stem cell transplantation: a trip from the bench to the bedside. Hematology 2024; 29:2346401. [PMID: 38687632 PMCID: PMC11285319 DOI: 10.1080/16078454.2024.2346401] [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: 03/26/2024] [Accepted: 04/17/2024] [Indexed: 05/02/2024] Open
Abstract
Allogeneic bone marrow transplantation is a curative intervention for both neoplastic and non-malignant conditions. However, not all patients have an HLA-matched donor. Therefore, the development of an approach that expand the donor pool was of paramount relevance. The development of post-transplantation cyclophosphamide as graft versus host disease prophylaxis allows the safe use of haploidentical donors, solving the donor availability problem to the vast majority of patients in need. The present paper reviews the history of the development of haploidentical transplantation at Johns Hopkins University, from the bench to the bedside.
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Affiliation(s)
| | - Javier Bolaños-Meade
- Johns Hopkins University School of Medicine, Clinical Director, BMT Program, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland, USA
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2
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Tameni A, Toffalori C, Vago L. Tricking the trickster: precision medicine approaches to counteract leukemia immune escape after transplant. Blood 2024; 143:2710-2721. [PMID: 38728431 DOI: 10.1182/blood.2023019962] [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: 12/27/2023] [Revised: 04/08/2024] [Accepted: 04/30/2024] [Indexed: 05/12/2024] Open
Abstract
ABSTRACT Over the last decades, significant improvements in reducing the toxicities of allogeneic hematopoietic cell transplantation (allo-HCT) have widened its use as consolidation or salvage therapy for high-risk hematological malignancies. Nevertheless, relapse of the original malignant disease remains an open issue with unsatisfactory salvage options and limited rationales to select among them. In the last years, several studies have highlighted that relapse is often associated with specific genomic and nongenomic mechanisms of immune escape. In this review we summarize the current knowledge about these modalities of immune evasion, focusing on the mechanisms that leverage antigen presentation and pathologic rewiring of the bone marrow microenvironment. We present examples of how this biologic information can be translated into specific approaches to treat relapse, discuss the status of the clinical trials for patients who relapsed after a transplant, and show how dissecting the complex immunobiology of allo-HCT represents a crucial step toward developing new personalized approaches to improve clinical outcomes.
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Affiliation(s)
- Annalisa Tameni
- Unit of Immunogenetics, Leukemia Genomics and Immunobiology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Cristina Toffalori
- Unit of Immunogenetics, Leukemia Genomics and Immunobiology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Luca Vago
- Unit of Immunogenetics, Leukemia Genomics and Immunobiology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
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3
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Epperly R, Li Y, Selukar S, Zeng E, Madden R, Mamcarz E, Naik S, Qudeimat A, Sharma A, Talleur A, Dallas MH, Gottschalk S, Srinivasan A, Triplett B. Disease Status and Interval between Hematopoietic Cell Transplantations Predict Outcome of Pediatric Patients Who Undergo Subsequent Transplantation for Relapsed Hematologic Malignancy. Transplant Cell Ther 2024; 30:526.e1-526.e11. [PMID: 38387720 PMCID: PMC11056306 DOI: 10.1016/j.jtct.2024.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 02/12/2024] [Accepted: 02/13/2024] [Indexed: 02/24/2024]
Abstract
Patients with hematologic malignancies who relapse after allogeneic hematopoietic cell transplantation (HCT) have a poor prognosis. Although proceeding to subsequent HCT can provide potential for long-term survival, there are limited data to guide which patients are most likely to benefit and which HCT strategies are best in this heavily pretreated population. The goals of this study were to describe the clinical outcomes of subsequent HCT in pediatric patients with relapsed hematologic malignancies in a cohort enriched for haploidentical donors, and to evaluate the associations of patient-, disease-, and treatment-related factors with survival. We retrospectively evaluated patients who underwent a subsequent HCT for management of post-HCT relapse at a single institution between 2000 and 2021. Among 106 patients who underwent a second allogeneic HCT, the 1-year event-free survival (EFS) was 34% and 1-year overall survival (OS) was 46%, with a 5-year EFS of 26% and 5-year OS of 31%. Only disease-related factors were associated with outcome after second HCT-specifically, the interval between HCTs and the presence or absence of active disease at the time of HCT. In this cohort, patient- and treatment-related factors were not associated with differences in EFS or OS. Patients undergoing a third or fourth HCT (n = 13) had comparable survival outcomes to those undergoing a second HCT. Our experience highlights that a subsequent HCT has curative potential for a subset of patients who relapse after HCT, including those who undergo a subsequent HCT from a haploidentical donor. Although relapse and treatment-related toxicities remain major challenges, our study indicates that achieving complete remission prior to subsequent HCTs has the potential to further improve outcomes.
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Affiliation(s)
- Rebecca Epperly
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Ying Li
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Subodh Selukar
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Emily Zeng
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Renee Madden
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Ewelina Mamcarz
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Swati Naik
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Amr Qudeimat
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Akshay Sharma
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Aimee Talleur
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Mari H Dallas
- Department of Pediatrics, Division of Pediatric Hematology Oncology, University Hospitals Rainbow Babies & Children's Hospital, Cleveland, Ohio; School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Stephen Gottschalk
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Ashok Srinivasan
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Brandon Triplett
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee.
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4
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Mina A, Greenberg PL, Deeg HJ. How I reduce and treat posttransplant relapse of MDS. Blood 2024; 143:1344-1354. [PMID: 38306658 PMCID: PMC11443576 DOI: 10.1182/blood.2023023005] [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: 10/23/2023] [Revised: 01/12/2024] [Accepted: 01/28/2024] [Indexed: 02/04/2024] Open
Abstract
ABSTRACT Allogeneic hematopoietic stem cell transplantation (HSCT) is the only potentially curative option for patients with high-risk myelodysplastic syndromes (MDS). Advances in conditioning regimens and supportive measures have reduced treatment-related mortality and increased the role of transplantation, leading to more patients undergoing HSCT. However, posttransplant relapse of MDS remains a leading cause of morbidity and mortality for this procedure, necessitating expert management and ongoing results analysis. In this article, we review treatment options and our institutional approaches to managing MDS relapse after HSCT, using illustrative clinical cases that exemplify different clinical manifestations and management of relapse. We address areas of controversy relating to conditioning regimen intensity, chemotherapeutic bridging, and donor selection. In addition, we discuss future directions for advancing the field, including (1) the need for prospective clinical trials separating MDS from acute myeloid leukemia and focusing on posttransplant relapse, as well as (2) the validation of measurable residual disease methodologies to guide timely interventions.
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Affiliation(s)
- Alain Mina
- Myeloid Malignancies Program, Center for Cancer Research, National Cancer Institute, Bethesda, MD
| | - Peter L Greenberg
- Department of Medicine, Division of Hematology, Stanford University School of Medicine, Stanford, CA
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5
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Zhang T, Zhang Y, Zhou M, Zhang Z, Bao X, Wen L, Feng Y, Li X, Zhai M, Liu X, Zeng Z, Wu X, Chen S. Risk factors and survival analysis of human leukocyte antigen loss in relapsed acute myeloid leukaemia/myelodysplastic syndrome patients after allogeneic haematopoietic stem cell transplantation. Br J Haematol 2024; 204:1402-1413. [PMID: 38327115 DOI: 10.1111/bjh.19304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 12/12/2023] [Accepted: 01/08/2024] [Indexed: 02/09/2024]
Abstract
To investigate the clinical characteristics and risk factors of specific human leukocyte antigen loss (HLA loss) in relapsed acute myeloid leukaemia (AML)/myelodysplastic syndrome (MDS) patients after allogeneic haematopoietic stem cell transplantation (allo-HSCT), and compare the responses of patients with HLA loss relapse with those without HLA loss (non-HLA loss) to different treatment regimens. Clinical data of traceable patients with AML/MDS after myeloablative allo-HSCT in our centre between January 2010 and June 2021, who experienced disease relapse after the transplantation, were collected. The patients were divided into the HLA loss relapse group and the non-HLA loss relapsed group based on HLA loss gene test findings by next-generation sequencing. The patients' median overall survival (OS) after the relapse were compared, and univariate and multivariate analyses were performed using the Kaplan-Meier survival curve and Cox proportional hazard model to explore the responses to different treatments after relapse. A total of 2359 patients were selected. Retrospective HLA gene loss gene detection was performed for the deoxyribonucleic acid in 179 relapsed patients, including 47 patients in the HLA loss group (27.2%), 126 patients in the non-HLA loss group (72.8%) and 6 patients were excluded due to a lack of confirmed results. There was no significant statistical difference in the baseline characteristics of patients between the two groups, but as to transplantation-related characteristics, the donor-recipient relationship and HLA mismatched loci were statistically different between the two groups (both p < 0.001). Multivariate Cox analysis showed that more HLA mismatched loci ≥3 (HR = 3.66; 95% CI: 1.61-8.31; p = 0.002), time (≤6 months) from HSCT to relapse (HR = 7.92; 95% CI: 3.35-18.74; p < 0.001) and donor chimerism (CD3) in bone marrow at relapse (HR = 1.02; 95% CI: 1.00-1.03; p = 0.036) were independent factors affecting HLA loss relapse. The ratio of negative conversion of FLT3-ITD or CEBPA mutation was significantly lower in patients with post-transplantation HLA loss relapse than in the non-HLA loss group (0.0% vs. 45.5%, p = 0.003; 0.0% vs. 80.0%, p = 0.035), with none of the patients with FLT3-ITD or CEBPA mutation turned negative in the HLA loss group. The number of gene mutations turned negative when relapse in the non-HLA loss group was remarkably higher than that in the HLA loss group (p = 0.001). Using donor lymphocyte infusion (DLI) could not prolong OS for the HLA loss group (p = 0.42). Nevertheless, second transplantation had a significant positive impact on OS in the HLA loss group (p = 0.017), although only five patients in the HLA loss group underwent second transplantation. However, patients in the non-HLA loss group using DLI had a relatively longer OS time than those without DLI (p = 0.017). Second transplantation could also prolong OS in the non-HLA loss group, but the effect was not as significant as in the HLA loss group (p = 0.053). In summary, HLA loss detection is essential for patients with recurrence after transplantation, especially for those with more HLA mismatched loci and non-sibling donor. Furthermore, the detection of HLA loss has a guiding role in choosing subsequent therapy when relapsed, as secondary transplantation is more suitable than DLI for those with HLA loss.
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Affiliation(s)
- Tingting Zhang
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Yuqi Zhang
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Meijia Zhou
- Department of Hematology, Changshu Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhibo Zhang
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Xiebing Bao
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Lijun Wen
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Yufeng Feng
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Xiaobo Li
- Beijing BoFuRui Gene Diagnostics Co., Ltd., Beijing, China
| | - Mingya Zhai
- Beijing BoFuRui Gene Diagnostics Co., Ltd., Beijing, China
| | - Xiangjun Liu
- Beijing BoFuRui Gene Diagnostics Co., Ltd., Beijing, China
| | - Zhao Zeng
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Xiaojin Wu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Suning Chen
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
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6
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Harada N, Okamura H, Makuuchi Y, Kuno M, Takakuwa T, Nakamae M, Nishimoto M, Nakashima Y, Koh H, Hino M, Nakamae H. Third HLA-haploidentical stem cell transplantation using post-transplant cyclophosphamide for relapsed acute leukemia. Bone Marrow Transplant 2023; 58:1403-1405. [PMID: 37714944 DOI: 10.1038/s41409-023-02108-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/25/2023] [Accepted: 09/07/2023] [Indexed: 09/17/2023]
Affiliation(s)
- Naonori Harada
- Hematology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan.
- Department of Hematology, Fuchu Hospital, Osaka, Japan.
| | - Hiroshi Okamura
- Hematology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Yosuke Makuuchi
- Hematology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Masatomo Kuno
- Hematology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Teruhito Takakuwa
- Hematology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Mika Nakamae
- Hematology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Mitsutaka Nishimoto
- Hematology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Yasuhiro Nakashima
- Hematology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Hideo Koh
- Hematology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Masayuki Hino
- Hematology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Hirohisa Nakamae
- Hematology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
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7
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Sauerer T, Velázquez GF, Schmid C. Relapse of acute myeloid leukemia after allogeneic stem cell transplantation: immune escape mechanisms and current implications for therapy. Mol Cancer 2023; 22:180. [PMID: 37951964 PMCID: PMC10640763 DOI: 10.1186/s12943-023-01889-6] [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: 08/11/2023] [Accepted: 10/24/2023] [Indexed: 11/14/2023] Open
Abstract
Acute myeloid leukemia (AML) is a heterogeneous disease characterized by the expansion of immature myeloid cells in the bone marrow (BM) and peripheral blood (PB) resulting in failure of normal hematopoiesis and life-threating cytopenia. Allogeneic hematopoietic stem cell transplantation (allo-HCT) is an established therapy with curative potential. Nevertheless, post-transplant relapse is common and associated with poor prognosis, representing the major cause of death after allo-HCT. The occurrence of relapse after initially successful allo-HCT indicates that the donor immune system is first able to control the leukemia, which at a later stage develops evasion strategies to escape from immune surveillance. In this review we first provide a comprehensive overview of current knowledge regarding immune escape in AML after allo-HCT, including dysregulated HLA, alterations in immune checkpoints and changes leading to an immunosuppressive tumor microenvironment. In the second part, we draw the line from bench to bedside and elucidate to what extend immune escape mechanisms of relapsed AML are yet exploited in treatment strategies. Finally, we give an outlook how new emerging technologies could help to improve the therapy for these patients, and elucidate potential new treatment options.
