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Munshi PN, McCurdy SR. Age barriers in allogeneic hematopoietic cell transplantation: Raising the silver curtain. Am J Hematol 2024; 99:922-937. [PMID: 38414188 DOI: 10.1002/ajh.27228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 12/13/2023] [Accepted: 01/01/2024] [Indexed: 02/29/2024]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) is no longer exclusively for the young. With an aging population, development of non-intensive remission-inducing strategies for hematologic malignancies, and novel graft-versus-host disease-prevention platforms, an older population of patients is pursuing HCT. The evolving population of HCT recipients requires an overhaul in the way we risk-stratify and optimize patients prior to HCT. Here, we review the history and current state of HCT for older adults and propose an assessment and intervention flow to bridge the gaps in today's clinical guidelines.
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Affiliation(s)
- Pashna N Munshi
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Shannon R McCurdy
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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2
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Ali H, Bacigalupo A. 2024 update on allogeneic hematopoietic stem cell transplant for myelofibrosis: A review of current data and applications on risk stratification and management. Am J Hematol 2024; 99:938-945. [PMID: 38450790 DOI: 10.1002/ajh.27274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 02/06/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND Allogeneic hemopoietic stem cell transplantation (HSCT) currently remains the only curative treatment for patients with myelofibrosis (MF). Transplant related mortality (TRM) and relapse, remain two significant complications which need to be addressed. AIMS The aim of this manuscript is to review current available reports on changes which have recently occurred, to improve the outcome of MF patients undergoing an allogeneic HSCT. METHODS Published papers were used to analyze different aspects of allogeneic HSCT. RESULTS Changes and updates are provided on selection of patients, prognostic systems, managing splenomegaly, conditioning regimens, predicting transplant outcome, stem cell sources, stem cell donors, graft versus host disease (GvHD) prophylaxis, patients with blast phase, hematopoietic reconstitution, disease markers, donor chimerism, and treatment of relapse. CONCLUSIONS The review outlines new transplant platforms which are now available for patients with myelofibrosis, together with persisting problems, among which, older age combined with marrow fibrosis and an inflammatory disease. Relapse also requires aggressive monitoring of drivers mutations, and early cellular therapy.
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Affiliation(s)
- Haris Ali
- Divison of Leukemia, Department of Hematology and Hemopoietic Cell Transplantation, City of Hope, Duarte, California, USA
| | - Andrea Bacigalupo
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Roma, Italy
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3
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Harbi S, Brac de la Perriere L, Bouchacourt B, Garciaz S, Pagliardini T, Calmels B, Cecile M, Lefloch AC, Hicheri Y, Hospital MA, Fürst S, Lemarie C, Braticevic C, Legrand F, Bekrieva E, Weiller PJ, Chabannon C, Vey N, Blaise D, Devillier R. Peripheral blood haploidentical hematopoietic cell transplantation for patients aged 70 years and over with acute myeloid leukemia or high-risk myelodysplastic syndrome. Bone Marrow Transplant 2024; 59:101-106. [PMID: 37923831 DOI: 10.1038/s41409-023-02134-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 10/04/2023] [Accepted: 10/17/2023] [Indexed: 11/06/2023]
Abstract
Haploidentical stem cell transplantation (Haplo-SCT) using non-myeloablative conditioning regimen (NMAC) has extended the feasibility of allogeneic transplantation, notably in older patients. However, there is few data specifically focusing on patients aged 70 years and over with AML and MDS. Thus the benefit of transplantation in this population is still debated. Here we report our single center experience of peripheral blood Haplo-SCT with NMAC and post-transplantation cyclophosphamide in AML and MDS patients aged 70 years and over. We analyzed 50 patients (27 AML, 23 MDS) with a median age of 72 years (70-77), 12/50 (24%) with active disease at Haplo-SCT. Cumulative incidence of grade 3-4 acute and moderate or severe chronic GVHD were 6% and 25%, respectively. Non-relapse mortality (NRM) at day +100 was 0%. NRM, relapse, PFS and OS at 3 years were 16%, 18%, 66%, and 69%, respectively. Among patients who were disease free at 2 years post Haplo-SCT, 88% are living without immunosuppressive treatment. Peripheral blood Haplo-SCT is feasible in selected AML/MDS patients over 70 years, without any early NRM. It produces long-term disease control and survival. Thus, age by itself should not be considered as a formal barrier to Haplo-SCT.
