1
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Rathje K, Gagelmann N, Salit RB, Schroeder T, Gurnari C, Pagliuca S, Panagiota V, Rautenberg C, Cassinat B, Thol F, Robin M, Oechsler S, Heuser M, Rubio MT, Maciejewski JP, Reinhardt HC, Scott BL, Kröger N. Anti-T-lymphocyte globulin improves GvHD-free and relapse-free survival in myelofibrosis after matched related or unrelated donor transplantation. Bone Marrow Transplant 2024; 59:1154-1160. [PMID: 38773281 PMCID: PMC11296946 DOI: 10.1038/s41409-024-02291-6] [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: 02/14/2024] [Revised: 04/03/2024] [Accepted: 04/12/2024] [Indexed: 05/23/2024]
Abstract
Acute and chronic graft-versus-host disease (GvHD) are major complications of allogeneic hematopoietic cell transplantation (alloHCT). In vivo T-cell depletion with anti-T-lymphocyte globulin (ATLG) as part of the conditioning regimen prior to alloHCT is frequently used as GvHD prophylaxis, but data on its role in myelofibrosis is scarce. We took advantage of an international collaborative network to investigate the impact of ATLG in myelofibrosis undergoing first alloHCT. We included 707 patients (n = 469 ATLG and n = 238 non-ATLG prophylaxis). The cumulative incidence of acute GvHD grade II-IV was 30% for the ATLG group vs. 56% for the non-ATLG group (P < 0.001). Acute GvHD grade III-IV occurred in 20% vs. 25%, respectively (P = 0.01). Incidence of mild-to-severe chronic GvHD was 49% vs. 50% (P = 0.52), while ATLG showed significantly lower rates of severe chronic GvHD (7% vs. 18%; P = 0.04). GvHD-free and relapse-free survival (GRFS) at 6 years was 45% for the ATLG group vs. 37% for the non-ATLG group (P = 0.02), driven by significantly improved GRFS of ATLG in matched related and matched unrelated donors. No significant differences in risk for relapse, non-relapse mortality, and overall survival were observed. Multivariable modeling for GRFS showed a 48% reduced risk of GvHD, relapse, or death when using ATLG.
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Affiliation(s)
- Kristin Rathje
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nico Gagelmann
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rachel B Salit
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Thomas Schroeder
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital of Essen, Essen, Germany
| | - Carmelo Gurnari
- Translational Hematology and Oncology Research Department, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH, USA
- Department of Biomedicine and Prevention, Tor Vergata University of Rome, Rome, Italy
| | - Simona Pagliuca
- Department of Hematology, Nancy University Hospital, and UMR 7365, University of Lorraine, Vandoeuvre-lès-Nancy, France
| | - Victoria Panagiota
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Christina Rautenberg
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital of Essen, Essen, Germany
| | - Bruno Cassinat
- APHP, Laboratoire de biologie cellulaire, Hôpital Saint-Louis, Paris, France
| | - Felicitas Thol
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Marie Robin
- Service d'Hématologie-Greffe, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Sofia Oechsler
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Heuser
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Marie-Thérèse Rubio
- Department of Hematology, Nancy University Hospital, and UMR 7365, University of Lorraine, Vandoeuvre-lès-Nancy, France
| | - Jaroslaw P Maciejewski
- Translational Hematology and Oncology Research Department, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH, USA
| | - Hans Christian Reinhardt
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital of Essen, Essen, Germany
| | - Bart L Scott
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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2
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Barbarito G, Hiroshima L, Oppizzi L, Saini G, Kristovich K, Klein O, Hosszu K, Boehlke K, Gupta A, Mcavoy D, Shyr D, Boelens JJ, Bertaina A. Model-Based Antithymocyte Globulin in αβhaplo-Hematopoietic Stem Cell Transplantation Facilitates Engraftment, Expedites T Cell Recovery, and Mitigates the Risk of Acute Graft-versus-Host Disease. Transplant Cell Ther 2024; 30:810.e1-810.e16. [PMID: 38768907 DOI: 10.1016/j.jtct.2024.05.015] [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: 02/08/2024] [Revised: 05/06/2024] [Accepted: 05/13/2024] [Indexed: 05/22/2024]
Abstract
In αβ T-cell/CD19 B-cell depleted hematopoietic stem cell transplantation (αβhaplo-HSCT) recipients, antithymocyte globulin (ATG; Thymoglobulin) is used for preventing graft rejection and graft-versus-host disease (GVHD). The optimal dosing remains to be established, however. Here we present the first comparative analysis of 3 different ATG dosing strategies and their impact on immune reconstitution and GVHD. Our study aimed to evaluate the effects of 3 distinct dosing strategies of ATG on engraftment success, αβ+ and γδ+ T cell immune reconstitution, and the incidence and severity of acute GVHD in recipients of αβhaplo-HSCT. This comparative analysis included 3 cohorts of pediatric patients with malignant (n = 36) or nonmalignant (n = 8) disease. Cohorts 1 and 2 were given fixed ATG doses, whereas cohort 3 received doses via a new nomogram, based on absolute lymphocyte count (ALC) and body weight (BW). Cohort 3 showed a 0% incidence of day 100 grade II-IV acute GVHD, compared to 48% in cohort 1 and 27% in cohort 2. Furthermore, cohort 3 (the ALC/BW-based cohort) had a significant increase in CD4+ and CD8+ naïve T cells by day 90 (P = .04 and .03, respectively). Additionally, we found that the reconstitution and maturation of γδ+ T cells post-HSCT was not impacted across all 3 cohorts. Cumulative ATG exposure in all cohorts was lower than previously reported in T cell-replete settings, with a lower pre-HSCT exposure (<40 AU*day/mL) correlating with engraftment failure (P = .007). Conversely, a post-HSCT ATG exposure of 10 to 15 AU*day/mL was optimal for improving day 100 CD4+ (P = .058) and CD8+ (P = .03) immune reconstitution without increasing the risk of relapse or nonrelapse mortality. This study represents the first comparative analysis of ATG exposure in αβhaplo-HSCT recipients. Our findings indicate that (1) a 1- to 2-fold ATG to ATLG bioequivalence is more effective than previously established standards, and (2) ATG exposure post-HSCT does not adversely affect γδ+ T cell immune reconstitution. Furthermore, a model-based ATG dosing strategy effectively reduces graft rejection and day 100 acute GVHD while also promoting early CD4+/CD8+ immune reconstitution. These insights suggest that further optimization, including more distal administration of higher ATG doses within an ALC/BW-based strategy, will yield even greater improvements in outcomes.
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Affiliation(s)
- Giulia Barbarito
- Division of Hematology, Oncology, Stem Cell Transplantation, and Regenerative Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Lyndsie Hiroshima
- Division of Hematology, Oncology, Stem Cell Transplantation, and Regenerative Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Linda Oppizzi
- Division of Hematology, Oncology, Stem Cell Transplantation, and Regenerative Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Gopin Saini
- Division of Hematology, Oncology, Stem Cell Transplantation, and Regenerative Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Karen Kristovich
- Division of Hematology, Oncology, Stem Cell Transplantation, and Regenerative Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Orly Klein
- Division of Hematology, Oncology, Stem Cell Transplantation, and Regenerative Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Kinga Hosszu
- MSK Kids, Transplantation and Cellular Therapy Service, Memorial Sloan Kettering Cancer Center, New York, New York; Immune Discovery and Monitoring Service, Department of Pediatrics and Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kylan Boehlke
- Division of Hematology, Oncology, Stem Cell Transplantation, and Regenerative Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Aditi Gupta
- Division of Hematology, Oncology, Stem Cell Transplantation, and Regenerative Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Devin Mcavoy
- MSK Kids, Transplantation and Cellular Therapy Service, Memorial Sloan Kettering Cancer Center, New York, New York; Immune Discovery and Monitoring Service, Department of Pediatrics and Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - David Shyr
- Division of Hematology, Oncology, Stem Cell Transplantation, and Regenerative Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Jaap Jan Boelens
- MSK Kids, Transplantation and Cellular Therapy Service, Memorial Sloan Kettering Cancer Center, New York, New York; Immune Discovery and Monitoring Service, Department of Pediatrics and Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Alice Bertaina
- Division of Hematology, Oncology, Stem Cell Transplantation, and Regenerative Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California.
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Steiner N, Massoud R, Klyuchnikov E, Gagelmann N, Richter J, Niederwieser C, Rathje K, Urbanowicz T, Kunte A, Engelmann J, Ihne C, Lastovytska I, Lindhauer C, Marquard F, Reichard M, Ryzhkova A, Sabauri R, Schäfersküpper M, Seyedi N, Kalogeropoulos G, Heidenreich S, Rudolph I, Zeck G, Janson D, Wolschke C, Ayuk F, Kröger N. Anti-T-lymphocyte globulin (ATLG) compared to post-transplant cyclophosphamide as GvHD prophylaxis in ALL patients undergoing allogeneic stem cell transplantation. Bone Marrow Transplant 2024:10.1038/s41409-024-02328-w. [PMID: 38877098 DOI: 10.1038/s41409-024-02328-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 06/04/2024] [Accepted: 06/06/2024] [Indexed: 06/16/2024]
Abstract
We retrospectively analyzed high-risk ALL patients in CR1 receiving total body irradiation based conditioning regimen with ATLG (n = 74) or PTCy (n = 73) for GVHD prophylaxis. The 3-year OS and LFS were similar in both groups: 65 and 60% in the ATLG group and 64 and 67% in the PTCy group (p = 0.9 and 0.5, respectively). CIR and NRM rate at three years was 12 and 21% after PTCy and 19 and 20% after ATLG (p = 0.4 and p = 0.9, respectively). Acute GvHD grades II-IV and grades III/IV at 100 days was 46 and 19% after PTCy and 33 and 10% after ATLG (p = 0.08 and p = 0.9, respectively). Chronic GvHD of all grade at two years was higher after PTCy: 55% versus 26% (p < 0.001). Based on the propensity score matching (PSM) analysis, aGvHD grades II-IV was trending higher in the PTCy group compared to the ATLG group (p = 0.07). In contrast to the PSM analysis, on multivariate analysis the receipt of PTCy compared with ATLG was associated with a reduced CIR (p = 0.026). Our retrospective single-center analysis shows a lower incidence of acute and chronic GvHD while displaying similar LFS and OS after ATLG compared to PTCy in TBI based allogeneic stem cell transplantation for high-risk ALL.