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Affiliation(s)
- Tatjana Sauerer
- Department of Hematology and Oncology, Augsburg University Hospital and Medical Faculty, Bavarian Cancer Research Center (BZKF) and Comprehensive Cancer Center Augsburg, Augsburg, Germany
| | - Giuliano Filippini Velázquez
- Department of Hematology and Oncology, Augsburg University Hospital and Medical Faculty, Bavarian Cancer Research Center (BZKF) and Comprehensive Cancer Center Augsburg, Augsburg, Germany
| | - Christoph Schmid
- Department of Hematology and Oncology, Augsburg University Hospital and Medical Faculty, Bavarian Cancer Research Center (BZKF) and Comprehensive Cancer Center Augsburg, Augsburg, Germany.
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8
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McCurdy SR, Luznik L. Relapse after allogeneic transplantation with post-transplant cyclophosphamide: Shattering myths and evolving insight. Blood Rev 2023; 62:101093. [PMID: 37198064 PMCID: PMC10777733 DOI: 10.1016/j.blre.2023.101093] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 04/18/2023] [Indexed: 05/19/2023]
Abstract
Early studies in allogeneic blood or marrow transplantation (alloBMT) demonstrated that HLA-mismatching was protective again relapse. However, benefits in relapse reduction were outweighed by a high risk of graft-versus-host disease (GVHD) when using conventional pharmacological immunosuppression. Post-transplant cyclophosphamide(PTCy)-based platforms abated the risk of GVHD thereby overcoming the negative effects of HLA-mismatching on survival. However, since its inception, PTCy has been shadowed by a reputation for a greater risk of relapse when compared with traditional GVHD prophylaxis. Specifically, whether PTCy reduces the anti-tumor efficacy of HLA-mismatched alloBMT by killing alloreactive T cells has been the subject of debate since the early 2000's. Here we review the many studies demonstrating the potent graft-versus-malignancy (GVM) properties of alloBMT with PTCy. We discuss the laboratory data from PTCy platforms supporting that T regulatory cells may be a major mechanism of prevention of GVHD and that natural killer (NK) cells may be early effectors of GVM. Finally, we propose potential paths to optimize GVM through selecting for class II mismatching and augmenting NK cell activity.
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Affiliation(s)
- Shannon R McCurdy
- Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, PA, USA; Division of Hematology and Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
| | - Leo Luznik
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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9
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Filippini Velázquez G, Labopin M, Tischer J, Raiola AM, Angelucci E, Kulagin AD, Galieni P, Bermúdez A, Bulabois CE, Kröger N, Díez-Martín JL, Kwon M, Nagler A, Schmid C, Ciceri F, Mohty M. Second haploidentical stem cell transplantation (HAPLO-SCT2) after relapse from a first HAPLO-SCT in acute leukaemia-a study on behalf of the Acute Leukaemia Working Party (ALWP) of the European Society for Blood and Marrow Transplantation (EBMT). Bone Marrow Transplant 2023; 58:907-915. [PMID: 37160941 PMCID: PMC10400422 DOI: 10.1038/s41409-023-01985-7] [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: 01/21/2023] [Revised: 03/20/2023] [Accepted: 04/04/2023] [Indexed: 05/11/2023]
Abstract
For patients with acute myeloid and lymphoblastic leukaemia (AML/ALL) lacking a matched sibling or unrelated donor, haploidentical stem cell transplantation (HAPLO-SCT) is increasingly used. However, available data on the treatment of relapse after HAPLO-SCT, including feasibility and efficacy of a second HAPLO-SCT (HAPLO-SCT2), is scarce. Hence, adults with AML/ALL, that had undergone HAPLO-SCT2 without ex-vivo manipulation after haematologic relapse from HAPLO-SCT1 were selected for a retrospective registry analysis. Eighty-two patients (AML, n = 63, ALL, n = 19, median follow-up: 33 months) were identified. Engraftment rate was 87%. At day +180, cumulative incidences of acute GvHD II-IV°/chronic GvHD were 23.9%/22.6%, respectively. Two-year overall survival/leukaemia-free survival (OS/LFS) were 34.3%/25.4%; 2-year non-relapse mortality (NRM) and relapse incidence (RI) were 17.6% and 57%. Leukaemia was the most frequent cause of death. Separated by disease, 2-year OS/LFS/NRM/RI were 28.7%/22.3%/16.2%/61.6% in AML, and 55.3%/38.4%/23.5%/38.2% in ALL patients. In a risk-factor analysis among patients with AML, stage at HAPLO-SCT1 and HAPLO-SCT2, and interval from HAPLO-SCT1 to relapse significantly influenced outcome. Our data demonstrate that HAPLO-SCT2 is a viable option in acute leukaemia relapse after HAPLO-SCT1. Engraftment, toxicity, risk factors and long-term outcome are comparable to data reported after allo-SCT2 in a matched donor setting.
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Affiliation(s)
| | - Myriam Labopin
- EBMT Paris Study Unit, Saint-Antoine Hospital, Paris, France
- Department of Haematology, Hôpital Saint-Antoine, Sorbonne University, INSERM UMRs 938, Paris, France
| | - Johanna Tischer
- Department of Internal Medicine III, University Hospital of Munich, Campus Grosshadern, Munich, Germany
| | - Anna Maria Raiola
- Hematology and cellular therapy unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Emanuele Angelucci
- Hematology and cellular therapy unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Alexander D Kulagin
- RM Gorbacheva Research Institute, Pavlov University, St. Petersburg, Russian Federation
| | - Piero Galieni
- Haematology Service, Mazzoni Hospital, Ascoli Piceno, Italy
| | - Arancha Bermúdez
- Servicio de Hematología-Hemoterapia, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Claude-Eric Bulabois
- Service d'Hématologie, CHU Grenoble Alpes-Université Grenoble Alpes, Grenoble, France
| | - Nicolaus Kröger
- University Medical Center Hamburg-Eppendorf, Department of Stem Cell Transplantation, Hamburg, Germany
| | | | - Mi Kwon
- Sección de Trasplante de Médula Ósea, Hospital Gregorio Marañón, Madrid, Spain
| | - Arnon Nagler
- Hematology and Bone Marrow Transplant Unit, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Christoph Schmid
- Section for Stem Cell Transplantation, Augsburg University Hospital and Medical Faculty, Augsburg, Germany.
| | - Fabio Ciceri
- Unit of Hematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Mohamad Mohty
- Department of Haematology, Hôpital Saint-Antoine, Sorbonne University, INSERM UMRs 938, Paris, France
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10
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Cao XY, Zhang JP, Zhao YL, Xiong M, Zhou JR, Lu Y, Sun RJ, Wei ZJ, Liu DY, Zhang X, Yang JF, Lu P. Analysis benefits of a second Allo-HSCT after CAR-T cell therapy in patients with relapsed/refractory B-cell acute lymphoblastic leukemia who relapsed after transplant. Front Immunol 2023; 14:1191382. [PMID: 37469510 PMCID: PMC10352576 DOI: 10.3389/fimmu.2023.1191382] [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: 03/22/2023] [Accepted: 06/13/2023] [Indexed: 07/21/2023] Open
Abstract
Background Chimeric antigen receptor (CAR) T-cell therapy has demonstrated high initial complete remission (CR) rates in B-cell acute lymphoblastic leukemia (B-ALL) patients, including those who relapsed after transplant. However, the duration of remission requires improvements. Whether bridging to a second allogeneic hematopoietic stem cell transplant (allo-HSCT) after CAR-T therapy can improve long-term survival remains controversial. We retrospectively analyzed long-term follow-up data of B-ALL patients who relapsed post-transplant and received CAR-T therapy followed by consolidation second allo-HSCT to investigate whether such a treatment sequence could improve long-term survival. Methods A single-center, retrospective study was performed between October 2017 and March 2022, involving 95 patients who received a consolidation second transplant after achieving CR from CAR-T therapy. Results The median age of patients was 22.8 years (range: 3.3-52.8) at the second transplant. After the first transplant, 71 patients (74.7%) experienced bone marrow relapse, 16 patients (16.8%) had extramedullary relapse, 5 patients (5.3%) had both bone marrow and extramedullary relapse and 3/95 patients (3.2%) had positive minimal residual disease (MRD) only. Patients received autologous (n=57, 60.0%) or allogeneic (n=28, 29.5%) CAR-T cells, while 10 patients (10.5%) were unknown. All patients achieved CR after CAR-T therapy. Before second HSCT, 86 patients (90.5%) were MRD-negative, and 9 (9.5%) were MRD-positive. All second transplant donors were different from the first transplant donors. The median follow-up time was 623 days (range: 33-1901) after the second HSCT. The 3-year overall survival (OS) and leukemia-free survival (LFS) were 55.3% (95%CI, 44.3-66.1%) and 49.8% (95%CI, 38.7-60.9%), respectively. The 3-year relapse incidence (RI) and non-relapse mortality (NRM) were 10.5% (95%CI, 5.6-19.6%) and 43.6% (95%CI, 33.9-56.2%), respectively. In multivariate analysis, the interval from CAR-T to second HSCT ≤90 days was associated with superior LFS(HR, 4.10, 95%CI,1.64-10.24; p=0.003) and OS(HR, 2.67, 95%CI, 1.24-5.74, p=0.012), as well as reduced NRM (HR, 2.45, 95%CI, 1.14-5.24, p=0.021). Conclusions Our study indicated that CAR-T therapy followed by consolidation second transplant could significantly improve long-term survival in B-ALL patients who relapsed post-transplant. The second transplant should be considered in suitable patients and is recommended to be performed within 90 days after CAR-T treatment.
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Affiliation(s)
- Xing-yu Cao
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - Jian-ping Zhang
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - Yan-li Zhao
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - Min Xiong
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - Jia-rui Zhou
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - Yue Lu
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - Rui-juan Sun
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - Zhi-jie Wei
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - De-yan Liu
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - Xian Zhang
- Department of Hematology, Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - Jun-fang Yang
- Department of Hematology, Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - Peihua Lu
- Department of Hematology, Hebei Yanda Lu Daopei Hospital, Langfang, China
- Beijing Lu Daopei Institute of Hematology, Beijing, China
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11
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Han TT, Liu Y, Chen Y, Zhang YY, Fu HX, Yan CH, Mo XD, Wang FR, Wang JZ, Han W, Chen YY, Chen H, Sun YQ, Cheng YF, Wang Y, Zhang XH, Huang XJ, Xu LP. [Efficacy and safety of secondary allogeneic hematopoietic stem cell transplantation in 70 patients with recurrent hematologic malignancies after transplantation]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2023; 44:458-464. [PMID: 37550200 PMCID: PMC10450553 DOI: 10.3760/cma.j.issn.0253-2727.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Indexed: 08/09/2023]
Abstract
Objectives: To investigate the role of donor change in the second hematopoietic stem cell transplantation (HSCT2) for hematological relapse of malignant hematology after the first transplantation (HSCT1) . Methods: We retrospectively analyzed patients with relapsed hematological malignancies who received HSCT2 at our single center between Mar 1998 and Dec 2020. A total of 70 patients were enrolled[49 males and 21 females; median age, 31.5 (3-61) yr]. Results: Forty-nine male and 21 female patients were enrolled in the trial. At the time of HSCT2, the median age was 31.5 (3-61) years old. Thirty-one patients were diagnosed with acute myeloid leukemia, 23 patients with ALL, and 16 patients with MDS or other malignant hematology disease. Thirty patients had HSCT2 with donor change, and 40 patients underwent HSCT2 without donor change. The median relapse time after HSCT1 was 245.5 (26-2 905) days. After HSCT2, 70 patients had neutrophil engraftment, and 62 (88.6%) had platelet engraftment. The cumulative incidence of platelet engraftment was (93.1±4.7) % in patients with donor change and (86.0±5.7) % in patients without donor change (P=0.636). The cumulative incidence of CMV infection in patients with and without donor change was (64.0±10.3) % and (37.0±7.8) % (P=0.053), respectively. The cumulative incidence of grade Ⅱ-Ⅳ acute graft versus host disease was (19.4±7.9) % vs (31.3±7.5) %, respectively (P=0.227). The cumulative incidence of TRM 100-day post HSCT2 was (9.2±5.1) % vs (6.7±4.6) % (P=0.648), and the cumulative incidence of chronic graft versus host disease at 1-yr post-HSCT2 was (36.7±11.4) % versus (65.6±9.1) % (P=0.031). With a median follow-up of 767 (271-4 936) days, 38 patients had complete remission (CR), and three patients had persistent disease. The CR rate was 92.7%. The cumulative incidences of overall survival (OS) and disease-free survival (DFS) 2 yr after HSCT2 were 25.8% and 23.7%, respectively. The cumulative incidence of relapse, OS, and DFS was (52.6±11.6) % vs (62.4±11.3) % (P=0.423), (28.3±8.6) % vs (23.8±7.5) % (P=0.643), and (28.3±8.6) % vs (22.3±7.7) % (P=0.787), respectively, in patients with changed donor compared with patients with the original donor. Relapses within 6 months post-HSCT1 and with persistent disease before HSCT2 were risk factors for OS, DFS, and CIR. Disease status before HSCT2 and early relapse (within 6 months post-HSCT1) was an independent risk factor for OS, DFS, and CIR post-HSCT2. Conclusion: Our findings indicate that changing donors did not affect the clinical outcome of HSCT2.