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Affiliation(s)
- Samia Harbi
- Hematology Department, Institut Paoli-Calmettes, Marseille, France
| | | | | | - Sylvain Garciaz
- Hematology Department, Institut Paoli-Calmettes, Aix Marseille Univ, CNRS, INSERM, CRCM, Marseille, France
| | | | - Boris Calmels
- Cell Therapy Facility, Institut Paoli-Calmettes, CIC-biotherapy, Marseille, France
| | - Maud Cecile
- Hematology Department, Institut Paoli-Calmettes, Marseille, France
| | - Anne-Charlotte Lefloch
- Hematology Department, Institut Paoli-Calmettes, Aix Marseille Univ, CNRS, INSERM, CRCM, Marseille, France
| | - Yosr Hicheri
- Hematology Department, Institut Paoli-Calmettes, Marseille, France
| | | | - Sabine Fürst
- Hematology Department, Institut Paoli-Calmettes, Marseille, France
| | - Claude Lemarie
- Cell Therapy Facility, Institut Paoli-Calmettes, CIC-biotherapy, Marseille, France
| | | | - Faezeh Legrand
- Hematology Department, Institut Paoli-Calmettes, Marseille, France
| | - Elena Bekrieva
- Hematology Department, Institut Paoli-Calmettes, Marseille, France
| | | | - Christian Chabannon
- Cell Therapy Facility, Institut Paoli-Calmettes, CIC-biotherapy, Marseille, France
| | - Norbert Vey
- Hematology Department, Institut Paoli-Calmettes, Aix Marseille Univ, CNRS, INSERM, CRCM, Marseille, France
| | - Didier Blaise
- Hematology Department, Institut Paoli-Calmettes, Aix Marseille Univ, CNRS, INSERM, CRCM, Marseille, France
| | - Raynier Devillier
- Hematology Department, Institut Paoli-Calmettes, Aix Marseille Univ, CNRS, INSERM, CRCM, Marseille, France.
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4
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Mei M, Palmer J, Tsai NNC, Simpson J, O'Hearn J, Stein A, Forman S, Spielberger R, Cai JL, Htut M, Nakamura R, Al Malki MM, Herrera A, Wong J, Nademanee A. Results of a Phase II Trial of Allogeneic Hematopoietic Stem Cell Transplantation Using 90Y-Ibritumomab Tiuxetan (Zevalin) in Combination With Fludarabine and Melphalan in Patients With High-Risk B-Cell Non-Hodgkin's Lymphoma. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:e268-e276. [PMID: 37301631 PMCID: PMC10524945 DOI: 10.1016/j.clml.2023.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 05/18/2023] [Accepted: 05/19/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Allogeneic hematopoietic stem cell transplantation (alloHCT) is potentially curative for relapsed/refractory (r/r) B-cell non-Hodgkin's lymphoma (B-cell NHL). However, relapse remains a major cause of treatment failure, especially in patients with either positron emission tomography (PET)-positive and/or chemoresistant disease prior to alloHCT. 90Y-ibritumomab tiuxetan (Zevalin) is a radiolabeled anti-CD20 antibody which is a safe and effective therapy in multiple histologic subtypes of B-cell NHL and has also been incorporated in both autologous HCT (autoHCT) and alloHCT conditioning regimens. OBJECTIVES The purpose of this study was to evaluate the efficacy and confirm the safety of the radiolabeled anti-CD20 antibody ibritumomab tiuxetan (Zevalin) combined with the reduced intensity conditioning (RIC) regimen of fludarabine and melphalan (Flu/Mel) in patients with high-risk B-cell NHL. STUDY DESIGN We conducted a phase II trial (NCT00577278) of Zevalin with Flu/Mel in patients with high-risk B-cell NHL. We enrolled 41 patients from October 2007 to April 2014, all of whom had either a fully matched sibling or 8/8 or 7/8 matched unrelated donor (MUD). Patients received 111In-Zevalin (5.0 mCi) on day -21 pre-HCT, followed by 90Y-Zevalin (0.4 mCi/kg) on day -14. Fludarabine (25 mg/m2 daily) was given from days -9 to -5 and melphalan (140 mg/m2) was administered on day -4. All patients received rituximab 250 mg/m2 on day +8 and an additional dose on either day +1 or -21 depending on the baseline rituximab level. Patients with a low rituximab level were given rituximab on days -21 and -15. All patients received tacrolimus/sirolimus (T/S) with or without methotrexate (MTX) for graft-versus-host disease (GVHD) prophylaxis starting on day -3, and stem cells were infused on day 0. RESULTS The 2-year overall survival (OS) and progression-free survival (PFS) for all patients were 63% and 61%, respectively. The incidence of relapse at 2 years was 20%. Nonrelapse mortality (NRM) at day +100 and 1 year were 5% and 12%, respectively. The overall cumulative incidence of grade II-IV and III-IV acute GVHD (aGVHD) were 44% and 15%, respectively. Extensive chronic GVHD (cGVHD) occurred in 44% of patients. On univariate analysis, histology (diffuse large B cell lymphoma (DLBCL) vs. others) was negatively predictive for OS (P = .0013) and PFS (P = .0004), while histology (DLBCL vs. others, P = .0128) predicted for relapse. PET positivity pre-HCT did not correlate with any of the efficacy endpoints. CONCLUSION Addition of Zevalin to Flu/Mel is safe and effective in high-risk NHL and met the prespecific endpoint. Results were suboptimal in patients with DLBCL.