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Affiliation(s)
- Normann Steiner
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
- University Hospital of Internal Medicine V (Hematology and Oncology), Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Radwan Massoud
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Evgeny Klyuchnikov
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Nico Gagelmann
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Johanna Richter
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Christian Niederwieser
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Kristin Rathje
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Tatjana Urbanowicz
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Ameya Kunte
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Janik Engelmann
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Christina Ihne
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Iryna Lastovytska
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Cecilia Lindhauer
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Franziska Marquard
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Mirjam Reichard
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Alla Ryzhkova
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Rusudan Sabauri
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Mathias Schäfersküpper
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Niloufar Seyedi
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Georgios Kalogeropoulos
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Silke Heidenreich
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Ina Rudolph
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Gaby Zeck
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Dietlinde Janson
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Christine Wolschke
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
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Giordano U, Mordak-Domagała M, Sobczyk-Kruszelnicka M, Giebel S, Gil L, Dudek KD, Dybko J. Comparing the Outcomes of Matched and Mismatched Unrelated Allogeneic Hematopoietic Stem Cell Transplantation with Different Anti-Thymocyte Globulin Formulations: A Retrospective, Double-Centre Experience on Behalf of the Polish Adult Leukemia Group. Cancers (Basel) 2024; 16:1891. [PMID: 38791969 PMCID: PMC11119435 DOI: 10.3390/cancers16101891] [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: 04/17/2024] [Revised: 05/08/2024] [Accepted: 05/13/2024] [Indexed: 05/26/2024] Open
Abstract
Despite notable advancements in immunotherapy in the past decades, allogeneic hematopoietic stem cell transplantation (allo-HCT) remains a promising, potentially curative treatment modality. Only a limited number of studies have performed a direct comparison of two prevalent rabbit anti-thymocyte globulin (r-ATG) formulations-specifically, Thymoglobuline (ATG-T, formerly Genzyme) and Grafalon (ATG-G, formerly Fresenius). The primary objective of our retrospective analysis was to compare the outcomes of adult patients undergoing matched or mismatched unrelated donor (MUD/MMUD) allo-HCT, with a graft-versus-host disease (GvHD) prophylaxis based on either ATG-T or ATG-G. A total of 87 patients who had undergone allo-HCT between 2012 and 2022 were included. We observed no significant differences between ATG-T and ATG-G concerning the occurrence of acute graft-versus-host disease (aGvHD), regardless of its severity. Conversely, chronic graft-versus-host disease (cGvHD) occurred less frequently in the ATG-T group compared to the ATG-G group (7.5% vs. 38.3%, p = 0.001). The negative impact of ATG-G on cGvHD was confirmed by multivariate analysis (HR 8.12, 95% CI 2.06-32.0, p = 0.003). Patients treated with ATG-T manifested a higher incidence of cytomegalovirus (CMV) reactivations (70% vs. 31.9%, p < 0.001), with a shorter time between transplant and CMV (<61 days, 77.8% vs. 33.3%, p = 0.008) and a higher median CMV copy number (1000 vs. 0, p = 0.004). Notably, despite a higher occurrence of CMV reactivations in the ATG-T cohort, most patients were asymptomatic compared to ATG-G (85.7% vs. 43.8%, p = 0.005). By multivariate analysis, only aGvHD had an influence on CMV reactivations (HR 0.18, 95% CI 0.04-0.75, p = 0.019). Finally, we observed no significant differences in terms of 5-year overall survival (OS) and 3-year relapse-free survival (RFS) while comparing ATG-T and ATG-G (32.0% vs. 40.3%, p = 0.423; 66.7% vs. 60.4%, p = 0.544, respectively).
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Affiliation(s)
- Ugo Giordano
- Department and Clinic of Endocrinology, Diabetes and Isotope Therapy, 50-367 Wroclaw, Poland
| | - Monika Mordak-Domagała
- Lower Silesian Center of Oncology, Pulmonology and Hematology, 53-439 Wroclaw, Poland; (M.M.-D.); (J.D.)
| | | | - Sebastian Giebel
- Maria Sklodowska-Curie National Research Institute of Oncology, 44-102 Gliwice, Poland; (M.S.-K.); (S.G.)
| | - Lidia Gil
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, 61-701 Poznań, Poland;
| | - Krzysztof D. Dudek
- Faculty of Mechanical Engineering, Wroclaw University of Science and Technology, 50-370 Wroclaw, Poland;
| | - Jarosław Dybko
- Lower Silesian Center of Oncology, Pulmonology and Hematology, 53-439 Wroclaw, Poland; (M.M.-D.); (J.D.)
- Department of Oncology and Hematology, Faculty of Medicine, Wroclaw University of Science and Technology, 50-370 Wroclaw, Poland
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5
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Kröger N, Wolschke C, Gagelmann N. How I treat transplant-eligible patients with myelofibrosis. Blood 2023; 142:1683-1696. [PMID: 37647853 DOI: 10.1182/blood.2023021218] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 08/14/2023] [Accepted: 08/18/2023] [Indexed: 09/01/2023] Open
Abstract
Despite the approval of Janus kinase inhibitors and novel agents for patients with myelofibrosis (MF), disease-modifying responses remain limited, and hematopoietic stem cell transplantation (HSCT) remains the only potentially curative treatment option. The number of HSCTs for MF continues to increase worldwide, but its inherent therapy-related morbidity and mortality limit its use for many patients. Furthermore, patients with MF often present at an older age, with cytopenia, splenomegaly, and severe bone marrow fibrosis, posing challenges in managing them throughout the HSCT procedure. Although implementation of molecular analyses enabled improved understanding of disease mechanisms and subsequently sparked development of novel drugs with promising activity, prospective trials in the HSCT setting are often lacking, making an evidence-based decision process particularly difficult. To illustrate how we approach patients with MF with respect to HSCT, we present 3 different clinical scenarios to capture relevant aspects that influence our decision making regarding indication for, or against, HSCT. We describe how we perform HSCT according to different risk categories and, furthermore, discuss our up-to-date approach to reduce transplant-related complications. Last, we show how to harness graft-versus-MF effects, particularly in the posttransplant period to achieve the best possible outcomes for patients.
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Affiliation(s)
- Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christine Wolschke
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nico Gagelmann
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Dybko J, Giordano U, Pilch J, Mizera J, Borkowski A, Mordak-Domagała M. Comparison of Different Rabbit Anti-Thymocyte Globulin Formulations in the Prophylaxis of Graft-Versus-Host Disease: A Systematic Review. J Clin Med 2023; 12:5449. [PMID: 37685516 PMCID: PMC10487811 DOI: 10.3390/jcm12175449] [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: 06/27/2023] [Revised: 08/09/2023] [Accepted: 08/20/2023] [Indexed: 09/10/2023] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HCT) is a potentially curative treatment modality, frequently used for patients suffering from haematological malignancies. In the last two decades, there have been multiple randomised controlled trials (RCTs), review articles, and meta-analyses addressing the efficacy of rabbit anti-thymocyte globulin (r-ATG) as a graft-versus-host disease (GvHD) prophylaxis. Nevertheless, only a few aimed to compare the effectiveness of different r-ATG formulations. Since the last article we retrieved comparing different r-ATGs in GvHD prophylaxis dates back to 2017, we performed a systematic literature review of articles published since 2017 to this day, utilising PubMed, Scopus, Cochrane, and MEDLINE, with the main endpoints being prophylaxis of acute GvHD (aGvHD) and chronic GvHD (cGvHD). We subjected to scrutiny a total of five studies, of which four compared the differences between Thymoglobulin (ATG-T) and Grafalon (ATG-G), and one discussed the impact of ATG-T dose. Overall, cGvHD, aGvHD grades II-IV, TRM, OS, NRM, LFS, relapse, overall infections, and EBV reactivation do not seem to be affected by the type of utilised rATG. However, data on aGvHD grades III-IV, GRFS, moderate-severe cGvHD, and CMV reactivation is conflicting. Through our research, we sought to summarise the most recent findings concerning r-ATGs in allo-HCT, and provide insight into the differences between the targets and origin of various ATG formulations.
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Affiliation(s)
- Jarosław Dybko
- Lower Silesia Centre for Oncology, Pulmonology and Hematology in Wrocław, 53-439 Wroclaw, Poland; (J.D.); (M.M.-D.)
| | - Ugo Giordano
- University Clinical Hospital in Wroclaw, Wroclaw Medical University, 50-556 Wroclaw, Poland
| | - Justyna Pilch
- Faculty of Medicine, Wroclaw Medical University, 50-367 Wroclaw, Poland; (J.P.); (J.M.)
| | - Jakub Mizera
- Faculty of Medicine, Wroclaw Medical University, 50-367 Wroclaw, Poland; (J.P.); (J.M.)
| | - Artur Borkowski
- Department of Nuclear Medicine and Endocrine Oncology, M. Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, 44-102 Gliwice, Poland;
| | - Monika Mordak-Domagała
- Lower Silesia Centre for Oncology, Pulmonology and Hematology in Wrocław, 53-439 Wroclaw, Poland; (J.D.); (M.M.-D.)