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Affiliation(s)
- T T Han
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Y Liu
- Hematology Department, the Third People's Hospital of Zhengzhou, Zhengzhou 450000, China
| | - Y Chen
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Y Y Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - H X Fu
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - C H Yan
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - X D Mo
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - F R Wang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - J Z Wang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - W Han
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Y Y Chen
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - H Chen
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Y Q Sun
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Y F Cheng
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Y Wang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - X H Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - X J Huang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - L P Xu
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
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12
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Lu Y, Zhang JP, Zhao YL, Xiong M, Sun RJ, Cao XY, Wei ZJ, Zhou JR, Liu DY, Yang JF, Zhang X, Lu DP, Lu P. Prognostic factors of second hematopoietic allogeneic stem cell transplantation among hematological malignancy patients relapsed after first hematopoietic stem cell transplantation: A single center study. Front Immunol 2023; 13:1066748. [PMID: 36685540 PMCID: PMC9846785 DOI: 10.3389/fimmu.2022.1066748] [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: 10/11/2022] [Accepted: 12/09/2022] [Indexed: 01/06/2023] Open
Abstract
Introduction We aimed to evaluate prognostic factors of a second allogeneic stem cell transplantation (allo-HSCT2) among hematological malignancy patients who have relapsed after the first allo-HSCT(allo-HSCT1). Methods We retrospectively analyzed 199 hematological malignancy patients who received allo-HSCT2 as a salvage treatment post allo-HSCT1 relapse between November 2012 and October 2021. Results The median age at allo-HSCT2 was 23 (range: 3-60) years. The median time to relapse after HSCT1 was 9 (range: 1-72) months. Prior to allo-HSCT2, patients had the following hematopoietic cell transplantation-comorbidity indexes (HCT-CI): 127 with a score of 0, 52 with a score of 1, and 20 with a score of 2 or greater. Fifty percent of patients received chimeric antigen receptor (CAR) T-cell therapy following HSCT1 relapse. Disease status was minimal residual disease (MRD)-negative complete remission (CR) among 119 patients, MRD-positive CR among 37 patients and non-remission (NR) for 43 patients prior to allo-HSCT2. Allo-HSCT2 was performed from a new donor in 194 patients (97.4%) and 134 patients (67.3%) received a graft with a new mismatched haplotype. The median follow-up time was 24 months (range: 6-98 months), and the 2-year OS and LFS were 43.8% ± 4.0% and 42.1% ± 4.1%, respectively. The 2-year cumulative incidence of relapse (CIR) and non-relapse mortality (NRM) was 30.0%±4.8% and 38.5%±3.8%, respectively. Cox regression multivariate analysis showed that disease statusof MRD-negative CR, HCT-CI score of 0 prior to allo-HSCT2, and new mismatched haplotype donor were predictive factors of improved OS and LFS compared to patients without these characteristics. Based on these three favorable factors, we developed a predictive scoring system for patients who received allo-HSCT2. Patients with a prognostic score of 3 who had the three factors showed a superior 2-year OS of 63.3% ± 6.7% and LFS of 63.3% ± 6.7% and a lower CIR of 5.5% ± 3.1% than patients with a prognostic score of 0. Allo-HSCT2 is feasible and patients with good prognostic features prior to allo-HSCT2 -disease status of CR/MRD- and HCT-CI score of 0 as well as a second donor with a new mismatched haplotype could have the maximal benefit from the second allo-HSCT. Conclusions Allo-HSCT2 is feasible and patients with good prognostic features prior to allo-HSCT2 -disease status of CR/MRD- and HCT-CI score of 0 as well as a second donor with a new mismatched haplotype could have the maximal benefit from the second allo-HSCT.
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Affiliation(s)
- Yue Lu
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang, China,*Correspondence: Yue Lu, ; Peihua Lu,
| | - Jian-Ping Zhang
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - Yan-Li Zhao
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - Min Xiong
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - Rui-Juan Sun
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - Xing-Yu Cao
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - Zhi-Jie Wei
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - Jia-Rui Zhou
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - De-Yan Liu
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - Jun-Fang Yang
- Department of Hematology and Immunology, Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - Xian Zhang
- Department of Hematology and Immunology, Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - Dao-Pei Lu
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - Peihua Lu
- Department of Hematology and Immunology, Hebei Yanda Lu Daopei Hospital, Langfang, China,Beijing Lu Daopei Institute of Hematology, Beijing, China,*Correspondence: Yue Lu, ; Peihua Lu,
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13
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Liu Y, Han TT, Chen Y, Chen H, Fu HX, Zhang YY, Wang FR, Wang JZ, Yan CH, Han W, Chen YY, Sun YQ, Wang Y, Tang FF, Liu KY, Zhang XH, Huang XJ, Xu LP. [Safety of rabbit anti-human thymocyte immunoglobulin in second allogeneic hematopoietic stem cell transplantation for patients with hematological diseases]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2022; 43:853-857. [PMID: 36709200 PMCID: PMC9669623 DOI: 10.3760/cma.j.issn.0253-2727.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Figures] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Indexed: 01/30/2023]
Abstract
Objective: To look into the security of a second allogeneic hematopoietic stem cell transplantation (allo-HSCT) using rabbit anti-human thymocyte immunoglobulin (rATG) . Methods: Twenty-seven patients who used rATG in the first and second allo-HSCT at the Institute of Hematology, Peking University were enrolled in the study. Experienced toxicities associated with the conditioning protocol within 10 days (-5 d to +3 d) following the beginning of the rATG application, including fever, diarrhea, arrhythmia, reduced blood pressure, liver damage, seizures, and other problems. Results: The overall incidence of conditioning regimen early adverse reactions during the first transplantation and the second allo-HSCT conditioning regimen was 96.3% and 77.8% (P=0.043) . Fever rates were 81.5% and 63.0% (P=0.129) , diarrhea rates were 59.3% and 25.9% (P=0.013) , liver damage rates were 22.2% and 25.9% (P=0.75) , and the rates of other events (cardiac arrhythmia, low blood pressure, and epilepsy) were 3.7% and 18.5% (P=0.083) . Adverse reactions that occurred during both the first and second course of rATG applications have been improved with symptomatic treatment, and no treatment interruptions occurred. Conclusion: Reusing rATG in a second transplant was risk-free and did not result in higher early toxicities.
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Affiliation(s)
- Y Liu
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China The Third People's Hospital of Zhengzhou, Zhengzhou 450099, China
| | - T T Han
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Y Chen
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - H Chen
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - H X Fu
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Y Y Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - F R Wang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - J Z Wang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - C H Yan
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - W Han
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Y Y Chen
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Y Q Sun
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Y Wang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - F F Tang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - K Y Liu
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - X H Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - X J Huang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - L P Xu
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
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14
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Lin MH, Huo MR, Zhao XY. [Progress of heterozygosity loss in HLA region after allogeneic stem cell transplantation for leukemia]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2022; 43:608-611. [PMID: 36709142 PMCID: PMC9395567 DOI: 10.3760/cma.j.issn.0253-2727.2022.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Indexed: 11/06/2022]
Affiliation(s)
- M H Lin
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Blood Diseases, Beijing 100044, China
| | - M R Huo
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Blood Diseases, Beijing 100044, China
| | - X Y Zhao
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Blood Diseases, Beijing 100044, China
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15
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McCurdy SR. Harnessing allogeneic NK cells: improving outcomes with tailored donor lymphocyte infusion. J Clin Invest 2022; 132:160584. [PMID: 35642633 PMCID: PMC9151684 DOI: 10.1172/jci160584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Since researchers first began to uncover the mechanisms underlying allogeneic transplantation, the focus has been on T cells. T cells are a major instigator of graft-versus-host disease (GVHD). The clear association between GVHD occurrence and subsequent reduction in relapse supported concentrating on T cells as the masterminds behind graft-versus-tumor (GVT) effects. Recently, an alternative mediator of GVT has taken center stage: natural killer (NK) cells. Part of the appeal of NK cells is their potential to provide antitumor immunity without GVHD. Donor lymphocyte infusion has been the predominant treatment of relapse after allogeneic transplant, but the mix of lymphocytes includes CD8+ T cells and, consequently, a substantial risk for GVHD. In this issue of the JCI, Shapiro and colleagues developed an adoptive NK cell transfer platform to treat relapse after haploidentical allogeneic transplant. The study demonstrated safety, sought to determine resistance mechanisms, and provided avenues for future research.
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16
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Epperly R, Talleur AC, Li Y, Schell S, Tuggle M, Métais JY, Huang S, Pei D, Cheng C, Madden R, Mamcarz E, Naik S, Qudeimat A, Sharma A, Srinivasan A, Suliman A, Gottschalk S, Triplett BM. Sub-myeloablative Second Transplantations with Haploidentical Donors and Post-Transplant Cyclophosphamide have limited Anti-Leukemic Effects in Pediatric Patients. Transplant Cell Ther 2022; 28:262.e1-262.e10. [PMID: 35151936 PMCID: PMC9081211 DOI: 10.1016/j.jtct.2022.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 02/01/2022] [Accepted: 02/06/2022] [Indexed: 10/19/2022]
Abstract
Pediatric patients with high-risk hematologic malignancies who experience relapse after a prior allogeneic hematopoietic cell transplant (HCT) have an exceedingly poor prognosis. A second allogeneic HCT offers the potential for long-term cure but carries high risks of both subsequent relapse and HCT-related morbidity and mortality. Using haploidentical donors for HCT (haploHCT) can expand the donor pool and potentially enhance the graft-versus-leukemia effect but is accompanied by a risk of graft-versus-host disease (GVHD). The goal of this protocol was to intensify the antileukemia effect of haploHCT for pediatric patients with hematologic malignancies that relapsed after prior allogeneic HCT, while limiting regimen-associated toxicities. This phase II clinical trial evaluated a sub-myeloablative preparative regimen consisting of anti-thymocyte globulin, clofarabine, cytarabine, busulfan, and cyclophosphamide, in combination with plerixafor to sensitize leukemic blasts. Participants received a mobilized peripheral blood unmanipulated haploidentical donor graft with one dose of post-transplant cyclophosphamide as GVHD prophylaxis, followed by natural killer (NK) cell addback. Here we report the clinical outcomes and immune reconstitution of 17 participants treated on the study and 5 additional patients treated on similar single-patient treatment plans. Of the 22 participants analyzed, 12 (55%) had active disease at the time of HCT. The regimen provided robust immune reconstitution, with 21 participants (95%) experiencing neutrophil engraftment at a median of 14 days after HCT. In this high-risk population, the overall survival was 45% (95% confidence interval [CI], 24%-64%), with a 12-month event-free survival of 31% (95% CI, 14%-51%) and cumulative incidence of relapse at 12 months of 50% (95% CI, 27%-69%). Four participants (18%) remain in remission at >5 years follow-up. Expected HCT-related organ-specific toxicities were observed, and 13 participants (59%) experienced acute or chronic GVHD. This intensified but sub-myeloablative regimen, followed by a high-dose unmanipulated haploidentical graft, post-transplantation cyclophosphamide, and NK cell infusion, resulted in adequate immune reconstitution but failed to overcome the elevated risks of relapse and treatment-related morbidity in this high-risk population.
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Affiliation(s)
- Rebecca Epperly
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Aimee C Talleur
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Ying Li
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Sarah Schell
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - MaCal Tuggle
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Jean-Yves Métais
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Sujuan Huang
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Deqing Pei
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Cheng Cheng
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Renee Madden
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Ewelina Mamcarz
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Swati Naik
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Amr Qudeimat
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Akshay Sharma
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Ashok Srinivasan
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Ali Suliman
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee; Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Stephen Gottschalk
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Brandon M Triplett
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee.
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17
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Kinoshita H, Cooke KR, Grant M, Stanojevic M, Cruz CR, Keller M, Fortiz MF, Hoq F, Lang H, Barrett AJ, Liang H, Tanna J, Zhang N, Shibli A, Datar A, Fulton K, Kukadiya D, Zhang A, Williams KM, Dave H, Dome JS, Jacobsohn D, Hanley PJ, Jones RJ, Bollard CM. Outcome of donor-derived TAA-T cell therapy in patients with high-risk or relapsed acute leukemia post allogeneic BMT. Blood Adv 2022; 6:2520-2534. [PMID: 35244681 PMCID: PMC9043933 DOI: 10.1182/bloodadvances.2021006831] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 02/14/2022] [Indexed: 12/02/2022] Open
Abstract
Patients with hematologic malignancies relapsing after allogeneic blood or marrow transplantation (BMT) have limited response to conventional salvage therapies, with an expected 1-year overall survival (OS) of <20%. We evaluated the safety and clinical outcomes following administration of a novel T-cell therapeutic targeting 3 tumor-associated antigens (TAA-T) in patients with acute leukemia who relapsed or were at high risk of relapse after allogeneic BMT. Lymphocytes obtained from the BMT donor were manufactured to target TAAs WT1, PRAME, and survivin, which are over-expressed and immunogenic in most hematologic malignancies. Patients received TAA-T infusions at doses of 0.5 to 4 × 107/m2. Twenty-three BMT recipients with relapsed/refractory (n = 11) and/or high-risk (n = 12) acute myeloid leukemia (n = 20) and acute lymphoblastic leukemia (n = 3) were infused posttransplant. No patient developed cytokine-release syndrome or neurotoxicity, and only 1 patient developed grade 3 graft-versus-host disease. Of the patients who relapsed post-BMT and received bridging therapy, the majority (n = 9/11) achieved complete hematologic remission before receiving TAA-T. Relapsed patients exhibited a 1-year OS of 36% and 1-year leukemia-free survival of 27.3% post-TAA-T. The poorest prognosis patients (relapsed <6 months after transplant) exhibited a 1-year OS of 42.8% postrelapse (n = 7). Median survival was not reached for high-risk patients who received preemptive TAA-T posttransplant (n = 12). Although as a phase 1 study, concomitant antileukemic therapy was allowed, TAA-T were safe and well tolerated, and sustained remissions in high-risk and relapsed patients were observed. Moreover, adoptively transferred TAA-T detected by T-cell receptor V-β sequencing persisted up to at least 1 year postinfusion. This trial was registered at clinicaltrials.gov as #NCT02203903.