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Affiliation(s)
- Matthew Mei
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA.
| | - Joycelynne Palmer
- Department of Computational and Quantitative Medicine, City of Hope National Medical Center, Duarte, CA
| | - Nicole Ni-Chun Tsai
- Department of Computational and Quantitative Medicine, City of Hope National Medical Center, Duarte, CA
| | - Jennifer Simpson
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - James O'Hearn
- Department of Clinical and Translational Project Development, City of Hope National Medical Center, Duarte, CA
| | - Anthony Stein
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Stephen Forman
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Ricardo Spielberger
- Department of Bone Marrow Transplantation, Southern California Permanente Medical Group, Los Angeles, CA
| | - Ji-Lian Cai
- Department of Bone Marrow Transplantation, Southern California Permanente Medical Group, Los Angeles, CA
| | - Myo Htut
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Ryotaro Nakamura
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Monzr M Al Malki
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Alex Herrera
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Jeffrey Wong
- Department of Radiation Oncology, City of Hope, Duarte, CA
| | - Auayporn Nademanee
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
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Sakatoku K, Kim SW, Okamura H, Kanaya M, Kato K, Yamasaki S, Uchida N, Kobayashi H, Fukuda T, Takayama N, Ishikawa J, Nakazawa H, Sakurai M, Ikeda T, Kondo T, Yoshioka S, Miyamoto T, Kimura T, Ichinohe T, Atsuta Y, Kondo E. Improved survival after single-unit cord blood transplantation using fludarabine and melphalan-based reduced-intensity conditioning for malignant lymphoma: impact of melphalan dose and graft-versus-host disease prophylaxis with mycophenolate mofetil. Ann Hematol 2022; 101:2743-2757. [PMID: 36195679 DOI: 10.1007/s00277-022-04990-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 09/23/2022] [Indexed: 11/01/2022]
Abstract
We evaluated 413 adult patients with lymphoma who underwent unrelated cord blood transplantation (UCBT) with fludarabine and melphalan (FM)-based reduced-intensity conditioning between 2002 and 2017 to investigate longitudinal changes in outcomes and the optimal melphalan dose and graft-versus-host disease (GVHD) prophylaxis regimen. Outcomes were compared between FM80/100 (melphalan dose: 80 or 100 mg/m2) and FM140 (melphalan dose: 140 mg/m2), as well as between calcineurin inhibitor (CNI) plus methotrexate (MTX), CNI plus mycophenolate mofetil (MMF), and CNI alone. The 3-year overall survival (OS) and non-relapse mortality (NRM) rates improved over time (OS: 27% in 2000s vs. 42% in 2010s, p < 0.001; NRM: 43% in 2000s vs. 26% in 2010s, p < 0.001). Multivariable analysis showed that in the 2000s, melphalan dose and GVHD prophylaxis regimen did not affect any outcomes. In the 2010s, FM80/100 (vs. FM140) related to better OS (hazard ratio [HR] 0.62, p = 0.01) and NRM (HR 0.52, p = 0.016). MTX + CNI and CNI alone (vs. CNI + MMF) related to worse OS (CNI + MTX, HR 2.01, p < 0.001; CNI alone, HR 2.65, p < 0.001) and relapse/progression (CNI + MTX, HR 2.40, p < 0.001; CNI alone, HR 2.13, p = 0.023). In recent years, the use of FM80/100 and CNI + MMF significantly reduced the risk of NRM and relapse/progression, respectively, and resulted in better OS after UCBT for lymphoma.