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Chakupurakal G, Freudenberger P, Skoetz N, Ahr H, Theurich S. Polyclonal anti-thymocyte globulins for the prophylaxis of graft-versus-host disease after allogeneic stem cell or bone marrow transplantation in adults. Cochrane Database Syst Rev 2023; 6:CD009159. [PMID: 37341189 PMCID: PMC10284458 DOI: 10.1002/14651858.cd009159.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
BACKGROUND Allogeneic haematopoietic stem cell transplantation (SCT) is an established treatment for many malignant and non-malignant haematological disorders. Graft-versus-host disease (GVHD), a condition frequently occurring after an allogeneic SCT, is the result of host tissues being attacked by donor immune cells. It affects more than half of the patients after transplant either as acute and or chronic GVHD. One strategy for the prevention of GVHD is the administration of anti-thymocyte globulins (ATGs), a set of polyclonal antibodies directed against a variety of immune cell epitopes, leading to immunosuppression and immunomodulation. OBJECTIVES To assess the effect of ATG used for the prevention of GVHD in patients undergoing allogeneic SCT with regard to overall survival, incidence and severity of acute and chronic GVHD, incidence of relapse, non-relapse mortality, graft failure and adverse events. SEARCH METHODS For this update we searched the CENTRAL, MEDLINE, Embase, trial registers and conference proceedings on the 18th November 2022 along with reference checking and contacting study authors to identify additional studies. We did not apply language restrictions. SELECTION CRITERIA We included randomised controlled trials (RCTs) investigating the impact of ATG on GVHD prophylaxis in adults suffering from haematological diseases and undergoing allogeneic SCT. The selection criteria were modified from the previous version of this review. Paediatric studies and studies where patients aged < 18 years constituted more than 20 % of the total number were excluded. Treatment arms had to differ only in the addition of ATG to the standard GVHD prophylaxis regimen. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by the Cochrane Collaboration for data collection, extraction and analyses. MAIN RESULTS For this update we included seven new RCTs, leading to a total of ten studies investigating 1413 participants. All patients had a haematological condition which warranted an allogeneic SCT. The risk of bias was estimated as low for seven and unclear for three studies. ATG probably has little or no influence on overall survival (HR (hazard ratio) 0.93 (95 % confidence interval (CI) 0.77 to 1.13, nine studies, n = 1249, moderate-certainty evidence)). Estimated absolute effect: 430 surviving people per 1000 people not receiving ATG compared to 456 people surviving per 1000 people receiving the intervention (95 % CI 385 to 522 per 1000 people). ATG results in a reduction in acute GVHD II to IV with relative risk (RR) 0.68 (95 % CI 0.60 to 0.79, 10 studies, n = 1413, high-certainty evidence). Estimated absolute effect: 418 acute GVHD II to IV per 1000 people not receiving ATG compared to 285 per 1000 people receiving the intervention (95 % CI 251 to 331 per 1000 people). Addition of ATG results in a reduction of overall chronic GvHD with a RR of 0.53 (95 % CI 0.45 to 0.61, eight studies, n = 1273, high-certainty evidence). Estimated absolute effect: 506 chronic GVHD per 1000 people not receiving ATG compared to 268 per 1000 people receiving the intervention (95 % CI 228 to 369 per 1000 people). Further data on severe acute GVHD and extensive chronic GVHD are available in the manuscript. ATG probably slightly increases the incidence of relapse with a RR of 1.21 (95 % CI 0.99 to 1.49, eight studies, n =1315, moderate-certainty evidence). Non relapse mortality is probably slightly or not affected by ATG with an HR of 0.86 (95 % CI 0.67 to 1.11, nine studies, n=1370, moderate-certainty evidence). ATG prophylaxis may result in no increase in graft failure with a RR of 1.55 (95 % CI 0.54 to 4.44, eight studies, n = 1240, low-certainty evidence). Adverse events could not be analysed due to the serious heterogeneity in the reporting between the studies, which limited comparability (moderate-certainty evidence) and are reported in a descriptive manner. Subgroup analyses on ATG types, doses and donor type are available in the manuscript. AUTHORS' CONCLUSIONS This systematic review suggests that the addition of ATG during allogeneic SCT probably has little or no influence on overall survival. ATG results in a reduction in the incidence and severity of acute and chronic GvHD. ATG intervention probably slightly increases the incidence of relapse and probably does not affect the non relapse mortality. Graft failure may not be affected by ATG prophylaxis. Analysis of data on adverse events was reported in a narrative manner. A limitation for the analysis was the imprecision in reporting between the studies thereby reducing the confidence in the certainty of evidence.
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Affiliation(s)
- Geothy Chakupurakal
- Praxis for Haematology and Oncology, Koblenz, Germany
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine at the University of Cologne, Cologne, Germany
| | | | - Nicole Skoetz
- Cochrane Cancer, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Hans Ahr
- Rheinland Klinikum, Dormagen, Germany
| | - Sebastian Theurich
- Department of Medicine III, University Hospital LMU, Ludwig-Maximilians-Universität München, Munich, Germany
- Cancer and Immunometabolism Research Group, Gene Center LMU, Munich, Germany
- German Cancer Consortium (DKTK), Munich Site , German Cancer Research Center, Heidelberg, Germany
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8
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Storci G, Barbato F, Ricci F, Tazzari PL, De Matteis S, Tomassini E, Dicataldo M, Laprovitera N, Arpinati M, Ursi M, Maffini E, Campanini E, Dan E, Manfroi S, Santi S, Ferracin M, Bonafe M, Bonifazi F. Pre-transplant CD69+ extracellular vesicles are negatively correlated with active ATLG serum levels and associate with the onset of GVHD in allogeneic HSCT patients. Front Immunol 2023; 13:1058739. [PMID: 36713433 PMCID: PMC9880409 DOI: 10.3389/fimmu.2022.1058739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 12/06/2022] [Indexed: 01/15/2023] Open
Abstract
Graft versus host disease (GVHD) is a major complication of allogeneic hematopoietic stem cell transplantation (HSCT). Rabbit anti-T lymphocyte globulin (ATLG) in addition to calcineurin inhibitors and antimetabolites is a suitable strategy to prevent GVHD in several transplant settings. Randomized studies already demonstrated its efficacy in terms of GVHD prevention, although the effect on relapse remains the major concern for a wider use. Tailoring of ATLG dose on host characteristics is expected to minimize its side effects (immunological reconstitution, relapse, and infections). Here, day -6 to day +15 pharmacokinetics of active ATLG serum level was first assayed in an explorative cohort of 23 patients by testing the ability of the polyclonal serum to bind antigens on human leukocytes. Significantly lower levels of serum active ATLG were found in the patients who developed GVHD (ATLG_AUCCD45: 241.52 ± 152.16 vs. 766.63 +/- 283.52 (μg*day)/ml, p = 1.46e-5). Consistent results were obtained when the ATLG binding capacity was assessed on CD3+ and CD3+/CD4+ T lymphocytes (ATLG_AUCCD3: 335.83 ± 208.15 vs. 903.54 ± 378.78 (μg*day)/ml, p = 1.92e-4; ATLG_AUCCD4: 317.75 ± 170.70 vs. 910.54 ± 353.35 (μg*day)/ml, p = 3.78e-5. Concomitantly, at pre-infusion time points, increased concentrations of CD69+ extracellular vesicles (EVs) were found in patients who developed GVHD (mean fold 9.01 ± 1.33; p = 2.12e-5). Consistent results were obtained in a validation cohort of 12 additional ATLG-treated HSCT patients. Serum CD69+ EVs were mainly represented in the nano (i.e. 100 nm in diameter) EV compartment and expressed the leukocyte marker CD45, the EV markers CD9 and CD63, and CD103, a marker of tissue-resident memory T cells. The latter are expected to set up a host pro-inflammatory cell compartment that can survive in the recipient for years after conditioning regimen and contribute to GVHD pathogenesis. In summary, high levels of CD69+ EVs are significantly correlated with an increased risk of GVHD, and they may be proposed as a tool to tailor ATLG dose for personalized GVHD prevention.
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Affiliation(s)
- Gianluca Storci
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Francesco Barbato
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy,Department of Experimental, Diagnostic and Specialty Medicine (DIMES) University of Bologna, Bologna, Italy
| | - Francesca Ricci
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | | | - Enrica Tomassini
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Michele Dicataldo
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy,Department of Experimental, Diagnostic and Specialty Medicine (DIMES) University of Bologna, Bologna, Italy
| | | | - Mario Arpinati
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Margherita Ursi
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy,Department of Experimental, Diagnostic and Specialty Medicine (DIMES) University of Bologna, Bologna, Italy
| | - Enrico Maffini
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Elena Campanini
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Elisa Dan
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES) University of Bologna, Bologna, Italy
| | - Silvia Manfroi
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Spartaco Santi
- Consiglio Nazionale delle Ricerche (CNR) Institute of Molecular Genetics "Luigi Luca Cavalli-Sforza", Bologna, Italy,IRCCS, Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Manuela Ferracin
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy,Department of Experimental, Diagnostic and Specialty Medicine (DIMES) University of Bologna, Bologna, Italy
| | - Massimiliano Bonafe
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy,Department of Experimental, Diagnostic and Specialty Medicine (DIMES) University of Bologna, Bologna, Italy
| | - Francesca Bonifazi
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy,*Correspondence: Francesca Bonifazi,
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9
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Wada F, Watanabe M, Konuma T, Okabe M, Kobayashi S, Uchida N, Ikegame K, Tanaka M, Sugio Y, Mukae J, Onizuka M, Kawakita T, Kuriyama T, Takahashi S, Fukuda T, Nakano N, Sawa M, Kimura T, Ichinohe T, Atsuta Y, Kanda J. HLA 1-3 antigen-mismatched related peripheral blood stem cells transplantation using low-dose antithymocyte globulin versus unrelated cord blood transplantation. Am J Hematol 2022; 97:311-321. [PMID: 34978726 DOI: 10.1002/ajh.26446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 12/15/2021] [Accepted: 12/17/2021] [Indexed: 11/08/2022]
Abstract
Little information is available regarding whether unrelated cord blood transplantation (CBT) or an HLA 1-3 antigen-mismatched related donor peripheral blood stem-cell transplantation (PBSCT) using low-dose anti-thymocyte globulin (ATG) is superior as an alternative transplantation for patients who lack an HLA-matched sibling or unrelated donor. Therefore, we evaluated 7861 patients with hematologic malignancies (aged 0 to 70 years) who received either a CBT without ATG (CBT-no ATG, n = 7034) or an HLA 1-3 antigen-mismatched related donor PBSCT using low-dose ATG (PBSCT-ATG, n = 827). CBT-no ATG was associated with significantly better overall survival (OS) than the use of a PBSCT-ATG (hazard ratio [HR], 0.77; p < .001), although PBSCT-ATG patients with an HLA 1 antigen-mismatch showed OS comparable to that in the CBT-no ATG group. Neutrophil and platelet engraftment was significantly delayed, whereas the incidences of nonrelapse mortality, and severe graft-versus-host disease (GVHD) were significantly lower in the CBT-no ATG group. The incidences of relapse and chronic GVHD were comparable between these donors. In conclusion, CBT-no ATG may be a better alternative than HLA-mismatched related donor PBSCT using low-dose ATG. Notably, HLA 2-3 antigen mismatch-related transplantation with low-dose ATG had significant adverse effects on transplantation outcomes.