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Affiliation(s)
- Hannah Kinoshita
- Center for Cancer and Immunology Research, Children’s National Research Institute, Children’s National Hospital, Washington, DC
- Division of Blood and Marrow Transplantation, Children’s National Hospital, Washington, DC
- Division of Oncology, Children’s National Hospital, Washington, DC
| | - Kenneth R. Cooke
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Melanie Grant
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Maja Stanojevic
- Center for Cancer and Immunology Research, Children’s National Research Institute, Children’s National Hospital, Washington, DC
| | - C. Russell Cruz
- Center for Cancer and Immunology Research, Children’s National Research Institute, Children’s National Hospital, Washington, DC
- Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC
- Stem Cell Transplantation and Cell Therapy Program, George Washington Cancer Center, Washington, DC
| | - Michael Keller
- Center for Cancer and Immunology Research, Children’s National Research Institute, Children’s National Hospital, Washington, DC
- Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Maria Fernanda Fortiz
- Center for Cancer and Immunology Research, Children’s National Research Institute, Children’s National Hospital, Washington, DC
| | - Fahmida Hoq
- Center for Cancer and Immunology Research, Children’s National Research Institute, Children’s National Hospital, Washington, DC
| | - Haili Lang
- Center for Cancer and Immunology Research, Children’s National Research Institute, Children’s National Hospital, Washington, DC
| | - A. John Barrett
- Stem Cell Transplantation and Cell Therapy Program, George Washington Cancer Center, Washington, DC
| | - Hua Liang
- Department of Statistics, The George Washington University, Washington, DC; and
| | - Jay Tanna
- Center for Cancer and Immunology Research, Children’s National Research Institute, Children’s National Hospital, Washington, DC
| | - Nan Zhang
- Center for Cancer and Immunology Research, Children’s National Research Institute, Children’s National Hospital, Washington, DC
| | - Abeer Shibli
- Center for Cancer and Immunology Research, Children’s National Research Institute, Children’s National Hospital, Washington, DC
| | - Anushree Datar
- Center for Cancer and Immunology Research, Children’s National Research Institute, Children’s National Hospital, Washington, DC
| | - Kenneth Fulton
- Center for Cancer and Immunology Research, Children’s National Research Institute, Children’s National Hospital, Washington, DC
| | - Divyesh Kukadiya
- Center for Cancer and Immunology Research, Children’s National Research Institute, Children’s National Hospital, Washington, DC
| | - Anqing Zhang
- Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Kirsten M. Williams
- Department of Pediatric Hematology/Oncology, Aflac Cancer & Blood Disorders Center, Children’s Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA
| | - Hema Dave
- Center for Cancer and Immunology Research, Children’s National Research Institute, Children’s National Hospital, Washington, DC
- Division of Oncology, Children’s National Hospital, Washington, DC
- Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Jeffrey S. Dome
- Center for Cancer and Immunology Research, Children’s National Research Institute, Children’s National Hospital, Washington, DC
- Division of Oncology, Children’s National Hospital, Washington, DC
- Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - David Jacobsohn
- Center for Cancer and Immunology Research, Children’s National Research Institute, Children’s National Hospital, Washington, DC
- Division of Blood and Marrow Transplantation, Children’s National Hospital, Washington, DC
- Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Patrick J. Hanley
- Center for Cancer and Immunology Research, Children’s National Research Institute, Children’s National Hospital, Washington, DC
- Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Richard J. Jones
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Catherine M. Bollard
- Center for Cancer and Immunology Research, Children’s National Research Institute, Children’s National Hospital, Washington, DC
- Division of Blood and Marrow Transplantation, Children’s National Hospital, Washington, DC
- Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC
- Stem Cell Transplantation and Cell Therapy Program, George Washington Cancer Center, Washington, DC
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18
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Arnold PY. Review: HLA loss and detection in the setting of relapse from HLA-mismatched hematopoietic cell transplant. Hum Immunol 2022; 83:712-720. [DOI: 10.1016/j.humimm.2022.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 02/09/2022] [Accepted: 03/02/2022] [Indexed: 01/25/2023]
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19
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Webster JA, Luznik L, Gojo I. Treatment of AML Relapse After Allo-HCT. Front Oncol 2022; 11:812207. [PMID: 34976845 PMCID: PMC8716583 DOI: 10.3389/fonc.2021.812207] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 11/25/2021] [Indexed: 01/02/2023] Open
Abstract
With advances in allogeneic hematopoietic stem cell transplant (allo-HCT), disease relapse has replaced transplant-related mortality as the primary cause of treatment failure for patients with acute myeloid leukemia (AML). The efficacy of allo-HCT in AML is a consequence of a graft-versus-leukemia (GVL) effect that is mediated by T lymphocytes, and unique mechanisms of immune evasion underlying post-allo-HCT AML relapses have recently been characterized. Relapsed AML following allo-HCT presents a particularly vexing clinical challenge because transplant-related toxicities, such as graft-versus-host (GVHD) and infections, increase the risk of treatment-related morbidity and mortality. In general, the prognosis of relapsed AML following allo-HCT is poor with most patients failing to achieve a subsequent remission and 2-year survival consistently <15%. The two factors that have been found to predict a better prognosis are a longer duration of post-transplant remission prior to relapse and a lower disease burden at the time of relapse. When considered in combination with a patient's age; co-morbidities; and performance status, these factors can help to inform the appropriate therapy for the treatment of post-transplant relapse. This review discusses the options for the treatment of post-transplant AML relapse with a focus on the options to achieve a subsequent remission and consolidation with cellular immunotherapy, such as a second transplant or donor lymphocyte infusion (DLI). While intensive reinduction therapy and less intensive approaches with hypomethylating agents have long represented the two primary options for the initial treatment of post-transplant relapse, molecularly targeted therapies and immunotherapy are emerging as potential alternative options to achieve remission. Herein, we highlight response and survival outcomes achieved specifically in the post-transplant setting using each of these approaches and discuss how some therapies may overcome the immunologic mechanisms that have been implicated in post-transplant relapse. As long-term survival in post-transplant relapse necessarily involves consolidation with cellular immunotherapy, we present data on the efficacy and toxicity of both DLI and second allo-HCT including when such therapies are integrated with reinduction. Finally, we provide our general approach to the treatment of post-transplant relapse, integrating both novel therapies and our improved understanding of the mechanisms underlying post-transplant relapse.
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Affiliation(s)
- Jonathan A Webster
- Hematologic Malignancies and Bone Marrow Transplantation Program, Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Leo Luznik
- Hematologic Malignancies and Bone Marrow Transplantation Program, Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Ivana Gojo
- Hematologic Malignancies and Bone Marrow Transplantation Program, Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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20
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Improved outcome in AML relapse after allogeneic transplant with high-intensity chemotherapy followed by 2nd allogeneic stem cell transplant or donor lymphocyte infusion. Ann Hematol 2021; 100:2585-2592. [PMID: 34322774 DOI: 10.1007/s00277-021-04616-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 07/16/2021] [Indexed: 10/20/2022]
Abstract
Acute myeloid leukemia (AML) relapse after allogeneic stem cell transplant (alloSCT) remains a major therapeutic challenge. While patients with longer remission after initial alloSCT are recommended to receive cell therapy (CT) such as 2ndalloSCT or donor lymphocyte infusion (DLI), survival for patients who relapse within 6 months of alloSCT has been dismal. We evaluated the outcomes of AML relapse after alloSCT to assess the impact of different treatments on long-term survival. One hundred and seventy-two patients with AML underwent alloSCT at the Penn State Cancer Institute from January 2014 to August 2019. Sixty-nine patients relapsed (median age, 60 years; range, 10-75). Of these, 4 patients underwent 2ndalloSCT, and 26 received DLI. One-year overall survival (OS) in all cases was 20.3% (95% CI: 11.8-30.4%). Patients with ECOG performance status (PS) 0-2 at relapse showed a better 1-year OS than those with PS 3-4. Median OS for patients who received chemotherapy only or chemotherapy with CT was 74 or 173.5 days, respectively (p < 0.001). Relapsed patients receiving conventional re-induction chemotherapy were categorized as the high-intensity chemotherapy (H) group, while those receiving treatments such as hypomethylating agents or targeted agents were categorized as the low-intensity chemotherapy (L) group. The H group showed a better 1-year OS compared with the L group. Patients who received H + CT showed a better 1-year OS of 52.9% than the other 3 groups (p < 0.001). Even for patients with post-alloSCT remission duration of less than 6 months, the statistical significance was preserved. Factors including age, donor source at 1stalloSCT, time to relapse, blast counts, PS at relapse, and treatment type after post-alloSCT relapse were used for a multivariate analysis, and matched or mismatched related donor and H + CT after alloSCT were identified as independent factors associated with OS. These findings support the use of H + CT as the treatment option of choice for AML patients who relapse after alloSCT when feasible.
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21
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Han T, Sun Y, Liu Y, Yan C, Wang Y, Xu L, Liu K, Huang X, Zhang X. Second unmanipulated allogeneic transplantation could be used as a salvage option for patients with relapsed acute leukemia post-chemotherapy plus modified donor lymphocyte infusion. Front Med 2021; 15:728-739. [PMID: 34279770 DOI: 10.1007/s11684-021-0833-x] [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: 04/09/2020] [Accepted: 10/14/2020] [Indexed: 10/20/2022]
Abstract
Relapse is the main problem after allogeneic hematopoietic stem cell transplantation (allo-HSCT). The outcome of a second allo-HSCT (HSCT2) for relapse post-HSCT has shown promising results in some previous studies. However, little is known about the efficacy of HSCT2 in patients with relapsed/refractory acute leukemia (AL) post-chemotherapy plus modified donor lymphocyte infusion (post-Chemo + m-DLI) after the first allo-HSCT (HSCT1). Therefore, we retrospectively analyzed the efficacy of HSCT2 in 28 patients with relapsed/refractory AL post-Chemo + m-DLI in our center. With a median follow-up of 918 (457-1732) days, 26 patients (92.9%) achieved complete remission, and 2 patients exhibited persistent disease. The probabilities of overall survival (OS) and disease-free survival (DFS) 1 year after HSCT2 were 25.0% and 21.4%, respectively. The cumulative incidences of nonrelapse mortality on day 100 and at 1 year post-HSCT2 were 7.1% ± 4.9% and 25.0% ± 8.4%. The cumulative incidences of relapse were 50.0% ± 9.8% and 53.5% ± 9.9% at 1 and 2 years post-HSCT2, respectively. Risk stratification prior to HSCT1 and percentage of blasts before HSCT2 were independent risk factors for OS post-HSCT2, and relapse within 6 months post-HSCT1 was an independent risk factor for DFS and relapse post-HSCT2. Our findings suggest that HSCT2 could be a salvage option for patients with relapsed AL post-Chemo + m-DLI.
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Affiliation(s)
- Tingting Han
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, 100044, China.,National Clinical Research Center for Hematologic Disease, Beijing, 100044, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, 100044, China
| | - Yuqian Sun
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, 100044, China.,National Clinical Research Center for Hematologic Disease, Beijing, 100044, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, 100044, China
| | - Yang Liu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, 100044, China.,National Clinical Research Center for Hematologic Disease, Beijing, 100044, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, 100044, China
| | - Chenhua Yan
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, 100044, China.,National Clinical Research Center for Hematologic Disease, Beijing, 100044, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, 100044, China
| | - Yu Wang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, 100044, China.,National Clinical Research Center for Hematologic Disease, Beijing, 100044, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, 100044, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, 100044, China
| | - Lanping Xu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, 100044, China.,National Clinical Research Center for Hematologic Disease, Beijing, 100044, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, 100044, China
| | - Kaiyan Liu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, 100044, China.,National Clinical Research Center for Hematologic Disease, Beijing, 100044, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, 100044, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, 100044, China
| | - Xiaojun Huang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, 100044, China.,National Clinical Research Center for Hematologic Disease, Beijing, 100044, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, 100044, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, 100044, China.,Peking-Tsinghua Center for Life Sciences, Beijing, 100044, China
| | - Xiaohui Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, 100044, China. .,National Clinical Research Center for Hematologic Disease, Beijing, 100044, China. .,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, 100044, China. .,Collaborative Innovation Center of Hematology, Peking University, Beijing, 100044, China.
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22
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Cao XY, Qiu LY, Zhang JP, Xiong M, Zhao YL, Lu Y, Zhou JR, Wei ZJ, Sun RJ, Liu DY, Zhang X, Yang JF, Lu PH. [CART therapy followed by allo-HSCT for patients with B-cell acute lymphoblastic leukemia relapsing after the first hematopoietic stem cell transplantation]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2021; 42:318-323. [PMID: 33979977 PMCID: PMC8120115 DOI: 10.3760/cma.j.issn.0253-2727.2021.04.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
目的 观察嵌合抗原受体T细胞(CART)序贯二次异基因造血干细胞移植(allo-HSCT)治疗移植后复发急性B淋巴细胞白血病(B-ALL)的疗效。 方法 回顾性分析2015年10月至2020年6月在河北燕达陆道培医院接受二次allo-HSCT的41例B-ALL患者的临床资料,入选患者均为移植后骨髓形态学或髓外复发且二次移植前接受CART治疗。 结果 全部41例患者中男21例、女20例,二次移植时中位年龄为16(3~46)岁。移植后骨髓复发31例(75.6%)、髓外复发5例(12.2%)、骨髓和髓外复发5例(12.2%)。复发后接受CD19-CART治疗35例(85.4%)、CD22-CART治疗2例(4.9%)、CD19-CART联合CD22-CART治疗4例(9.8%)。二次移植后预期3年总生存(OS)率为48.9%(95% CI 23.0%~70.6%)、无白血病生存(LFS)率为41.8%(95% CI 17.3%~64.9%),累积复发率(RI)为8.8%(95% CI 2.9%~26.4%),非复发相关死亡率(NRM)为51.1%(95% CI 31.2%~83.6%)。首次移植后复发时间≤6个月组(10例)二次移植后1年OS率低于复发时间>6个月组(31例)[45.0%(95% CI 12.7%~73.5%)对75.0%(95% CI 51.4%~88.8%),P=0.017]。 结论 CART序贯二次allo-HSCT可使部分造血干细胞移植后复发B-ALL患者获得长生存,但NRM较高,移植方案有待进一步改进。
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Affiliation(s)
- X Y Cao
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang 065201, China
| | - L Y Qiu
- Cryopreservation Department, Hebei Yanda Lu Daopei Hospital, Langfang 065201, China
| | - J P Zhang
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang 065201, China
| | - M Xiong
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang 065201, China
| | - Y L Zhao
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang 065201, China
| | - Y Lu
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang 065201, China
| | - J R Zhou
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang 065201, China
| | - Z J Wei
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang 065201, China
| | - R J Sun
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang 065201, China
| | - D Y Liu
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang 065201, China
| | - X Zhang
- Department of Hematology, Hebei Yanda Lu Daopei Hospital, Langfang 065201, China
| | - J F Yang
- Department of Hematology, Hebei Yanda Lu Daopei Hospital, Langfang 065201, China
| | - P H Lu
- Department of Hematology, Hebei Yanda Lu Daopei Hospital, Langfang 065201, China
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23
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Muñiz P, Kwon M, Carbonell D, Chicano M, Bailén R, Oarbeascoa G, Suárez-González J, Andrés-Zayas C, Menárguez J, Dorado N, Gómez-Centurión I, Anguita J, Díez-Martín JL, Martínez-Laperche C, Buño I. Clinical Utility of the Detection of the Loss of the Mismatched HLA in Relapsed Hematological Patients After Haploidentical Stem Cell Transplantation With High-Dose Cyclophosphamide. Front Immunol 2021; 12:642087. [PMID: 33841425 PMCID: PMC8027082 DOI: 10.3389/fimmu.2021.642087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 02/24/2021] [Indexed: 11/13/2022] Open
Abstract
Haploidentical hematopoietic stem cell transplantation (Haplo-HSCT) with high-dose cyclophosphamide (PTCy) has resulted in a low incidence of graft-vs.-host disease (GVHD), graft failure, and non-relapse mortality. However, post-transplantation relapse remains a common cause of treatment failure in high-risk patients. Unraveling the mechanisms of relapse is therefore crucial for designing effective relapse treatment strategies. One of these mechanisms is the loss of the mismatched HLA on the recipient's leukemic cells. To study the incidence and clinical relevance of this phenomenon, we analyzed 181 patients treated with Haplo-HSCT with PTCy (2007–2019), of which 37 relapsed patients after transplantation. According to the kit employed for HLA-loss analysis, among 22 relapsed patients, we identified HLA loss at relapse in 6 of the 22 patients (27%) studied. Based on the results obtained, the genomic loss of HLA was more common in females than males (66 vs. 33%) and HLA-loss relapses occurred later than classical relapses (345 vs. 166 days). Moreover, the patients with HLA-loss had a greater presence of active disease at the time of transplantation and had undergone a larger number of treatment lines than the group with classical relapses (66 vs. 43% and 66 vs. 18%, respectively). Four of these relapses were studied retrospectively, while two were studied prospectively, the results of which could be considered for patient management. Additionally, two relapsed patients analyzed retrospectively had myeloid neoplasms. One patient had not undergone any treatment, and three had undergone donor lymphocyte infusions (DLIs) and chemotherapy. All presented severe GVHD and disease progression. In contrast, the two patients studied prospectively had a lymphoid neoplasm and were not treated with DLIs. One of them was treated with chemotherapy but died from disease progression, and the other patient underwent a second Haplo-HSCT from a different donor and is still alive. We can conclude that the detection of HLA-loss at the onset of relapse after Haplo-HSCT with PTCy could help in clinical practice to select appropriate rescue treatment, thereby avoiding the use of DLIs or a second transplantation from the same donor.
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Affiliation(s)
- Paula Muñiz
- Department of Hematology, Gregorio Marañón General University Hospital, Madrid, Spain.,Gregorio Marañón Health Research Institute (IiSGM), Madrid, Spain
| | - Mi Kwon
- Department of Hematology, Gregorio Marañón General University Hospital, Madrid, Spain.,Gregorio Marañón Health Research Institute (IiSGM), Madrid, Spain
| | - Diego Carbonell
- Department of Hematology, Gregorio Marañón General University Hospital, Madrid, Spain.,Gregorio Marañón Health Research Institute (IiSGM), Madrid, Spain
| | - María Chicano
- Department of Hematology, Gregorio Marañón General University Hospital, Madrid, Spain.,Gregorio Marañón Health Research Institute (IiSGM), Madrid, Spain
| | - Rebeca Bailén
- Department of Hematology, Gregorio Marañón General University Hospital, Madrid, Spain.,Gregorio Marañón Health Research Institute (IiSGM), Madrid, Spain
| | - Gillen Oarbeascoa
- Department of Hematology, Gregorio Marañón General University Hospital, Madrid, Spain.,Gregorio Marañón Health Research Institute (IiSGM), Madrid, Spain
| | - Julia Suárez-González
- Gregorio Marañón Health Research Institute (IiSGM), Madrid, Spain.,Genomics Unit, Gregorio Marañón General University Hospital, Madrid, Spain
| | - Cristina Andrés-Zayas
- Gregorio Marañón Health Research Institute (IiSGM), Madrid, Spain.,Genomics Unit, Gregorio Marañón General University Hospital, Madrid, Spain
| | - Javier Menárguez
- Gregorio Marañón Health Research Institute (IiSGM), Madrid, Spain.,Pathology Department, Gregorio Marañón General University Hospital, Madrid, Spain
| | - Nieves Dorado
- Department of Hematology, Gregorio Marañón General University Hospital, Madrid, Spain.,Gregorio Marañón Health Research Institute (IiSGM), Madrid, Spain
| | - Ignacio Gómez-Centurión
- Department of Hematology, Gregorio Marañón General University Hospital, Madrid, Spain.,Gregorio Marañón Health Research Institute (IiSGM), Madrid, Spain
| | - Javier Anguita
- Department of Hematology, Gregorio Marañón General University Hospital, Madrid, Spain.,Gregorio Marañón Health Research Institute (IiSGM), Madrid, Spain
| | - José Luis Díez-Martín
- Department of Hematology, Gregorio Marañón General University Hospital, Madrid, Spain.,Gregorio Marañón Health Research Institute (IiSGM), Madrid, Spain.,Department of Medicine, School of Medicine, Complutense University of Madrid, Madrid, Spain
| | - Carolina Martínez-Laperche
- Department of Hematology, Gregorio Marañón General University Hospital, Madrid, Spain.,Gregorio Marañón Health Research Institute (IiSGM), Madrid, Spain
| | - Ismael Buño
- Department of Hematology, Gregorio Marañón General University Hospital, Madrid, Spain.,Gregorio Marañón Health Research Institute (IiSGM), Madrid, Spain.,Genomics Unit, Gregorio Marañón General University Hospital, Madrid, Spain.,Department of Cell Biology, School of Medicine, Complutense University of Madrid, Madrid, Spain
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24
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Elmariah H, Brunstein CG, Bejanyan N. Immune Reconstitution after Haploidentical Donor and Umbilical Cord Blood Allogeneic Hematopoietic Cell Transplantation. Life (Basel) 2021; 11:102. [PMID: 33572932 PMCID: PMC7911120 DOI: 10.3390/life11020102] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 01/19/2021] [Accepted: 01/25/2021] [Indexed: 02/07/2023] Open
Abstract
Allogeneic hematopoietic cell transplantation (HCT) is the only potentially curative therapy for a variety of hematologic diseases. However, this therapeutic platform is limited by an initial period when patients are profoundly immunocompromised. There is gradual immune recovery over time, that varies by transplant platform. Here, we review immune reconstitution after allogeneic HCT with a specific focus on two alternative donor platforms that have dramatically improved access to allogeneic HCT for patients who lack an HLA-matched related or unrelated donor: haploidentical and umbilical cord blood HCT. Despite challenges, interventions are available to mitigate the risks during the immunocompromised period including antimicrobial prophylaxis, modified immune suppression strategies, graft manipulation, and emerging adoptive cell therapies. Such interventions can improve the potential for long-term overall survival after allogeneic HCT.
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Affiliation(s)
- Hany Elmariah
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL 33612, USA;
| | - Claudio G. Brunstein
- Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, MN 55455, USA;
| | - Nelli Bejanyan
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL 33612, USA;
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25
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Choi Y, Choi EJ, Lee JH, Lee KH, Jo JC, Park HS, Lee YJ, Seol M, Lee YS, Kang YA, Jeon M, Lee JH. Second allogeneic hematopoietic stem cell transplantation in patients with acute leukemia relapsed after allogeneic hematopoietic stem cell transplantation. Clin Transplant 2021; 35:e14199. [PMID: 33349948 DOI: 10.1111/ctr.14199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 12/10/2020] [Accepted: 12/12/2020] [Indexed: 11/30/2022]
Abstract
The prognosis of patients with acute leukemia relapsed after allogeneic hematopoietic stem cell transplantation (HSCT) is dismal. We aimed to evaluate the outcomes and prognostic factors of the second HSCT (HSCT2) in acute leukemia patients relapsed after the first HSCT (HSCT1). We analyzed 80 patients who received HSCT2 for relapsed acute leukemia in two Korean institutes. All but four patients received HSCT2 from a donor other than matched sibling donor: an unrelated donor (URD) in 30 and a familial haploidentical donor (FHD) in 46. Forty-four patients (55.0%) were in complete remission (CR) or CR with incomplete count recovery (CRi) at HSCT2, and the median time from HSCT1 to relapse was 9 months. The 2-year overall survival (OS) and event-free survival (EFS) were 21.0% and 17.5%, respectively. The outcomes were similar between URD and FHD. Multivariate analysis demonstrated that disease status (active disease vs. CR/CRi) at HSCT2 and remission duration after HSCT1 were independent prognostic factors for OS and EFS after HSCT2. HSCT2 from URD or FHD was feasible in patients with acute leukemia relapsed after allogeneic HSCT. Also, our study confirmed two critical prognostic factors; disease status at HSCT2 and remission duration after HSCT1.
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Affiliation(s)
- Yunsuk Choi
- Department of Hematology and Oncology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea
| | - Eun-Ji Choi
- Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jung-Hee Lee
- Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Kyoo-Hyung Lee
- Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jae-Cheol Jo
- Department of Hematology and Oncology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea
| | - Han-Seung Park
- Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Yoo Jin Lee
- Department of Hematology and Oncology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea
| | - Miee Seol
- Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Young-Shin Lee
- Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Young-Ah Kang
- Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Mijin Jeon
- Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Je-Hwan Lee
- Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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26
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Jimenez-Antolinez YV, Gonzalez-Lopez EE, Ruiz IYV, Cantu-Moreno M, Gomez-Almaguer D, Gonzalez-Llano O. Concordant acute myeloblastic leukemia in identical twins treated with allogeneic transplantation from a younger HLA-identical sibling following a single apheresis procedure. Int J Hematol Oncol 2020; 10:IJH32. [PMID: 34136123 PMCID: PMC8191650 DOI: 10.2217/ijh-2020-0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
A concordant leukemia is that which occurs in a pair of monozygotic twins; a similar genetic background suggests an in utero monoclonal origin. We present the case of a pair of monozygotic infants with concordant acute myeloid leukemia who underwent a peripheral blood hematopoietic stem-cell transplant (HSCT) from a single, younger human leukocyte antigen-identical sibling donor, using a fractioned graft collected during only one apheresis procedure. Twin A relapsed at +456 and received a second haploidentical HSCT from his father, twin B has been in complete remission since the first HSCT. Both children are in complete remission and with negative minimal residual disease at +900 (after second transplant) and +1488, respectively.