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Affiliation(s)
- Fumiya Wada
- Department of Hematology and Oncology, Graduate School of Medicine Kyoto University Kyoto Japan
- Department of Hematology Kobe City Medical Center General Hospital Kobe Japan
| | - Mizuki Watanabe
- Department of Hematology and Oncology, Graduate School of Medicine Kyoto University Kyoto Japan
| | - Takaaki Konuma
- Department of Hematology/Oncology, The Institute of Medical Science The University of Tokyo Tokyo Japan
| | - Motohito Okabe
- Department of Hematology/Oncology, The Institute of Medical Science The University of Tokyo Tokyo Japan
| | - Shinichi Kobayashi
- Division of Hematology, Department of Internal Medicine National Defense Medical College Saitama Japan
| | - Naoyuki Uchida
- Department of Hematology Federation of National Public Service Personnel Mutual Aid Associations Toranomon Hospital Tokyo Japan
| | - Kazuhiro Ikegame
- Department of Hematology Hyogo College of Medicine Hospital Nishinomiya Japan
| | | | - Yasuhiro Sugio
- Department of Hematology Kitakyushu City Hospital Organization, Kitakyushu Municipal Medical Center Kitakyushu Japan
| | - Junichi Mukae
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital Tokyo Japan
| | - Makoto Onizuka
- Department of Hematology/Oncology Tokai University School of Medicine Isehara‐shi Japan
| | - Toshiro Kawakita
- Department of Hematology National Hospital Organization Kumamoto Medical Center Kumamoto Japan
| | | | - Satoshi Takahashi
- Division of Clinical Precision Research Platform, The Institute of Medical Science The University of Tokyo Tokyo Japan
| | - Takahiro Fukuda
- Department of Hematopoietic Stem Cell Transplantation National Cancer Center Hospital Tokyo Japan
| | - Nobuaki Nakano
- Department of Hematology Imamura General Hospital Kagoshima Japan
| | - Masashi Sawa
- Department of Hematology and Oncology Anjo Kosei Hospital Anjo Japan
| | - Takafumi Kimura
- Preparation Department Japanese Red Cross Kinki Block Blood Center Osaka Japan
| | - Tatsuo Ichinohe
- Department of Hematology and Oncology, Research Institute for Radiation Biology and Medicine Hiroshima University Hiroshima Japan
| | - Yoshiko Atsuta
- Department of Healthcare Administration, Japanese Data Center for Hematopoietic Cell Transplantation Nagoya University Graduate School of Medicine Nagoya Japan
| | - Junya Kanda
- Department of Hematology and Oncology, Graduate School of Medicine Kyoto University Kyoto Japan
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10
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Fuji S, Hirakawa T, Takano K, Doki N, Sawa M, Kanda Y, Uchida N, Ara T, Miyamoto T, Eto T, Matsuoka KI, Kawakita T, Ozawa Y, Katayama Y, Onizuka M, Fukuda T, Atsuta Y, Nakasone H. Disease-specific impact of anti-thymocyte globulin in allogeneic hematopoietic cell transplantation: a nationwide retrospective study on behalf of the JSTCT, transplant complications working group. Bone Marrow Transplant 2022; 57:479-486. [PMID: 35039621 DOI: 10.1038/s41409-022-01569-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 12/18/2021] [Accepted: 01/06/2022] [Indexed: 01/22/2023]
Abstract
The disease-specific impact of anti-thymocyte globulin (ATG) in allogeneic hematopoietic cell transplantation (allo-HCT) has not been determined. We retrospectively assessed the impact of ATG in allo-HCT using nationwide registry data from the Japan Society for Transplantation and Cellular Therapy. We included patients who received their first allo-HCT between 2007 and 2018 for acute lymphoblastic leukemia (ALL), acute myeloid leukemia (AML), myelodysplastic syndrome (MDS), or malignant lymphoma (ML). In total, 8747 patients were included: 7635 patients did not receive ATG and 1112 patients received ATG as GVHD prophylaxis. The median follow-up period of surviving patients was 1457 days. There was no significant impact of pretransplant ATG on the OS or NRM rates in patients with ALL, AML, or ML. In patients with MDS, the probability of 3-year OS was 53.3% in the non-ATG group and 64.2% in the ATG group (P = 0.001). The cumulative incidence rates of relapse and NRM at 3 years were 14.2% and 30.3% (95% CI 27.2-33.3%), respectively, in the non-ATG group and 17.1% and 18.1% in the ATG group (P = 0.15 and P < 0.001). The same finding was observed in a propensity-score matched cohort. Our study suggests that the clinical benefit of ATG could vary among hematological diseases.
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Affiliation(s)
- Shigeo Fuji
- Department of Hematology, Osaka International Cancer Institute, Osaka, Japan.
| | - Tsuneaki Hirakawa
- Department of Hematology and Oncology, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Kuniko Takano
- Department of Medical Oncology and Hematology, Oita University Faculty of Medicine, Oita, Japan
| | - Noriko Doki
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Masashi Sawa
- Department of Hematology and Oncology, Anjo Kosei Hospital, Aichi, Japan
| | - Yoshinobu Kanda
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Naoyuki Uchida
- Department of Hematology, Federation of National Public Service Personnel Mutual Aid Associations Toranomon Hospital, Tokyo, Japan
| | - Takahide Ara
- Department of Hematology, Hokkaido University Hospital, Hokkaido, Japan
| | - Toshihiro Miyamoto
- Hematology, Oncology & Cardiovascular medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Tetsuya Eto
- Department of Hematology, Hamanomachi Hospital, Fukuoka, Japan
| | - Ken-Ichi Matsuoka
- Department of Hematology and Oncology, Okayama University Hospital, Okayama, Japan
| | - Toshiro Kawakita
- Department of Hematology, National Hospital Organization Kumamoto Medical Center, Kumamoto, Japan
| | - Yukiyasu Ozawa
- Department of Hematology, Japanese Red Cross Aichi Medical Center Nagoya Daiichi Hospital, Aichi, Japan
| | - Yuta Katayama
- Department of Hematology, Hiroshima Red Cross Hospital & Atomic-bomb Survivors Hospital, Hiroshima, Japan
| | - Makoto Onizuka
- Department of Hematology/Oncology, Tokai University School of Medicine, Kanagawa, Japan
| | - Takahiro Fukuda
- Hematopoietic Stem Cell Transplantation Division, National Cancer Center Hospital, Tokyo, Japan
| | - Yoshiko Atsuta
- Japanese Data Center for Hematopoietic Cell Transplantation, Aichi, Japan.,Department of Registry Science for Transplant and Cellular Therapy, Aichi Medical University School of Medicine, Aichi, Japan
| | - Hideki Nakasone
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
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11
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Miyao K, Kuwatsuka Y, Murata M, Nagafuji K, Teshima T, Takeuchi Y, Shiratori S, Najima Y, Uchida N, Tanaka M, Sawa M, Ota S, Fukuda T, Ozawa Y, Kako S, Kawakita T, Ara T, Tanaka J, Kanda Y, Atsuta Y, Kanda J, Terakura S. Anti-thymocyte globulin could potentially overcome an adverse effect of acute GVHD in matched-related PBSCT. Transplant Cell Ther 2021; 28:153.e1-153.e11. [PMID: 34954151 DOI: 10.1016/j.jtct.2021.12.009] [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: 10/01/2021] [Revised: 11/30/2021] [Accepted: 12/09/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Previous Japanese studies have shown that bone marrow transplantation (BMT) is associated with a better survival compared with peripheral blood stem cell transplantation (PBSCT) from matched related donors (MRDs). PBSCT recipients showed a higher incidence of severe graft-versus-host disease (GVHD) and non-relapse mortality (NRM) than BMT recipients. In recent years, the efficacy and safety of anti-thymocyte globulin (ATG) for PBSCT recipients has been reported from around the world. OBJECTIVE We aimed to compare BMT and PBSCT to identify current improvements and unmet needs among PBSCT recipients from MRDs. Moreover, we evaluated the impact of ATG administration on the outcomes for PBSCT recipients. STUDY DESIGN We retrospectively analyzed patients aged 16 years or older with acute leukemia, myelodysplastic syndrome, or chronic myeloid leukemia who received their first BMT or PBSCT from MRDs between 2009 and 2018 in Japan. RESULTS In total, 3599 transplantations were performed (BMT, 1218; PBSCT without ATG [PBSCT-ATG(-)], 2288; and PBSCT with ATG [PBSCT-ATG(+)], 93). The PBSCT-ATG(-) group had a higher NRM rate (hazard ratio [HR], 1.30; 95% confidence interval [CI], 1.08-1.57; p = 0.005) and lower overall survival (OS) rate (HR, 1.16; 95% CI, 1.04-1.30; p = 0.011) than the BMT group. Furthermore, the PBSCT-ATG(-) group had a higher incidence of grade III-IV, stage 2-4 gut, high-risk, and steroid-refractory acute GVHD than the BMT group. Acute GVHDs had a negative impact on NRM and OS rates. PBSCT-ATG(-) was also associated with a higher risk of chronic GVHD (HR: 1.89; 95% CI: 1.24-1.57; p < 0.001) and extensive chronic GVHD (HR: 1.44; 95% CI: 1.23-1.68; p < 0.001). The incidence of acute GVHD, chronic GVHD, and NRM and chronic GVHD-free relapse-free survival rates were comparable between the PBSCT-ATG(+) and BMT groups. The OS rate of patients with acute GVHD in the three donor groups was similar. Patients treated with reduced-intensity conditioning in the PBSCT-ATG(+) group had a higher relapse rate and lower OS rate than those in the BMT group. CONCLUSIONS In this Japanese cohort, standard calcineurin inhibitor-based GVHD prophylaxis was not sufficient for PBSCT recipients from MRDs because of the high incidence of severe acute GVHD. Moreover, prophylactic ATG was found to be a promising strategy against GVHD.
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Affiliation(s)
- Kotaro Miyao
- Department of Hematology and Oncology, Anjo Kosei Hospital, Anjo, Japan.
| | - Yachiyo Kuwatsuka
- Department of Advanced Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Makoto Murata
- Department of Hematology and Oncology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Koji Nagafuji
- Division of Hematology and Oncology, Kurume University School of Medicine, Kurume, Japan
| | - Takanori Teshima
- Department of Hematology, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Yuki Takeuchi
- Department of Hematology and Oncology, Anjo Kosei Hospital, Anjo, Japan
| | - Souichi Shiratori
- Department of Hematology, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Yuho Najima
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Naoyuki Uchida
- Department of Hematology, Toranomon Hospital, Tokyo, Japan
| | - Masatsugu Tanaka
- Department of Hematology, Kanagawa Cancer Center, Yokohama, Japan
| | - Masashi Sawa
- Department of Hematology and Oncology, Anjo Kosei Hospital, Anjo, Japan
| | - Shuichi Ota
- Department of Hematology, Sapporo Hokuyu Hospital, Sapporo, Japan
| | - Takahiro Fukuda
- Division of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Yukiyasu Ozawa
- Department of Hematology, Japanese Red Cross Aichi Medical Center Nagoya Daiichi Hospital, Nagoya, Japan
| | - Shinichi Kako
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Toshiro Kawakita
- Department of Hematology, National Hospital Organization Kumamoto Medical Center, Kumamoto, Japan
| | - Takahide Ara
- Department of Hematology, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Junji Tanaka
- Department of Hematology, Tokyo Women's Medical University, Tokyo, Japan
| | - Yoshinobu Kanda
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Yoshiko Atsuta
- Japanese Data Center for Hematopoietic Cell Transplantation, Nagoya, Japan; Department of Registry Science for Transplant and Cellular Therapy, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Junya Kanda
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Seitaro Terakura
- Department of Hematology and Oncology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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12
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Orfali N, Zhang MJ, Allbee-Johnson M, Boelens JJ, Artz AS, Brunstein CG, McNiece IK, Milano F, Abid MB, Chee L, Diaz MA, Grunwald MR, Hematti P, Hsu J, Lazarus HM, Munshi PN, Prestidge T, Ringden O, Rizzieri D, Riches ML, Seo S, Solh M, Solomon S, Szwajcer D, Yared J, Besien KV, Eapen M. Planned Granulocyte Colony-Stimulating Factor Adversely Impacts Survival after Allogeneic Hematopoietic Cell Transplantation Performed with Thymoglobulin for Myeloid Malignancy. Transplant Cell Ther 2021; 27:993.e1-993.e8. [PMID: 34507002 DOI: 10.1016/j.jtct.2021.08.031] [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: 07/17/2021] [Revised: 08/24/2021] [Accepted: 08/31/2021] [Indexed: 10/20/2022]
Abstract
The in vivo depletion of recipient and donor T lymphocytes using antithymocyte globulin (ATG; Thymoglobulin) is widely adopted in allogeneic hematopoietic stem cell transplantation (HCT) to reduce the incidence of both graft failure and graft-versus-host disease (GVHD). However, excess toxicity to donor lymphocytes may hamper immune reconstitution, compromising antitumor effects and increasing infection. Granulocyte-colony stimulating factor (G-CSF) administered early after HCT may increase ATG-mediated lymphotoxicity. This study aimed to investigate the effect of an interaction between ATG and post-transplantation granulocyte colony-stimulating factor (G-CSF) on allogeneic HCT outcomes, using the Center for International Blood and Marrow Transplant Research (CIBMTR) registry. We studied patients age ≥18 years with acute myelogenous leukemia (AML) and myelodysplastic syndrome (MDS) who received Thymoglobulin-containing preparative regimens for HLA-matched sibling/unrelated or mismatched unrelated donor HCT between 2010 and 2018. The effect of planned G-CSF that was started between pretransplantation day 3 and post-transplantation day 12 was studied in comparison with transplantations that did not include G-CSF. Cox regression models were built to identify risk factors associated with outcomes at 1 year after transplantation. A total of 874 patients met the study eligibility criteria, of whom 459 (53%) received planned G-CSF. HCT with planned G-CSF was associated with a significantly increased risk for nonrelapse mortality (NRM) (hazard ratio [HR] 2.03; P <.0001; 21% versus 12%) compared to HCT without G-CSF. The 6-month incidence of viral infection was higher with G-CSF (56% versus 47%; P = .007), with a particular increase in Epstein-Barr virus infections (19% versus 11%; P = .002). The observed higher NRM with planned G-CSF led to lower overall survival (HR, 1.52; P = .0005; 61% versus 72%). There was no difference in GVHD risk between the treatment groups. We performed 2 subgroup analyses showing that our findings held true in patients age ≥50 years and in centers where G-CSF was used in some, but not all, patients. In allogeneic peripheral blood HCT performed with Thymoglobulin for AML and MDS, G-CSF administered early post-transplantation resulted in a 2-fold increase in NRM and a 10% absolute decrement in survival. The use of planned G-CSF in the early post-transplantation period should be carefully considered on an individual patient basis, weighing any perceived benefits against these risks.
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Affiliation(s)
- Nina Orfali
- Haematology Department, St. James's Hospital, Dublin, Ireland; Department of Medicine, Weill Cornell Medicine, New York, New York.
| | - Mei-Jie Zhang
- Division of Biostatistics, Institute for Heath and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Mariam Allbee-Johnson
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jaap Jan Boelens
- Pediatric Transplantation and Cellular Therapy Division, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrew S Artz
- Department of Hematology & Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Claudio G Brunstein
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Ian K McNiece
- Stem Cell Transplantation and Cellular Therapy Clinical Laboratory, MD Anderson Cancer Center, Houston, Texas
| | - Filippo Milano
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Muhammad Bilal Abid
- Division of Infectious Diseases, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Lynette Chee
- Haematology Department, Peter MacCallum Cancer Centre, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Miguel A Diaz
- Pediatric Haematology Division, Hospital Infantil Universitario "Niño Jesus" Madrid, Spain
| | - Michael R Grunwald
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Peiman Hematti
- Division of Hematology, Medical Oncology and Palliative Care, University of Wisconsin, Madison, Wisconsin
| | - Jingmei Hsu
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Hillard M Lazarus
- Department of Hematologic Oncology, Case Western Reserve University, Cleveland, Ohio
| | - Pashna N Munshi
- Stem Cell Transplant and Cellular Immunotherapy division, MedStar Georgetown University Hospital, Washington, DC
| | - Timothy Prestidge
- Blood and Cancer Centre, Starship Hospital, University of Auckland, Auckland, New Zealand
| | - Olle Ringden
- Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - David Rizzieri
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Marcie L Riches
- Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Sachiko Seo
- Department of Hematology and Oncology, Dokkyo Medical University, Tochigi, Japan
| | - Melhem Solh
- Blood and Marrow Transplant Program, Northside Hospital, Atlanta, Georgia
| | - Scott Solomon
- Blood and Marrow Transplant Program, Northside Hospital, Atlanta, Georgia
| | - David Szwajcer
- Department of Hematology and Oncology, Cancer Care Manitoba, Winnipeg, Manitoba, Canada
| | - Jean Yared
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Koen van Besien
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Mary Eapen
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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13
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Yang X, Li D, Xie Y. Anti-Thymocyte Globulin Prophylaxis in Patients With Hematological Malignancies Undergoing Allogeneic Hematopoietic Stem Cell Transplantation: An Updated Meta-Analysis. Front Oncol 2021; 11:717678. [PMID: 34490116 PMCID: PMC8417733 DOI: 10.3389/fonc.2021.717678] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 07/29/2021] [Indexed: 11/13/2022] Open
Abstract
Background Anti-thymocyte globulin (ATG) prophylaxis reduces graft-versus-host disease (GVHD) incidence. This meta-analysis aimed to explore the long-term efficacy of ATG and the influencing factors in patients undergoing allogeneic hematopoietic stem cell transplantation (allo-HSCT). Methods PubMed, Embase, and Cochrane databases were searched for the relevant studies published up to August 2020. Data from randomized controlled trials (RCTs) on ATG prophylaxis for GVHD prevention in allo-HSCT patients were extracted. Results A total of eight relevant RCTs (1,348 patients) were included. ATG significantly reduced the incidence of grade III–IV aGVHD (P = 0.001) and cGVHD (P < 0.001). ATG significantly improved the GVHD relapse-free survival (GRFS) (P < 0.001). The immunosuppressive regimen (number and dose of immunosuppressants) was significantly reduced when using ATG (P = 0.005). Epstein-Barr virus (EBV) reactivation was high in patients receiving ATG (P = 0.003). No significant differences were detected in relapses, overall survival (OS), relapse-free survival (RFS), and non-relapse mortality (NRM) between the ATG and no ATG groups. Subgroup analyses revealed that the donor type and ATG formulation might be the possible sources of heterogeneity among the included studies. Meta-regression analysis showed that the cumulative dose of ATG did not affect GVHD, OS, relapse, RFS, and NRM. Conclusion Although ATG had no significant effect on relapse, RFS, and NRM, it significantly reduced the occurrence and severity of GVHD, improved the GRFS, and reduced the number and dose of immunosuppressants in patients undergoing allo-HSCT.
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Affiliation(s)
- Xue Yang
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Dongjun Li
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Yao Xie
- Department of Obstetrics and Gynaecology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China.,Chinese Academy of Sciences, Sichuan Translational Medicine Research Hospital, Chengdu, China
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14
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Scheinberg P. Acquired severe aplastic anaemia: how medical therapy evolved in the 20th and 21st centuries. Br J Haematol 2021; 194:954-969. [PMID: 33855695 DOI: 10.1111/bjh.17403] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 02/16/2021] [Indexed: 11/28/2022]
Abstract
The progress in aplastic anaemia (AA) management is one of success. Once an obscure entity resulting in death in most affected can now be successfully treated with either haematopoietic stem cell transplantation (HSCT) or immunosuppressive therapy (IST). The mechanisms that underly the diminution of haematopoietic stem cells (HSCs) are now better elucidated, and include genetics and immunological alterations. Advances in supportive care with better antimicrobials, safer blood products and iron chelation have greatly impacted AA outcomes. Working somewhat 'mysteriously', anti-thymocyte globulin (ATG) forms the base for both HSCT and IST protocols. Efforts to augment immunosuppression potency have not, unfortunately, led to better outcomes. Stimulating HSCs, an often-sought approach, has not been effective historically. The thrombopoietin receptor agonists (Tpo-RA) have been effective in stimulating early HSCs in AA despite the high endogenous Tpo levels. Dosing, timing and best combinations with Tpo-RAs are being defined to improve HSCs expansion in AA with minimal added toxicity. The more comprehensive access and advances in HSCT and IST protocols are likely to benefit AA patients worldwide. The focus of this review will be on the medical treatment advances in AA.
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Affiliation(s)
- Phillip Scheinberg
- Division of Haematology, Hospital A Beneficência Portuguesa, São Paulo, Brazil
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15
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Gagelmann N, Wolschke C, Klyuchnikov E, Christopeit M, Ayuk F, Kröger N. TKI Maintenance After Stem-Cell Transplantation for FLT3-ITD Positive Acute Myeloid Leukemia: A Systematic Review and Meta-Analysis. Front Immunol 2021; 12:630429. [PMID: 33790903 PMCID: PMC8006462 DOI: 10.3389/fimmu.2021.630429] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 02/22/2021] [Indexed: 12/20/2022] Open
Abstract
This analysis aimed to systematically review and synthesize the existing evidence regarding the outcome of tyrosine kinase inhibitor (TKI) maintenance therapy after allogeneic stem-cell transplantation for patients with FLT3-ITD-mutated acute myeloid leukemia (AML). We searched publicly available databases, references lists of relevant reviews, registered trials, and relevant conference proceedings. A total of 7 studies comprising 680 patients were included. Five studies evaluated sorafenib and 2 studies evaluated midostaurin, compared with control. The incidence of relapse was significantly reduced after TKI therapy, showing an overall pooled risk ratio (RR) of 0.35 (95% confidence interval [CI], 0.23-0.51; P < 0.001), with a marked 65% reduced risk for relapse. The overall pooled RR for relapse-free survival and overall survival showed significantly improved outcome after TKI maintenance therapy, being 0.48 (95% CI, 0.37–0.61; P < 0.001) and 0.48 (95% CI, 0.36–0.64; P < 0.001). The risk for relapse or death from any cause was reduced by 52% using TKI. No difference in outcome was seen for non-relapse mortality, and the risk for chronic or acute graft-vs. -host disease appeared to be increased, at least for sorafenib. In conclusion, post-transplant maintenance therapy with TKI was associated with significantly improved outcome in relapse and survival in patients with FLT3-ITD positive AML.