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Affiliation(s)
| | - Elias Eugenio Gonzalez-Lopez
- Hematology Service, Hospital Universitario 'Dr. Jose E. Gonzalez', Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Ileana Yazmín Velasco Ruiz
- Hematology Service, Hospital Universitario 'Dr. Jose E. Gonzalez', Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Marcela Cantu-Moreno
- Hematology Service, Hospital Universitario 'Dr. Jose E. Gonzalez', Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - David Gomez-Almaguer
- Hematology Service, Hospital Universitario 'Dr. Jose E. Gonzalez', Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Oscar Gonzalez-Llano
- Hematology Service, Hospital Universitario 'Dr. Jose E. Gonzalez', Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
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27
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Mori Y, Sasaki K, Ito Y, Kuriyama T, Ueno T, Kadowaki M, Aoki T, Sugio T, Yoshimoto G, Kato K, Maeda T, Nagafuji K, Akashi K, Miyamoto T. Outcome predictors after retransplantation in relapsed acute lymphoblastic leukemia: a multicenter, retrospective study. Ann Hematol 2020; 100:197-208. [PMID: 33150464 DOI: 10.1007/s00277-020-04310-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 10/15/2020] [Indexed: 11/30/2022]
Abstract
Retransplantation is the only curative treatment option for patients with acute lymphoblastic leukemia (ALL) that has relapsed after allogeneic hematopoietic cell transplantation (allo-HCT); however, data in this setting remain scant. Hence, this multicenter, retrospective study aims to determine outcome predictors after retransplantation in relapsed ALL. We examined 55 recipients who underwent multiple allo-HCTs during 2006-2018. The 2-year overall survival (OS), progression-free survival (PFS), and non-relapse mortality rates were 35.9%, 29.1%, and 23.6%, respectively. We observed a trend of better outcome in Ph + ALL (n = 22) patients compared with non-Ph ALL (n = 33) patients; the 2-year PFS was 40.9% versus 21.2%, indicating a beneficial effect of more potent second- or third-generation tyrosine kinase inhibitors. Univariate analysis revealed that late relapse after the previous transplant was the only significant predictor of better transplant outcome among Ph + ALL patients, whereas factors related to prolonged OS/PFS in non-Ph ALL patients were late relapse after the previous transplant, longer duration from disease relapse/progression to second or more allo-HCT, disease status at the transplantation, and good performance status. Nevertheless, further investigations are warranted to determine whether novel molecular-targeted agents with higher efficacy and fewer toxicities could exceed conventional chemotherapies as a bridging strategy to next allo-HCT and improve the outcomes of non-Ph ALL patients.
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Affiliation(s)
- Yasuo Mori
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Science, 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Kensuke Sasaki
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Science, 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yoshikiyo Ito
- Department of Hematology, Imamura General Hospital, Kagoshima, Japan
| | - Takuro Kuriyama
- Department of Hematology, Hamanomachi Hospital, Fukuoka, Japan
| | - Toshiyuki Ueno
- Department of Internal Medicine, Kitakyushu Municipal Medical Center, Fukuoka, Japan
| | - Masanori Kadowaki
- Department of Hematology and Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Takatoshi Aoki
- Department of Hematology, Harasanshin Hospital, Fukuoka, Japan
| | - Takeshi Sugio
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Science, 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Goichi Yoshimoto
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Science, 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Koji Kato
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Science, 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Takahiro Maeda
- Center for Cellular and Molecular Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Koji Nagafuji
- Division of Hematology/Oncology, Kurume University School of Medicine, Fukuoka, Japan
| | - Koichi Akashi
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Science, 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Toshihiro Miyamoto
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Science, 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
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28
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Allogeneic hematopoietic stem cell transplantation from a 2-HLA-haplotype-mismatched family donor for posttransplant relapse: a prospective phase I/II study. Bone Marrow Transplant 2020; 56:70-83. [PMID: 32564055 DOI: 10.1038/s41409-020-0980-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 05/20/2020] [Accepted: 06/12/2020] [Indexed: 11/08/2022]
Abstract
HLA haploidentical hematopoietic stem cell transplantation (HSCT), i.e., HSCT from a 1-HLA-haplotype-mismatched family donor, has been successfully performed even as a second transplantation for posttransplant relapse. Is the haploidentical the limit of HLA mismatches in HSCT? In order to explore the possibility of HLA-mismatched HSCT from family donors beyond haploidentical relatives, we conducted a prospective phase I/II study of 2-HLA-haplotype-mismatched HSCT (2-haplo-mismatch HSCT). We enrolled 30 patients with posttransplant relapse (acute myeloid leukemia: 18, acute lymphoblastic leukemia: 11, non-Hodgkin lymphoma: 1). 2-haplo-mismatch HSCT was performed as the second to sixth transplantations. The donors were siblings (n = 12), cousins (n = 16), and second cousins (n = 2). The conditioning regimen consisted of fludarabine, cytarabine, melphalan, low-dose anti-thymocyte globulin, and 3 Gy of total body irradiation. Graft-versus-host disease (GVHD) prophylaxis consisted of tacrolimus, methylprednisolone, and mycophenolate mofetil. All patients achieved neutrophil engraftment, except for a case of early death. The cumulative incidences of grades II-IV and III-IV acute GVHD were 36.7% and 16.7%, respectively. The overall survival at 1 year, relapse, and non-relapse mortality rates was 30.1%, 38.9%, and 44.3%, respectively. Considering the poor prognosis of posttransplant relapse, 2-haplo-mismatch HSCT can be an alternative option in a second or third transplantation.
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29
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Sterling C, Webster J. Harnessing the immune system after allogeneic stem cell transplant in acute myeloid leukemia. Am J Hematol 2020; 95:529-547. [PMID: 32022292 DOI: 10.1002/ajh.25750] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 01/17/2020] [Accepted: 01/21/2020] [Indexed: 02/06/2023]
Abstract
Allogeneic stem cell transplantation (allo-SCT) is the most successful and widely used immunotherapy for the treatment of acute myeloid leukemia (AML), as a result of its anti-leukemic properties driven by T cells and natural killer (NK) cells, leading to a graft-vs-leukemia (GVL) effect. Despite its essential role in AML treatment, relapse after allo-SCT is common and associated with a poor prognosis. There is longstanding interest in developing immunologic strategies to augment the GVL effect post-transplant to prevent relapse and improve outcomes. In addition to prophylactic maintenance strategies, the GVL effect can also be used in relapsed patients to reinduce remission. While immune checkpoint inhibitors and other novel immune-targeted agents have been successfully used in the post-transplant setting to augment the GVL effect and induce remission in small clinical trials of relapsed patients, exacerbations of graft-vs-host disease (GVHD) have limited their broader use. Here we review advances in three areas of immunotherapy that have been studied in post-transplant AML: donor lymphocyte infusion (DLI), immune checkpoint inhibitors, and other monoclonal antibodies (mAbs), including antibody-drug conjugates (ADCs) and ligand receptor antagonists. We also discuss additional therapies with proposed immunologic mechanisms, such as hypomethylating agents, histone deacetylase inhibitors, and the FLT3 inhibitor sorafenib.
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Affiliation(s)
- Cole Sterling
- Sidney Kimmel Comprehensive Cancer CenterJohns Hopkins University School of Medicine Baltimore Maryland
| | - Jonathan Webster
- Sidney Kimmel Comprehensive Cancer CenterJohns Hopkins University School of Medicine Baltimore Maryland
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30
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Rovatti PE, Gambacorta V, Lorentino F, Ciceri F, Vago L. Mechanisms of Leukemia Immune Evasion and Their Role in Relapse After Haploidentical Hematopoietic Cell Transplantation. Front Immunol 2020; 11:147. [PMID: 32158444 PMCID: PMC7052328 DOI: 10.3389/fimmu.2020.00147] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 01/20/2020] [Indexed: 01/05/2023] Open
Abstract
Over the last decade, the development of multiple strategies to allow the safe transfer from the donor to the patient of high numbers of partially HLA-incompatible T cells has dramatically reduced the toxicities of haploidentical hematopoietic cell transplantation (haplo-HCT), but this was not accompanied by a similar positive impact on the incidence of post-transplantation relapse. In the present review, we will elaborate on how the unique interplay between HLA-mismatched immune system and malignancy that characterizes haplo-HCT may impact relapse biology, shaping the selection of disease variants that are resistant to the “graft-vs.-leukemia” effect. In particular, we will present current knowledge on genomic loss of HLA, a relapse modality first described in haplo-HCT and accounting for a significant proportion of relapses in this setting, and discuss other more recently identified mechanisms of post-transplantation immune evasion and relapse, including the transcriptional downregulation of HLA class II molecules and the enforcement of inhibitory checkpoints between T cells and leukemia. Ultimately, we will review the available treatment options for patients who relapse after haplo-HCT and discuss on how a deeper insight into relapse immunobiology might inform the rational and personalized selection of therapies to improve the largely unsatisfactory clinical outcome of relapsing patients.
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Affiliation(s)
- Pier Edoardo Rovatti
- Unit of Immunogenetics, Leukemia Genomics and Immunobiology, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Valentina Gambacorta
- Unit of Immunogenetics, Leukemia Genomics and Immunobiology, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Unit of Senescence in Stem Cell Aging, Differentiation and Cancer, San Raffaele Telethon Institute for Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesca Lorentino
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fabio Ciceri
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Luca Vago
- Unit of Immunogenetics, Leukemia Genomics and Immunobiology, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
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31
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Dholaria B, Savani BN, Labopin M, Luznik L, Ruggeri A, Mielke S, Al Malki MM, Kongtim P, Fuchs E, Huang XJ, Locatelli F, Aversa F, Castagna L, Bacigalupo A, Martelli M, Blaise D, Ben Soussan P, Arnault Y, Handgretinger R, Roy DC, O'Donnell P, Bashey A, Solomon S, Romee R, Lewalle P, Gayoso J, Maschan M, Lazarus HM, Ballen K, Giebel S, Baron F, Ciceri F, Esteve J, Gorin NC, Spyridonidis A, Schmid C, Ciurea SO, Nagler A, Mohty M. Clinical applications of donor lymphocyte infusion from an HLA-haploidentical donor: consensus recommendations from the Acute Leukemia Working Party of the EBMT. Haematologica 2020; 105:47-58. [PMID: 31537691 PMCID: PMC6939532 DOI: 10.3324/haematol.2019.219790] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Accepted: 09/19/2019] [Indexed: 01/30/2023] Open
Abstract
Donor lymphocyte infusion has been used in the management of relapsed hematologic malignancies after allogeneic hematopoietic cell transplantation. It can eradicate minimal residual disease or be used to rescue a hematologic relapse, being able to induce durable remissions in a subset of patients. With the increased use of haploidentical hematopoietic cell transplantation, there is renewed interest in the use of donor lymphocytes to either treat or prevent disease relapse post transplant. Published retrospective and small prospective studies have shown encouraging results with therapeutic donor lymphocyte infusion in different haploidentical transplantation platforms. In this consensus paper, finalized on behalf of the Acute Leukemia Working Party of the European Society for Blood and Marrow Transplantation, we summarize the available evidence on the use of donor lymphocyte infusion from haploidentical donor, and provide recommendations on its therapeutic, pre-emptive and prophylactic use in clinical practice.
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Affiliation(s)
- Bhagirathbhai Dholaria
- Department of Hematology-Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Bipin N Savani
- Department of Hematology-Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Myriam Labopin
- Department of Haematology and EBMT Paris study office / CEREST-TC, Saint Antoine Hospital, Paris, France
| | - Leo Luznik
- Department of Oncology Hematologic Malignancies, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Annalisa Ruggeri
- Department of Pediatric Hematology/Oncology and Cell and Gene Therapy, IRCCS Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Stephan Mielke
- Department of Laboratory Medicine, CAST, Karolinska Institutet and University Hospital, Stockholm, Sweden
| | - Monzr M Al Malki
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
| | - Piyanuch Kongtim
- Stem Cell Transplant and Cellular Therapy, Thammasat University, Pathumthani, Thailand
| | - Ephraim Fuchs
- Johns Hopkins University, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - Xiao-Jun Huang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing China
| | - Franco Locatelli
- Department of Pediatric Hematology/Oncology, IRCCS Ospedale Pediatrico Bambino Gesù, Rome, Sapienza, University of Rome, Italy
| | - Franco Aversa
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | | | - Andrea Bacigalupo
- Fondazione Policlinico Universitario Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Didier Blaise
- Department of Hematology, Institut Paoli Calmettes, Marseille France
| | - Patrick Ben Soussan
- Department of Clinical Psychology, Paoli-Calmettes Institute, Marseille, France
| | - Yolande Arnault
- Institut Paoli-Calmette, département de psychologie clinique, Marseille, France
| | - Rupert Handgretinger
- Department of Hematology and Oncology, University Children's Hospital Tübingen, Tübingen Germany
| | - Denis-Claude Roy
- Division of Hematology and Medical Oncology, Hospital Maisonneuve-Rosemont, Montreal, QC, Canada
| | - Paul O'Donnell
- Hematology-Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Asad Bashey
- Blood and Marrow Transplant Program at Northside Hospital, Atlanta, GA, USA
| | - Scott Solomon
- Blood and Marrow Transplant Program at Northside Hospital, Atlanta, GA, USA
| | - Rizwan Romee
- Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Philippe Lewalle
- Hematology Department, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Jorge Gayoso
- HGU Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Michael Maschan
- Oncology and immunology, Dmitriy Rogachev National Medical Center of pediatric hematology, Moscow, Russia
| | - Hillard M Lazarus
- Adult Hematologic Malignancies & Stem Cell Transplant Section, University Hospitals Seidman Cancer Center, Cleveland, OH, USA
| | - Karen Ballen
- Division of hematology/oncology, University of Virginia Health System, Charlottesville, VA, USA
| | - Sebastian Giebel
- Dept. of Bone Marrow Transplantation and Onco-Hematology, Maria Sklodowska-Curie Institute - Oncology Center, Gliwice Branch, Gliwice, Poland
| | - Frederic Baron
- Laboratory of Hematology, University of Liège, Liège, Belgium
| | - Fabio Ciceri
- Hematology and Bone Marrow Transplantation Unit, San Raffaele Scientific Institute, Milano Italy
| | - Jordi Esteve
- Hematology department, Hospital Clínic de Barcelona, Barcelona Spain
| | - Norbert-Claude Gorin
- Service d'hématologie et thérapie cellulaire Centre international greffes APHP-EBMT-INCa Hospital, Saint Antoine Hospital, Paris France
| | - Alexandros Spyridonidis
- Bone Marrow Transplantation Unit and CBMDP Donor Center, University Hospital of Patras, Patras, Greece
| | - Christoph Schmid
- Department of Hematology and Oncology, Klinikum Augsburg, Augsburg, Germany
| | - Stefan O Ciurea
- Stem Cell Transplant and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Arnon Nagler
- Chaim Sheba Medical Center, Tel Aviv University, Tel-Hashomer, Israel and EBMT ALWP office, Saint Antoine Hospital, Paris, France
| | - Mohamad Mohty
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, AP-HP, Sorobonne University, and INSERM UMRs 938, Paris, France
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32
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McCurdy SR, Luznik L. How we perform haploidentical stem cell transplantation with posttransplant cyclophosphamide. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2019; 2019:513-521. [PMID: 31808908 PMCID: PMC6913422 DOI: 10.1182/hematology.2019001323] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
HLA-haploidentical hematopoietic stem cell transplantation is now one of the most commonly employed alternative donor techniques, with most centers applying T-cell-replete strategies such as that developed by the Baltimore group using high-dose posttransplant cyclophosphamide. HLA-haploidentical hematopoietic stem cell transplantation using posttransplant cyclophosphamide is associated with low rates of severe graft-versus-host disease and nonrelapse mortality and does not require graft manipulation or storage, which results in a low graft acquisition cost. Its remarkable safety when used with reduced-intensity conditioning has been demonstrated in patients up to 75 years old with outcomes similar to those of patients in their 50s. Several large, registry-based retrospective studies have confirmed the efficacy of HLA-haploidentical hematopoietic stem cell transplantation with posttransplant cyclophosphamide, achieving results comparable to those of HLA-matched hematopoietic stem cell transplantation. In this article, we describe our approach to this rapidly available and clinically simple platform and address some of the key clinical questions associated with its use.
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Affiliation(s)
- Shannon R McCurdy
- Abramson Cancer Center and
- Division of Hematology and Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA; and
| | - Leo Luznik
- Department of Oncology and
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
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33
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Vago L. Clonal evolution and immune evasion in posttransplantation relapses. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2019; 2019:610-616. [PMID: 31808847 PMCID: PMC6913457 DOI: 10.1182/hematology.2019000005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Despite the considerable improvements witnessed over the last few decades in the feasibility and safety of allogeneic hematopoietic cell transplantation (allo-HCT) for hematological malignancies, disease relapse continues to represent a frequent occurrence, with largely unsatisfactory salvage options. Recent studies have shed new light on the biology of posttransplantation relapses, demonstrating that they can frequently be explained using an evolutionary perspective: The changes in disease clonal structure and immunogenicity that are often documented at relapse may in fact represent the end results of a process of selection, allowing the outgrowth of variants that are more capable of resisting the therapeutic control of allo-HCT. This review provides an overview of the mechanisms forming the basis of relapse, including clonal evolution, gain of tropism for privileged sites, genomic and nongenomic changes in the HLA asset, and enforcement of immune checkpoints. Finally, this review discusses how these mechanisms may combine in complex patterns and how understanding and untangling these interactions may provide key knowledge for the selection of personalized therapeutic approaches.
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Affiliation(s)
- Luca Vago
- Unit of Immunogenetics, Leukemia Genomics and Immunobiology, and
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
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McCurdy SR, Luznik L. How we perform haploidentical stem cell transplantation with posttransplant cyclophosphamide. Blood 2019; 134:1802-1810. [PMID: 31751485 PMCID: PMC6872960 DOI: 10.1182/blood.2019001323] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 09/09/2019] [Indexed: 12/19/2022] Open
Abstract
HLA-haploidentical hematopoietic stem cell transplantation is now one of the most commonly employed alternative donor techniques, with most centers applying T-cell-replete strategies such as that developed by the Baltimore group using high-dose posttransplant cyclophosphamide. HLA-haploidentical hematopoietic stem cell transplantation using posttransplant cyclophosphamide is associated with low rates of severe graft-versus-host disease and nonrelapse mortality and does not require graft manipulation or storage, which results in a low graft acquisition cost. Its remarkable safety when used with reduced-intensity conditioning has been demonstrated in patients up to 75 years old with outcomes similar to those of patients in their 50s. Several large, registry-based retrospective studies have confirmed the efficacy of HLA-haploidentical hematopoietic stem cell transplantation with posttransplant cyclophosphamide, achieving results comparable to those of HLA-matched hematopoietic stem cell transplantation. In this article, we describe our approach to this rapidly available and clinically simple platform and address some of the key clinical questions associated with its use.
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Affiliation(s)
- Shannon R McCurdy
- Abramson Cancer Center and
- Division of Hematology and Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA; and
| | - Leo Luznik
- Department of Oncology and
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
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35
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Shimoni A, Labopin M, Finke J, Ciceri F, Deconinck E, Kröger N, Gramatzki M, Stelljes M, Blaise D, Stoelzel F, Chevallier P, Holler E, Fegueux N, Mohty M, Nagler A. Donor selection for a second allogeneic stem cell transplantation in AML patients relapsing after a first transplant: a study of the Acute Leukemia Working Party of EBMT. Blood Cancer J 2019; 9:88. [PMID: 31740656 PMCID: PMC6861251 DOI: 10.1038/s41408-019-0251-3] [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: 09/11/2019] [Revised: 10/29/2019] [Accepted: 10/30/2019] [Indexed: 01/17/2023] Open
Abstract
Second allogeneic stem-cell transplantation (SCT2) is a therapeutic option for patients with AML relapsing after a first transplant. Prior studies have shown similar results after SCT2 from the same or different donor; however, there are limited data on second non-T-depleted haplo-identical transplant in this setting. We retrospectively analyzed SCT2 outcomes in 556 patients, median age 46 years, relapsing after first transplant given in CR1. Patients were divided into three groups based on SCT2 donor (donor2): same donor (n = 163, sib/sib-112, UD/UD-51), different matched donor (n = 305, sib/different sib-44, sib/UD-93, UD/different UD-168), or haplo-donor (n = 88, sib/haplo-45, UD/haplo-43). Two-year leukemia-free survival (LFS) rate after SCT2 was 23.5%, 23.7%, and 21.8%, respectively (P = 0.30). Multivariate analysis showed no effect of donor2 type on relapse: hazard ratio (HR) 0.89 (P = 0.57) and 1.11 (P = 0.68) for different donor and haplo-donor compared to same donor, respectively. However, donor2 did predict for non-relapse mortality (NRM) after SCT2: HR 1.21 (P = 0.50) and 2.08 (P = 0.03), respectively, and for LFS: HR 1.00 (P = 0.97) and 1.43 (P = 0.07), respectively. In conclusion, SCT2 with the same or different matched donor is associated with similar outcomes in patients with relapsed AML. Non-T-depleted haplo-identical transplant may be associated with higher NRM, similar relapse rate and with no better results in this setting.
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Affiliation(s)
- Avichai Shimoni
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel-Aviv University, Tel Aviv, Israel.
| | | | - Jürgen Finke
- Department of Medicine, Hematology-Oncology, University of Freiburg, Freiburg, Germany
| | - Fabio Ciceri
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Eric Deconinck
- Service d'Hématologie, Hopital Jean Minjoz, Besancon, France
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Gramatzki
- Division of Stem Cell Transplantation & Immunotherapy, 2nd Medical Department, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Matthias Stelljes
- Department of Internal Medicine A, University of Muenster, Muenster, Germany
| | - Didier Blaise
- Department of Hematology, Institut Paoli Calmettes, Marseille, France
| | - Friedrich Stoelzel
- Department of Hematology/Oncology, Medical Clinic and Policlinic, University Hospital Carl Gustav Carus Dresden, Technical University Dresden, Dresden, Germany
| | | | - Ernst Holler
- Department of Hematology and Oncology, University Hospital Regensburg, Regensburg, Germany
| | | | - Mohamad Mohty
- Acute Leukemia Working Party of EBMT, Paris, France.,Department of Haematology, Saint Antoine Hospital, Paris, France
| | - Arnon Nagler
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel-Aviv University, Tel Aviv, Israel.,Acute Leukemia Working Party of EBMT, Paris, France
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36
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Nagler A, Labopin M, Dholaria B, Finke J, Brecht A, Schanz U, Niittyvuopio R, Neubauer A, Bornhäuser M, Santarone S, Beelen D, Shimoni A, Rösler W, Giebel S, Savani BN, Mohty M. Second allogeneic stem cell transplantation in patients with acute lymphoblastic leukaemia: a study on behalf of the Acute Leukaemia Working Party of the European Society for Blood and Marrow Transplantation. Br J Haematol 2019; 186:767-776. [DOI: 10.1111/bjh.15973] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 03/16/2019] [Indexed: 12/28/2022]
Affiliation(s)
- Arnon Nagler
- Chaim Sheba Medical Centre Tel Aviv University Tel‐Hashomer Israel
- EBMT ALWP office Saint Antoine Hospital ParisFrance
| | - Myriam Labopin
- Department of Haematology and EBMT Paris study office/CEREST‐TC Saint Antoine Hospital Paris France
| | | | - Jürgen Finke
- Department of Medicine–Haematology Oncology University of Freiburg FreiburgGermany
| | - Arne Brecht
- Deutsche Klinik fuer Diagnostik KMT Zentrum Wiesbaden Germany
| | - Urs Schanz
- Clinic of Haematology University Hospital Zurich Switzerland
| | - Riitta Niittyvuopio
- Stem Cell Transplantation Unit HUCH Comprehensive Cancer Centre Helsinki Finland
| | - Andreas Neubauer
- Philipps Universitaet MarburgUniversity Hospital Giessen and Marburg MarburgGermany
| | - Martin Bornhäuser
- Medizinische Klinik und Poliklinik I Universitaetsklinikum Dresden Dresden Germany
| | - Stella Santarone
- Dipartimento di Ematologia Medicina Trasfusionale e BiotecnologieOspedale Civile Pescara Italy
| | - Dietrich Beelen
- Department of Bone Marrow Transplantation University Hospital Essen Germany
| | - Avichai Shimoni
- Department of Bone Marrow Transplantation Chaim Sheba Medical Centre Chaim Sheba Medical Centre Tel Hashomer Israel
| | - Wolf Rösler
- Department of Internal Medicine 5 University Hospital Erlangen Erlangen Germany
| | - Sebastian Giebel
- Department of Bone Marrow Transplantation and Oncohaematology Maria Sklodowska‐Curie Memorial Cancer Centre and Institute of Oncology, Gliwice Branch Gliwice Poland
| | - Bipin N. Savani
- Department of Hematology‐Oncology Vanderbilt University Medical Center Nashville TN USA
| | - Mohamad Mohty
- AService d'Hématologie Clinique et Thérapie Cellulaire Hôpital Saint-Antoine, AP-HP, Sorobonne University, INSERM UMR 938 and Université Pierre et Marie Curie Paris France
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37
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Biology-Driven Approaches to Prevent and Treat Relapse of Myeloid Neoplasia after Allogeneic Hematopoietic Stem Cell Transplantation. Biol Blood Marrow Transplant 2019; 25:e128-e140. [DOI: 10.1016/j.bbmt.2019.01.016] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 01/08/2019] [Indexed: 12/22/2022]
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38
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Toffalori C, Zito L, Gambacorta V, Riba M, Oliveira G, Bucci G, Barcella M, Spinelli O, Greco R, Crucitti L, Cieri N, Noviello M, Manfredi F, Montaldo E, Ostuni R, Naldini MM, Gentner B, Waterhouse M, Zeiser R, Finke J, Hanoun M, Beelen DW, Gojo I, Luznik L, Onozawa M, Teshima T, Devillier R, Blaise D, Halkes CJM, Griffioen M, Carrabba MG, Bernardi M, Peccatori J, Barlassina C, Stupka E, Lazarevic D, Tonon G, Rambaldi A, Cittaro D, Bonini C, Fleischhauer K, Ciceri F, Vago L. Immune signature drives leukemia escape and relapse after hematopoietic cell transplantation. Nat Med 2019; 25:603-611. [PMID: 30911134 DOI: 10.1038/s41591-019-0400-z] [Citation(s) in RCA: 256] [Impact Index Per Article: 51.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 02/15/2019] [Indexed: 01/17/2023]
Abstract
Transplantation of hematopoietic cells from a healthy individual (allogeneic hematopoietic cell transplantation (allo-HCT)) demonstrates that adoptive immunotherapy can cure blood cancers: still, post-transplantation relapses remain frequent. To explain their drivers, we analyzed the genomic and gene expression profiles of acute myeloid leukemia (AML) blasts purified from patients at serial time-points during their disease history. We identified a transcriptional signature specific for post-transplantation relapses and highly enriched in immune-related processes, including T cell costimulation and antigen presentation. In two independent patient cohorts we confirmed the deregulation of multiple costimulatory ligands on AML blasts at post-transplantation relapse (PD-L1, B7-H3, CD80, PVRL2), mirrored by concomitant changes in circulating donor T cells. Likewise, we documented the frequent loss of surface expression of HLA-DR, -DQ and -DP on leukemia cells, due to downregulation of the HLA class II regulator CIITA. We show that loss of HLA class II expression and upregulation of inhibitory checkpoint molecules represent alternative modalities to abolish AML recognition from donor-derived T cells, and can be counteracted by interferon-γ or checkpoint blockade, respectively. Our results demonstrate that the deregulation of pathways involved in T cell-mediated allorecognition is a distinctive feature and driver of AML relapses after allo-HCT, which can be rapidly translated into personalized therapies.