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Affiliation(s)
- Nico Gagelmann
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christine Wolschke
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Evgeny Klyuchnikov
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maximilian Christopeit
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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16
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Dou L, Wang L, Li X, Liu Y, Li F, Wang L, Gao X, Huang W, Wang S, Gao C, Yu L, Liu D. Role of antithymocyte globulin in matched sibling donor peripheral blood stem cell transplantation for hematologic malignancies. Medicine (Baltimore) 2021; 100:e24725. [PMID: 33663084 PMCID: PMC7909208 DOI: 10.1097/md.0000000000024725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 01/19/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND High incidence of chronic graft-versus-host disease (GVHD) has been a major drawback of matched sibling donor peripheral blood stem cell transplantation (MSD -PBSCT). This study aimed to investigate the safety and efficacy of antithymocyte globulin (ATG) as a standardized part of GVHD prophylaxis in patients receiving MSD -PBSCT. METHODS A total of 72 patients with hematological malignancies receiving MSD -PBSCT who displayed similar baseline characteristics were either given rabbit ATG ( n = 42) or no ATG (n = 30), in addition to cyclosporine, methotrexate, and mycophenolate mofetil as a standard GVHD prophylaxis regimen. Either patients or donors aged ≥40 years were included in the study. Thymoglobulin was administered at a daily dose of 1.5 mg/kg on day -5 and 3.5 mg/kg on day -4 prior to transplant (the total dose was 5 mg/kg). RESULTS After a median follow-up of 874 days, the 3-year cumulative incidence of chronic GVHD (cGVHD) was 37.3% in the ATG group and 52.1% in the non -ATG group. The 3-year overall and disease-free survival probability were 71.0% and 62.0% (ATG versus non -ATG, P = .262) and 66.7% and 58.4% (ATG versus non -ATG, P = .334). No difference was found in the 2-year cumulative incidence of nonrelapse mortality and relapse between the ATG and non -ATG groups. This significant reduction in the incidence of cGVHD without increased relapse risk and nonrelapse mortality led to a 3-year GVHD-free, relapse-free survival probability of 66.7% and 40.0% in the ATG and non-ATG groups, respectively. CONCLUSIONS These data suggested that rabbit antithymocyte globulin in the current protocol for GVHD prophylaxis was well tolerable and efficacious.The clinical trial was registered on January 1, 2016 (ClinicalTrials.gov Identifier NCT02677181). https://clinicaltrials.gov/ct2/show/NCT02677181.
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Affiliation(s)
| | | | - Xin Li
- Department of Quality Control, Chinese PLA General Hospital, Beijing, China
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17
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Kröger N. Preventing Graft-Versus-Host Disease Without Losing Graft-Versus-Leukemia Effect After Allogeneic Stem-Cell Transplantation. J Clin Oncol 2020; 38:3357-3360. [PMID: 32706637 DOI: 10.1200/jco.20.01756] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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18
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Impact of antithymocyte globulin on outcomes of allogeneic hematopoietic cell transplantation with TBI. Blood Adv 2020; 3:1950-1960. [PMID: 31262738 DOI: 10.1182/bloodadvances.2019000030] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 03/26/2019] [Indexed: 12/31/2022] Open
Abstract
The impact of the use of antithymocyte globulin (ATG) following a total body irradiation (TBI)-based myeloablative conditioning regimen has been poorly explored. We retrospectively analyzed 724 patients who underwent a first allogeneic hematopoietic cell transplantation (allo-HCT) following a TBI-based conditioning regimen for acute myeloid leukemia (AML) and compared the outcomes of 251 (35%) patients who received ATG (ATG group) with 473 (65%) patients who did not (non-ATG group). Median follow-up of surviving patients was 59 months (interquartile range, 28-83). The cumulative incidence of grade II-IV acute graft-versus-host disease (aGVHD) for non-ATG and ATG groups in the first 100 days was 33% vs 24%, respectively (P = .0098). The 2-year cumulative incidence of chronic graft-versus-host disease (cGVHD) was reduced significantly in the ATG group in comparison with the non-ATG group (46% vs 34%, P = .003). Using multivariate analysis, in vivo T-cell depletion (ATG group) was independently associated with a decreased incidence of grade II-IV aGVHD (hazard ratio [HR], 0.28; P < .001), grade III-IV aGVHD (HR, 0.21; P < .001), cGVHD (HR, 0.63; P = .02), and nonrelapse mortality (NRM) (HR, 0.54; P = .02). Relapse risk, overall survival, and leukemia-free survival were similar between the 2 groups. Our results suggest that the addition of ATG to TBI-based myeloablative conditioning for allo-HCT in AML patients results in a significant reduction in aGVHD and cGVHD, translating into a significant reduction in NRM without increasing the relapse rate.
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19
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Bonifazi F, Rubio MT, Bacigalupo A, Boelens JJ, Finke J, Greinix H, Mohty M, Nagler A, Passweg J, Rambaldi A, Socie G, Solano C, Walker I, Barosi G, Kröger N. Rabbit ATG/ATLG in preventing graft-versus-host disease after allogeneic stem cell transplantation: consensus-based recommendations by an international expert panel. Bone Marrow Transplant 2020; 55:1093-1102. [PMID: 31969678 PMCID: PMC7269907 DOI: 10.1038/s41409-020-0792-x] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 12/04/2019] [Accepted: 01/13/2020] [Indexed: 11/26/2022]
Abstract
This collaborative initiative aimed to provide recommendations on the use of polyclonal antithymocyte globulin (ATG) or anti-T lymphocyte globulin (ATLG) for the prevention of graft-versus-host disease (GvHD) after allogeneic hematopoietic stem cell transplantation (HSCT). A comprehensive review of articles released up to October, 2018 was performed as a source of scientific evidence. Fourteen clinically relevant key questions to the domains indication, administration, and post-transplant management were developed and recommendations were produced using the Delphi technique involving a Panel of 14 experts. ATG/ATLG was strongly recommended as part of myeloablative conditioning regimen prior to matched or mismatched unrelated bone marrow or peripheral blood allogeneic HSCT in malignant diseases to prevent severe acute and chronic GvHD. ATG/ATLG was also recommended prior to HLA-identical sibling peripheral HSCT with good but lesser bulk of evidence. In reduced intensity or nonmyeloablative conditioning regimens, ATG/ATLG was deemed appropriate to reduce the incidence of acute and chronic GvHD, but a higher risk of relapse should be taken into account. Recommendations regarding dose, application, and premedication were also provided as well as post-transplant infectious prophylaxis and vaccination. Overall, these recommendations can be used for a proper and safe application of polyclonal ATG/ATLG to prevent GvHD after allogeneic HSCT.
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Affiliation(s)
- Francesca Bonifazi
- Institute of Hematology "Seragnoli", University Hospital "S. Orsola Malpighi", Bologna, Italy.
| | - Marie-Thérèse Rubio
- Department of Hematology, Hôpital Brabois, CHRU Nancy and CNRS UMR 7365, Biopole del'Université del Lorraine, Vendoeuvre les Nancy, France
| | - Andrea Bacigalupo
- "Fondazione Policlinico Universitario A. Gemelli IRCCS", Rome, Italy
- Institute of Hematology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Jaap Jan Boelens
- Stem Cell Transplantation and Cellular Therapies, MSK Kids, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jürgen Finke
- Freiburg University Medical Faculty and Medical Center, Department for Medicine, Hematology, Oncology and Stem Cell Transplantation, Freiburg, Germany
| | - Hildegard Greinix
- Division of Hematology, Medical University of Graz, Auenbruggerplatz 38, 8036, Graz, Austria
| | - Mohamad Mohty
- Service d'Hématologie clinique et Thérapie cellulaire, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne University, INSERM UMRs 938, Paris, France
| | - Arnon Nagler
- Hematology Division, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Jakob Passweg
- Division of Hematology, Department of Medicine, University Hospital Basel, Basel, Switzerland
| | - Alessandro Rambaldi
- Department of Oncology, University of Milano and Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Gérard Socie
- Service d' Hématologie-greffe, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Université Paris Diderot, Inserm UMR 976, Paris, France
| | - Carlos Solano
- Hematology Service, Hospital Clínico Universitario-INCLIVA; Department of Medicine, School of Medicine, University of Valencia, Valencia, Spain
| | - Irwin Walker
- Department of Medicine, McMaster University, Hamilton, ON, Canada
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20
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Bucher C, Halter J, Passweg J. Addition of anti-thymocyte globulin to standard graft-versus-host disease prophylaxis. Lancet Haematol 2020; 7:e364. [PMID: 32359449 DOI: 10.1016/s2352-3026(20)30040-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 02/04/2020] [Indexed: 06/11/2023]
Affiliation(s)
- Christoph Bucher
- Department of hematology, University Hospital Basel, Basel 4032, Switzerland.
| | - Joerg Halter
- Department of hematology, University Hospital Basel, Basel 4032, Switzerland
| | - Jakob Passweg
- Department of hematology, University Hospital Basel, Basel 4032, Switzerland
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21
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Kawamura K, Kanda J, Ohashi K, Fukuda T, Iwato K, Eto T, Fujiwara SI, Mori T, Fukushima K, Ozawa Y, Uchida N, Ashida T, Ichinohe T, Atsuta Y, Kanda Y. Influence of HLA 1-3-locus mismatch and antithymocyte globulin administration in unrelated bone marrow transplantation. Ann Hematol 2020; 99:1099-1110. [PMID: 32206853 DOI: 10.1007/s00277-020-03995-7] [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: 11/07/2019] [Accepted: 03/11/2020] [Indexed: 11/24/2022]
Abstract
For patients without an HLA-matched donor, an HLA-mismatched unrelated donor (MMUD) has been considered as an alternative donor in allogeneic hematopoietic cell transplantation (allo-HCT). We conducted a nationwide retrospective study to compare the transplant outcomes among 1-, 2-, and 3-locus (allele/antigen) mismatched unrelated donors (1MMUD n = 2044, 2MMUD n = 492, and 3MMUD n = 73) in allo-HCT and to assess the impact of antithymocyte globulin (ATG) in allo-HCT from 1-3MMUD. 2MMUD and 3MMUD were independent significant adverse factors for grade III-IV acute graft-versus-host disease (GVHD) (hazard ratio [HR] 1.72, p < 0.001 and HR 2.48, p < 0.001), non-relapse mortality (NRM) (HR 1.47, p < 0.001 and HR 2.00, p < 0.001), and overall survival (OS) (HR 1.21, p = 0.0066 and HR 1.60, p = 0.0015). Conversely, the use of ATG was an independent favorable factor for grade III-IV acute GVHD (HR 0.43, p < 0.001), NRM (HR 0.51, p < 0.001), and OS (HR 0.74, p = 0.0012). On the other hand, HLA compatibility and the use of ATG were not associated with a risk of relapse. An interaction test between the number of HLA mismatches and the use of ATG revealed that the effect of ATG on NRM and OS in the 2MMUD group was significantly less than that in the 1MMUD group (HR 1.53, p = 0.036 and HR 2.34, p = 0.0046). This study indicated that the number of HLA mismatches and the use of ATG were significantly associated with not only GVHD, but also NRM and OS. Whereas the use of ATG could improve transplant outcomes in allo-HCT from 1MMUD, its effectiveness with 2MMUD and 3MMUD was limited.