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Affiliation(s)
- Cristina Toffalori
- Unit of Immunogenetics, Leukemia Genomics and Immunobiology, Division of Immunology, Transplantation and Infectious Disease, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Laura Zito
- Unit of Immunogenetics, Leukemia Genomics and Immunobiology, Division of Immunology, Transplantation and Infectious Disease, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Valentina Gambacorta
- Unit of Immunogenetics, Leukemia Genomics and Immunobiology, Division of Immunology, Transplantation and Infectious Disease, IRCCS San Raffaele Scientific Institute, Milano, Italy.,Unit of Senescence in Stem Cell Aging, Differentiation and Cancer, San Raffaele Telethon Institute for Gene Therapy, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Michela Riba
- Center for Translational Genomics and Bioinformatics, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Giacomo Oliveira
- Unit of Immunogenetics, Leukemia Genomics and Immunobiology, Division of Immunology, Transplantation and Infectious Disease, IRCCS San Raffaele Scientific Institute, Milano, Italy.,Experimental Hematology Unit, Division of Immunology, Transplantation and Infectious Disease, IRCCS San Raffaele Scientific Institute, Milano, Italy.,Dana-Farber Cancer Institute, Boston, MA, USA
| | - Gabriele Bucci
- Unit of Immunogenetics, Leukemia Genomics and Immunobiology, Division of Immunology, Transplantation and Infectious Disease, IRCCS San Raffaele Scientific Institute, Milano, Italy.,Center for Translational Genomics and Bioinformatics, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Matteo Barcella
- Genomic and Bioinformatics Unit, Department of Health Sciences, University of Milano, Milano, Italy
| | - Orietta Spinelli
- Hematology and Bone Marrow Transplant Unit, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Raffaella Greco
- Unit of Hematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Lara Crucitti
- Unit of Hematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, Milano, Italy.,University of Milano, Milano, Italy
| | - Nicoletta Cieri
- Experimental Hematology Unit, Division of Immunology, Transplantation and Infectious Disease, IRCCS San Raffaele Scientific Institute, Milano, Italy.,Unit of Hematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, Milano, Italy.,University of Milano, Milano, Italy
| | - Maddalena Noviello
- Experimental Hematology Unit, Division of Immunology, Transplantation and Infectious Disease, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Francesco Manfredi
- Experimental Hematology Unit, Division of Immunology, Transplantation and Infectious Disease, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Elisa Montaldo
- Genomics of the Innate Immune System Unit, San Raffaele Telethon Institute for Gene Therapy, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Renato Ostuni
- Genomics of the Innate Immune System Unit, San Raffaele Telethon Institute for Gene Therapy, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Matteo M Naldini
- Translational Stem Cell and Leukemia Unit, San Raffaele Telethon Institute for Gene Therapy, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Bernhard Gentner
- Unit of Hematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, Milano, Italy.,Translational Stem Cell and Leukemia Unit, San Raffaele Telethon Institute for Gene Therapy, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Miguel Waterhouse
- Department of Hematology, Oncology and Stem Cell Transplantation, Universitätsklinikum Freiburg, Freiburg, Germany
| | - Robert Zeiser
- Department of Hematology, Oncology and Stem Cell Transplantation, Universitätsklinikum Freiburg, Freiburg, Germany
| | - Jurgen Finke
- Department of Hematology, Oncology and Stem Cell Transplantation, Universitätsklinikum Freiburg, Freiburg, Germany
| | - Maher Hanoun
- Department of Bone Marrow Transplantation, Universitätsklinikum Essen, Essen, Germany
| | - Dietrich W Beelen
- Department of Bone Marrow Transplantation, Universitätsklinikum Essen, Essen, Germany
| | - Ivana Gojo
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Leo Luznik
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Masahiro Onozawa
- Department of Hematology, Hokkaido University Faculty of Medicine, Graduate School of Medicine, Sapporo, Japan
| | - Takanori Teshima
- Department of Hematology, Hokkaido University Faculty of Medicine, Graduate School of Medicine, Sapporo, Japan
| | - Raynier Devillier
- Department of Haematology, Institut Paoli Calmettes, Marseille, France
| | - Didier Blaise
- Department of Haematology, Institut Paoli Calmettes, Marseille, France
| | | | - Marieke Griffioen
- Department of Hematology, Leiden University Medical Center, Leiden, The Netherlands
| | - Matteo G Carrabba
- Unit of Hematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Massimo Bernardi
- Unit of Hematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Jacopo Peccatori
- Unit of Hematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Cristina Barlassina
- Genomic and Bioinformatics Unit, Department of Health Sciences, University of Milano, Milano, Italy
| | - Elia Stupka
- Center for Translational Genomics and Bioinformatics, IRCCS San Raffaele Scientific Institute, Milano, Italy.,Dana-Farber Cancer Institute, Boston, MA, USA
| | - Dejan Lazarevic
- Center for Translational Genomics and Bioinformatics, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Giovanni Tonon
- Center for Translational Genomics and Bioinformatics, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Alessandro Rambaldi
- Hematology and Bone Marrow Transplant Unit, ASST Papa Giovanni XXIII, Bergamo, Italy.,Department of Oncology and Hemato-Oncology, University of Milano, Milano, Italy
| | - Davide Cittaro
- Center for Translational Genomics and Bioinformatics, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Chiara Bonini
- Experimental Hematology Unit, Division of Immunology, Transplantation and Infectious Disease, IRCCS San Raffaele Scientific Institute, Milano, Italy.,San Raffaele Vita-Salute University, Milano, Italy
| | - Katharina Fleischhauer
- Unit of Immunogenetics, Leukemia Genomics and Immunobiology, Division of Immunology, Transplantation and Infectious Disease, IRCCS San Raffaele Scientific Institute, Milano, Italy.,Institute for Experimental Cellular Therapy, Universitätsklinikum Essen, Essen, Germany
| | - Fabio Ciceri
- Unit of Hematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, Milano, Italy.,San Raffaele Vita-Salute University, Milano, Italy
| | - Luca Vago
- Unit of Immunogenetics, Leukemia Genomics and Immunobiology, Division of Immunology, Transplantation and Infectious Disease, IRCCS San Raffaele Scientific Institute, Milano, Italy. .,Unit of Hematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, Milano, Italy.
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39
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Mechanisms of immune escape after allogeneic hematopoietic cell transplantation. Blood 2018; 133:1290-1297. [PMID: 30578254 DOI: 10.1182/blood-2018-10-846824] [Citation(s) in RCA: 99] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 12/15/2018] [Indexed: 02/04/2023] Open
Abstract
Relapse of the original disease is a major cause of death after allogeneic hematopoietic cell transplantation for acute leukemias. There is growing evidence that relapses may be explained not only by resistance to chemotherapy but also by the escape of tumor cells from the control of the allogeneic immune response. Mechanisms of immune evasion can involve abrogation of leukemia cell recognition due to loss of HLA genes, immunosuppression by immune-checkpoint ligand expression, production of anti-inflammatory factors, release of metabolically active enzymes, loss of proinflammatory cytokine production, and acquisition of novel driver mutations that promote leukemia outgrowth. These mechanisms, and therapeutic targeting of immune escape, will be discussed. We divide the evidence in support of immune-escape mechanisms into animal studies, human laboratory studies, and human clinical experience. A better understanding of the molecular pathways connected to immune escape and relapse may help to improve our therapeutic armamentarium against acute myeloid leukemia relapse.
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40
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Myeloablative and reduced-intensity conditioning in HLA-haploidentical peripheral blood stem cell transplantation using post-transplant cyclophosphamide. Bone Marrow Transplant 2018; 54:432-441. [PMID: 30087460 DOI: 10.1038/s41409-018-0279-1] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 06/13/2018] [Accepted: 06/27/2018] [Indexed: 02/07/2023]
Abstract
We conducted two parallel prospective, multicenter, phase II studies to evaluate the safety and efficacy of HLA-haploidentical peripheral blood stem cell transplantation using post-transplant cyclophosphamide (PTCy-haploPBSCT) following myeloablative conditioning (MAC, n = 50) and reduced-intensity conditioning (RIC, n = 77). Event-free survival (EFS) at 1-year as for primary endpoint was 64% and 43% in the MAC and RIC groups, respectively. Neutrophil engraftment was achieved in 98% and 94% in the MAC and RIC groups, respectively. The incidences of grades II-IV and III-IV acute graft-versus-host disease (GVHD) were 18% and 8% in the MAC group, and 14% and 5% in the RIC group, respectively. Those of all grade and moderate to severe chronic GVHD at 2-year were 36% and 20% in the MAC group, and 27% and 20% in the RIC group, respectively. Overall survival (OS), EFS, nonrelapse mortality, and relapse rate at 2-year were 68%, 54%, 10%, and 36% in the MAC group, and 44%, 35%, 20%, and 45% in the RIC group, respectively. Notably, 83% and 86% of patients who survived without relapse stopped immunosuppressant at 2-year in the MAC and RIC groups, respectively. Our results indicate that both MAC and RIC are valid options for PTCy-haploPBSCT for adults with hematological malignancies.
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Akahoshi Y, Mizuta S, Shimizu H, Uchida N, Fukuda T, Kanamori H, Onizuka M, Ozawa Y, Ohashi K, Ohta S, Eto T, Tanaka J, Atsuta Y, Kako S. Additional Cytogenetic Abnormalities with Philadelphia Chromosome-Positive Acute Lymphoblastic Leukemia on Allogeneic Stem Cell Transplantation in the Tyrosine Kinase Inhibitor Era. Biol Blood Marrow Transplant 2018; 24:2009-2016. [PMID: 29908230 DOI: 10.1016/j.bbmt.2018.06.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 06/06/2018] [Indexed: 01/24/2023]
Abstract
Cytogenetic abnormalities are well known and powerful independent prognostic factors for various hematologic disorders. Although the combination of chemotherapy with tyrosine kinase inhibitor (TKI) is now considered the standard of care in patients with Philadelphia chromosome-positive acute lymphoblastic leukemia, little is known about the impact of additional cytogenetic abnormalities (ACAs). Therefore, we retrospectively evaluated 1375 adult patients who underwent their first allogeneic hematopoietic stem cell transplantation in the TKI era. In this study, 224 patients had ACAs (16.3%). The ACAs that were seen in more than 20 cases (1.5%) were as follows: -7, der(22), der(9), +8, and +X. Overall survival at 4 years was 56.9% (95% confidence interval [CI], 49.4% to 63.7%) in the group with ACAs and 60.5% (95% CI, 57.3% to 63.5%) in the group without ACAs (P = .266). The cumulative incidence of relapse at 4 years was 28.9% (95% CI, 22.6% to 35.6%) in the group with ACAs and 21.9% (95% CI, 19.4% to 24.6%) in the group with Ph alone (P = .051). In multivariate analyses there were no statistically significant differences in the risk of overall mortality or risk of relapse between the groups with and without ACAs. In the subgroup analyses of specific ACAs, although the presence of +8 was associated with a higher relapse rate in univariate and multivariate analyses, no specific ACA was associated with poor overall survival. Further studies will be needed to verify the impact of specific ACAs on transplantation outcomes.
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Affiliation(s)
- Yu Akahoshi
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Shuichi Mizuta
- Department of Hematology and Immunology, Medicine, Kanazawa Medical University, Ishikawa, Japan
| | - Hiroaki Shimizu
- Department of Medicine and Clinical Science, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Naoyuki Uchida
- Department of Hematology, Federation of National Public Service Personnel Mutual Aid Associations Toranomon Hospital, Tokyo, Japan
| | - Takahiro Fukuda
- Division of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Heiwa Kanamori
- Department of Hematology, Kanagawa Cancer Center, Yokohama, Japan
| | - Makoto Onizuka
- Department of Hematology and Oncology, Tokai University School of Medicine, Kanagawa, Japan
| | - Yukiyasu Ozawa
- Department of Hematology, Japanese Red Cross Nagoya First Hospital, Nagoya, Japan
| | - Kazuteru Ohashi
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Shuichi Ohta
- Department of Hematology, Sapporo Hokuyu Hospital, Sapporo, Japan
| | - Tetsuya Eto
- Department of Hematology, Hamanomachi Hospital, Fukuoka, Japan
| | - Junji Tanaka
- Department of Hematology, Tokyo Women's Medical University, Tokyo, Japan
| | - Yoshiko Atsuta
- Japanese Data Center for Hematopoietic Cell Transplantation, Nagoya, Japan
| | - Shinichi Kako
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Saitama, Japan.
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42
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Have haploidentical transplants replaced umbilical cord transplants for acute leukemias? Curr Opin Hematol 2018; 25:103-111. [DOI: 10.1097/moh.0000000000000412] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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43
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Choosing the Alternative. Biol Blood Marrow Transplant 2017; 23:1813-1814. [PMID: 28939457 DOI: 10.1016/j.bbmt.2017.09.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Accepted: 09/11/2017] [Indexed: 01/21/2023]
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