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Affiliation(s)
- Koji Kawamura
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847, Amanuma-cho, Omiya-ku, Saitama-city, Saitama, 330-8503, Japan
| | - Junya Kanda
- Department of Hematology/Oncology, Kyoto University Hospital, Kyoto, Japan
| | - Kazuteru Ohashi
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Takahiro Fukuda
- Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Koji Iwato
- Department of Blood Transfusion, Hiroshima Red Cross and Atomic Bomb Survivors Hospital, Hiroshima, Japan
| | - Tetsuya Eto
- Department of Hematology, Hamanomachi Hospital, Fukuoka, Japan
| | - Shin-Ichiro Fujiwara
- Division of Hematology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Takehiko Mori
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Kentaro Fukushima
- Department of Hematology and Oncology, Osaka University Hospital, Suita, Japan
| | - Yukiyasu Ozawa
- Department of Hematology, Japanese Red Cross Nagoya First Hospital, Nagoya, Japan
| | - Naoyuki Uchida
- Department of Hematology, Toranomon Hospital, Tokyo, Japan
| | - Takashi Ashida
- Division of Hematology and Rheumatology, Department of Internal Medicine, Kindai University Faculty of Medicine, Osakasayama, Japan
| | - Tatsuo Ichinohe
- Department of Hematology and Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Yoshiko Atsuta
- Japanese Data Center for Hematopoietic Cell Transplantation, Nagoya, Japan.,Department of Healthcare Administration, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshinobu Kanda
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847, Amanuma-cho, Omiya-ku, Saitama-city, Saitama, 330-8503, Japan. .,Division of Hematology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan.
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22
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Nagler A, Dholaria B, Labopin M, Socie G, Huynh A, Itälä-Remes M, Deconinck E, Yakoub-Agha I, Cahn JY, Bourhis JH, Labussière-Wallet H, Chantepie S, Esteve J, Savani B, Mohty M. The impact of anti-thymocyte globulin on the outcomes of Patients with AML with or without measurable residual disease at the time of allogeneic hematopoietic cell transplantation. Leukemia 2019; 34:1144-1153. [PMID: 31728052 DOI: 10.1038/s41375-019-0631-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 10/14/2019] [Accepted: 11/03/2019] [Indexed: 02/03/2023]
Abstract
Measurable residual disease (MRD) status pre-allogeneic hematopoietic cell transplantation (allo-HCT) has been shown to predict transplant outcomes. We investigated the effect of Anti-Thymocyte Globulin (ATG) on acute myelogenous leukemia (AML) relapse by pretransplant MRD status. AML patients undergoing allo-HCT in first complete remission from either a matched sibling or unrelated donor during the 2006-2017 period were selected. Outcomes of 1509 patients (MRD+, n = 426) were studied. ATG was used in 561 (52%) and 239 (58%) patients within the MRD- and MRD+ cohorts, respectively. In MRD- patients, ATG did not affect relapse incidence (RI) (HR = 0.80, p = 0.17), but was associated with reduced incidence of grade II-IV acute GVHD, grade II-IV and chronic GVHD, reduced nonrelapse mortality (HR = 0.66, p = 0.05), improved leukemia-free survival (HR = 0.74, p = 0.02), overall survival (HR = 0.69, p = 0.01), and GVHD-relapse free survival (HR = 0.62, p < 0.01). In MRD+ patients, ATG was associated with a lower incidence of chronic GVHD (total, HR 0.56 p = 0.03; extensive, HR 0.40 P = 0.01), without an impact on other allo-HCT outcome parameters, including RI(HR = 1.02, p = 0.92). The use of ATG was associated with reduced risk for GVHD. ATG did not increase RI, even in high-risk AML patients who were MRD+ before allo-HCT.
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Affiliation(s)
- Arnon Nagler
- Hematology Department, Chaim Sheba Medical Center, Tel Hashomer, Israel.,Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, AP-HP, Sorobonne University, and INSERM UMRs 938, Paris, France
| | - Bhagirathbhai Dholaria
- Department of Hematology-Oncology, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Myriam Labopin
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, AP-HP, Sorobonne University, and INSERM UMRs 938, Paris, France
| | - Gerard Socie
- Bone Marrow Transplantation Department, CHU Saint-Louis, Paris, France
| | - Anne Huynh
- Oncopole, Institut Universitaire du Cancer Toulouse, Toulouse, France
| | - Maija Itälä-Remes
- Stem Cell Transplantation Unit, HUCH Comprehensive Cancer Center, Helsinki, Finland
| | - Eric Deconinck
- Service d'Hématologie, CHU Besançon, Besançon, France.,Inserm UMR 1098, Besançon, France
| | | | - Jean-Yves Cahn
- Service d'Hématologie, CHU Grenoble Alpes-Université Grenoble Alpes, Grenoble, France
| | - Jean-Henri Bourhis
- Division of Hematology, Department of Medical Oncology, Gustave Roussy, institut de cancérologie, BMT Service, Villejuif, France
| | - Hélène Labussière-Wallet
- Service Hématologie, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Pierre Bénite, Lyon, France
| | | | - Jordi Esteve
- Hematology department, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Bipin Savani
- Department of Hematology-Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - 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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23
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Effect of plasmapheresis on ATG (Thymoglobulin) clearance prior to adoptive T cell transfer. Bone Marrow Transplant 2019; 54:2110-2116. [PMID: 30890771 DOI: 10.1038/s41409-019-0505-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 02/06/2019] [Accepted: 03/02/2019] [Indexed: 01/01/2023]
Abstract
The effect of anti-thymocyte globulin (ATG) on the outcome of hematopoietic stem cell transplantation (SCT) is dependent on formulation, dose and exposure. However, ATG levels are not routinely measured and therapeutic levels are not well defined. In ex vivo T cell-deplete SCT, the potential effect of residual ATG has important implications on the timing of adoptive T cell transfer. Here we measured active rabbit ATG concentration using a flow cytometry-based method that can be implemented in any laboratory. Three adult patients received 6 mg/kg Thymoglobulin over 4 days, leading to peak plasma active ATG concentration of 20.8 ± 1.4 µg/mL, suggesting volume of distribution of 16-19 L. The half-life of active ATG was 6.1 ± 0.7 days and plasmapheresis at Day 25 ± 1 post-transplant reduced mean plasma concentration from 1.25 to 0.61 µg/mL. Total ATG and active ATG do not have a constant relationship because of differences in volumes of distribution and half-lives. Thymoglobulin can mediate antibody-dependent cell-mediated cytotoxicity (ADCC) in vitro at concentrations as low as 0.03 µg/mL, with a log-linear relationship between ATG concentration and ADCC. Plasmapheresis can remove ATG but likely has modest biological impact when performed 4 weeks after 6 mg/kg ATG.
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24
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Effect of antithymocyte globulin on HLA-mismatched unrelated transplantation. Int J Hematol 2019; 110:22-29. [DOI: 10.1007/s12185-019-02597-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 12/28/2018] [Accepted: 01/16/2019] [Indexed: 10/27/2022]
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25
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Gagelmann N, Eikema DJ, Stelljes M, Beelen D, de Wreede L, Mufti G, Knelange NS, Niederwieser D, Friis LS, Ehninger G, Nagler A, Yakoub-Agha I, Meijer E, Ljungman P, Maertens J, Kanz L, Lopez-Corral L, Brecht A, Craddock C, Finke J, Cornelissen JJ, Bernasconi P, Chevallier P, Sierra J, Robin M, Kröger N. Optimized EBMT transplant-specific risk score in myelodysplastic syndromes after allogeneic stem-cell transplantation. Haematologica 2019; 104:929-936. [PMID: 30655377 PMCID: PMC6518902 DOI: 10.3324/haematol.2018.200808] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 01/09/2019] [Indexed: 01/01/2023] Open
Abstract
The aim of this study was to develop and validate a clinical and transplant-specific prognostic score using data from a large cohort of patients with myelodysplastic syndromes reported to the European Society for Blood and Marrow Transplantation registry. A Cox model was fitted to detect clinical and transplant-related variables prognostic of outcome. Then, cross-validation was performed to evaluate the validity and consistency of the model. Seven independent risk factors for survival were identified: age ≥50 years, matched unrelated donor, Karnofsky Performance Status <90%, very poor cytogenetics or monosomal karyotype, positive cytomegalovirus status of the recipient, blood blasts >1%, and platelet count ≤50 × 109/L prior to transplantation. Incorporating these factors into a four-level risk score yielded hazard ratios for death, with low-risk (score of 0-1) as reference, of 2.02 (95% CI: 1.41-2.90) for the intermediate-risk group (score of 2-3), 3.49 (95% CI: 2.45-4.97) for the high-risk group (score of 4-5), and 5.90 (95% CI: 4.01-8.67) for the very high-risk group (score of >5). The score was predictive of survival, relapse-free survival, relapse, and non-relapse mortality (P<0.001, respectively). Cross-validation yielded significant and reproducible improvement in prognostic ability with C-statistics being 0.609 (95% CI: 0.588-0.629) versus 0.555 for the Gruppo Italiano Trapianto di Midollo Osseo registry and 0.579 for the Center for Blood and Marrow Transplant Research registry. Prediction was even further augmented after applying a nomogram using age and platelets as continuous variables showing C-statistics of 0.628 (95% CI: 0.616-0.637). In conclusion, compared to existing prognostic systems, this proposed transplant-specific risk score offers improved performance with respect to post-transplant risk stratification in myelodysplastic syndromes.
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Affiliation(s)
- Nico Gagelmann
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | | | - Dietrich Beelen
- Department of Bone Marrow Transplantation, West German Cancer Center, University Hospital of Essen, Germany
| | | | | | | | | | | | | | - Arnon Nagler
- Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | | | - Ellen Meijer
- VU University Medical Center, Amsterdam, the Netherlands
| | - Per Ljungman
- Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | | | | | | | - Arne Brecht
- Deutsche Klinik für Diagnostik, Wiesbaden, Germany
| | | | | | - Jan J Cornelissen
- Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | | | - Jorge Sierra
- Hospital Santa Creu i Sant Pau, Jose Carreras Leukemia Research Institute, Barcelona, Spain
| | | | - Nicolaus Kröger
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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26
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Kumar A, Reljic T, Hamadani M, Mohty M, Kharfan-Dabaja MA. Antithymocyte globulin for graft-versus-host disease prophylaxis: an updated systematic review and meta-analysis. Bone Marrow Transplant 2018; 54:1094-1106. [PMID: 30446739 DOI: 10.1038/s41409-018-0393-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 10/08/2018] [Accepted: 10/12/2018] [Indexed: 12/11/2022]
Abstract
Graft-versus-host disease (GVHD) remains a limiting factor for successful allogeneic hematopoietic cell transplantation (allo-HCT). Conflicting data exist on the benefit of ATG on post-transplant survival. We performed a systematic review of randomized controlled trials (RCTs) to assess benefits and harms of thymoglobulin and Fresenius (re-branded as Grafalon) ATG formulations in patients undergoing allo-HCT for a variety of hematologic malignancies and bone marrow failure syndromes. A comprehensive search of MEDLINE, EMBASE, and Cochrane Library was performed. Data on methodological quality, benefits, and harms were extracted for each trial and pooled under a random-effects model. Eight RCTs (1134 patients) met the inclusion criteria. Methodological quality ranged from moderate to very low. Pooled results showed no difference in overall survival (OS) with the use of ATG (hazard ratio (HR) = 0.97; 95% confidence interval (CI) = 0.74-1.28; P = 0.83). ATG reduced grade II/III acute GVHD (risk ratio (RR) = 0.61; 95% CI = 0.48-0.77; P < 0.0001), grade III/IV acute GVHD (RR = 0.52; 95% CI = 0.34-0.81; P = 0.004), and chronic GVHD (RR = 0.52; 95% CI = 0.40-0.69; P < 0.00001) without an increase in non-relapse mortality (NRM) (RR = 0.91; 95% CI = 0.74-1.13; P = 0.40). Future studies with better methodological quality are needed to provide conclusive answers related to optimal dosing and timing of ATG for prevention of GVHD.
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Affiliation(s)
- Ambuj Kumar
- Program for Comparative Effectiveness Research, University of South Florida Morsani College of Medicine, Tampa, FL, USA.
| | - Tea Reljic
- Program for Comparative Effectiveness Research, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Mehdi Hamadani
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Mohamad Mohty
- Department of Haematology, Saint Antoine Hospital, University Pierre & Marie Curie and Inserm UMRs938, Paris, France
| | - Mohamed A Kharfan-Dabaja
- Division of Hematology-Oncology, Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL, USA
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27
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Gooptu M, Kim HT, Chen YB, Rybka W, Artz A, Boyer M, Johnston L, McGuirk J, Shea TC, Jagasia M, Shaughnessy PJ, Reynolds CG, Fields M, Alyea EP, Ho VT, Glavin F, Dipersio JF, Westervelt P, Ritz J, Soiffer RJ. Effect of Antihuman T Lymphocyte Globulin on Immune Recovery after Myeloablative Allogeneic Stem Cell Transplantation with Matched Unrelated Donors: Analysis of Immune Reconstitution in a Double-Blind Randomized Controlled Trial. Biol Blood Marrow Transplant 2018; 24:2216-2223. [PMID: 30006305 DOI: 10.1016/j.bbmt.2018.07.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 07/03/2018] [Indexed: 02/06/2023]
Abstract
We recently conducted a randomized double-blind study in which we demonstrated that moderate/severe chronic graft-versus-host disease (cGVHD) but not cGVHD-free survival was reduced in patients receiving anti-T lymphocyte globulin (ATLG) versus placebo. In a companion study we performed immunophenotypic analysis to determine the impact of ATLG on immune reconstitution (IR) and to correlate IR with clinical outcomes. The randomized study (n = 254) included patients (aged 18 to 65 years) who underwent myeloablative transplants for acute myeloid leukemia, myelodysplastic syndrome, or acute lymphoblastic leukemia from HLA-matched unrelated donors. Ninety-one patients consented for the companion IR study (ATLG = 44, placebo = 47). Blood samples were collected on days 30, 100, 180, and 360 after hematopoietic cell transplantation (HCT), and multiparameter flow cytometry was performed in a blinded fashion. Reconstitution of CD3+ and CD4+ T cells was delayed up to 6 months post-HCT in the ATLG arm, whereas absolute regulatory T cell (Treg) (CD4+25+127-) numbers were lower only in the first 100 days. Analysis of the CD4+ Treg and conventional T cells (Tconv) (CD4+25-127+) compartments showed a profound absence of naive Tregs and Tconv in the first 100 days post-HCT, with very slow recovery for 1 year. B cell and natural killer cell recovery were similar in each arm. Higher absolute counts of CD3+, CD4+, CD8+ T, Tregs, and Tconv were associated with improved overall survival, progression-free survival, and nonrelapse mortality but not moderate/severe cGVHD. Although ATLG delays CD3+ and CD4+ T cell recovery post-transplant, it has a relative Treg sparing effect after the early post-HCT period, with possible implications for protection from cGVHD. ATLG severely compromises the generation of naive CD4+ cells (Treg and Tconv), potentially affecting the diversity of the TCR repertoire and T cell responses against malignancy and infection.
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Affiliation(s)
- Mahasweta Gooptu
- Dana-Farber Cancer Institute, Department of Hematologic Malignancies, Boston, Massachusetts USA
| | - Haesook T Kim
- Dana-Farber Cancer Institute, Department of Biostatistics and Computation Biology, Boston, Massachusetts USA
| | - Yi-Bin Chen
- Massachussetts General Hospital Department of Hematology/Oncology, Boston, Massachussetts, USA
| | - Witold Rybka
- Milton Hershey Medical Center, Department of Hematology/Oncology, Hershey, Pennsylvania, USA
| | - Andrew Artz
- University of Chicago, Comprehensive Cancer Center, Chicago, Illinois, USA. University of Utah, Pediatric Hematology/Oncology
| | - Michael Boyer
- Primary Children's Hospital, Salt Lake City, UT, USA
| | | | - Joseph McGuirk
- University of Kansas Medical Center, Department of Hematology/Oncology, Kansas City, Missouri, USA
| | - Thomas C Shea
- University of North Carolina, Chapel Hill, Division of Hematology/Oncology, North Carolina, USA
| | - Madan Jagasia
- Vanderbilt University Medical Center, Department of Hematology/Oncology, Nashville, TN, USA
| | | | - Carol G Reynolds
- Dana-Farber Cancer Institute, Department of Biostatistics and Computation Biology, Boston, Massachusetts USA
| | - Marie Fields
- Dana-Farber Cancer Institute, Department of Biostatistics and Computation Biology, Boston, Massachusetts USA
| | - Edwin P Alyea
- Dana-Farber Cancer Institute, Department of Biostatistics and Computation Biology, Boston, Massachusetts USA
| | - Vincent T Ho
- Dana-Farber Cancer Institute, Department of Biostatistics and Computation Biology, Boston, Massachusetts USA
| | | | - John F Dipersio
- BMT and Leukemia Program, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Peter Westervelt
- BMT and Leukemia Program, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Jerome Ritz
- Dana-Farber Cancer Institute, Department of Biostatistics and Computation Biology, Boston, Massachusetts USA
| | - Robert J Soiffer
- Dana-Farber Cancer Institute, Department of Biostatistics and Computation Biology, Boston, Massachusetts USA
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28
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Gagelmann N, Ljungman P, Styczynski J, Kröger N. Comparative Efficacy and Safety of Different Antiviral Agents for Cytomegalovirus Prophylaxis in Allogeneic Hematopoietic Cell Transplantation: A Systematic Review and Meta-Analysis. Biol Blood Marrow Transplant 2018; 24:2101-2109. [PMID: 29777868 DOI: 10.1016/j.bbmt.2018.05.017] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 05/15/2018] [Indexed: 11/17/2022]
Abstract
Over the past 25 years, several randomized controlled trials have investigated the efficacy of different antiviral agents for cytomegalovirus (CMV) prophylaxis in allogeneic hematopoietic cell transplantation. We performed a systematic literature review, conventional meta-analysis, and network meta-analysis using a random-effects model and risk ratios (RRs) with corresponding 95% confidence intervals (CIs) as effect estimates. Fifteen randomized controlled trials were identified, including 7 different antiviral agents: acyclovir, ganciclovir, maribavir, brincidofovir, letermovir, valacyclovir, and vaccine. Twelve trials used placebo as comparator while 3 trials compared different antiviral agents. We found evidence for CMV disease and infection being significantly reduced by antiviral prophylaxis, with an RR of .66 (95% CI, .48 to .90) and .63 (95% CI, .50 to .79). Across the network, ganciclovir showed the best relative efficacy for CMV disease while letermovir provided first rank of being the best option for CMV infection. The risk for death was not significantly influenced by antiviral prophylaxis in the meta-analysis, with an RR of .92 (95% CI, .78 to 1.08), as well as in the network meta-analysis. In terms of safety, letermovir was at least similar in comparison with placebo and most agents while both letermovir and acyclovir showed significantly reduced risk for serious adverse events compared with ganciclovir, with RRs of .55 (95% CI, .30 to 1.00) for letermovir and .63 (95% CI, .42 to .93) for acyclovir. With a probability of 81%, letermovir appears to be the best option in terms of safety. Future randomized head-to-head comparisons are needed to evaluate the definite efficacy and safety of different prophylactic strategies.
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Affiliation(s)
- Nico Gagelmann
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Per Ljungman
- Department of Cellular Therapy and Allogeneic Stem Cell Transplantation, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Jan Styczynski
- Collegium Medicum, Nicolaus Copernicus University Torun, Bydgoszcz, Poland
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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