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Affiliation(s)
- Kazuki Sakatoku
- Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Sung-Won Kim
- Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan.
| | - Hiroshi Okamura
- Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Minoru Kanaya
- Department of Cancer Immunology, Institute for Cancer Research, Oslo University Hospital, Oslo, Norway.,Department of Hematology, Hokkaido University Hospital, Sapporo, Japan
| | - Koji Kato
- Hematology, Oncology & Cardiovascular Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Satoshi Yamasaki
- Department of Internal Medicine, Kyushu University Beppu Hospital, Beppu, Japan
| | - Naoyuki Uchida
- Department of Hematology, Federation of National Public Service Personnel Mutual Aid Associations Toranomon Hospital, Tokyo, Japan
| | - Hikaru Kobayashi
- Department of Hematology, Nagano Red Cross Hospital, Nagano, Japan
| | - Takahiro Fukuda
- Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Nobuyuki Takayama
- Department of Hematology, Kyorin University Faculty of Medicine, Tokyo, Japan
| | - Jun Ishikawa
- Department of Hematology, Osaka International Cancer Institute, Osaka, Japan
| | - Hideyuki Nakazawa
- Department of Hematology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Masatoshi Sakurai
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Takashi Ikeda
- Division of Hematology and Stem Cell Transplantation, Shizuoka Cancer Center, Shizuoka, Japan
| | - Tadakazu Kondo
- Department of Hematology, Kyoto University Hospital, Kyoto, Japan
| | - Satoshi Yoshioka
- Department of Hematology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Toshihiro Miyamoto
- Hematology, Oncology & Cardiovascular Medicine, Kyushu University Hospital, Fukuoka, 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
- 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
| | - Eisei Kondo
- Department of Hematology, Kawasaki Medical School, Kurashiki, Japan
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6
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Sockel K, Stölzel F, Hönl F, Baldauf H, Röllig C, Wermke M, von Bonin M, Teipel R, Link-Rachner C, Brandt K, Kroschinsky F, Hänel M, Morgner A, Klesse C, Ehninger G, Platzbecker U, Bornhäuser M, Schetelig J, Middeke JM. Allogeneic Stem Cell Transplantation with Sequential Melphalan-Based Conditioning in AML: Residual Morphological Blast Count Determines the Risk of Relapse. Cancer Manag Res 2022; 14:547-559. [PMID: 35210852 PMCID: PMC8857952 DOI: 10.2147/cmar.s339846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 12/23/2021] [Indexed: 11/29/2022] Open
Abstract
Introduction Allogeneic hematopoietic cell transplantation (HCT) during chemotherapy-induced aplasia may offer long-term survival in acute myeloid leukemia (AML) with otherwise poor prognosis including ELN adverse risk, relapsed or refractory disease. However, the value of residual morphologic disease prior HCT in this context has not been conclusively settled until yet. Therefore, we aimed to investigate variables predicting outcome in this unique setting of sequential conditioning therapy, with a focus on pretreatment morphologic blast count. In contrast to the most popular FLAMSA-RIC protocol, we used a melphalan-based conditioning regimen during aplasia. Methods We retrospectively analyzed data from 173 AML patients who underwent a sequential melphalan-based conditioning therapy between 2003 and 2015 at our centre. All patients participated either in the prospective Phase 2 BRIDGE trial (NCT01295307), the Phase 3 AML2003 study (NCT00180102) or were treated according to this protocol and underwent allogeneic HCT after melphalan-based conditioning in treatment-induced aplasia. Results Median bone marrow blast count prior to conditioning was 10% (range, 0–96%). Four year probabilities of EFS and OS were 34% (95% CI, 28–43%) and 43% (95% CI, 36–52%), respectively. In multivariate analysis, blast count >20% was associated with worse EFS (HR = 1.93; p = 0.009) and OS (HR = 1.80; p = 0.026). This effect was not significant anymore for HCT during 1st line therapy. Conclusion Allogeneic HCT in aplasia with a melphalan-based conditioning regimen has the potential to cure a subset of adverse risk AML patients, even with persistent morphological disease prior HCT. However, a high pre-transplant blast count still indicates patients with a dismal prognosis, especially in the relapsed patient group, for whom post-transplant strategies should be considered to further optimize post HCT outcome.
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Affiliation(s)
- Katja Sockel
- Medical Clinic and Policlinic I, University Hospital Carl Gustav Carus and Medical Faculty of the TU Dresden, Dresden, Germany
| | - Friedrich Stölzel
- Medical Clinic and Policlinic I, University Hospital Carl Gustav Carus and Medical Faculty of the TU Dresden, Dresden, Germany
| | - Franziska Hönl
- Medical Clinic and Policlinic I, University Hospital Carl Gustav Carus and Medical Faculty of the TU Dresden, Dresden, Germany
| | | | - Christoph Röllig
- Medical Clinic and Policlinic I, University Hospital Carl Gustav Carus and Medical Faculty of the TU Dresden, Dresden, Germany
| | - Martin Wermke
- Medical Clinic and Policlinic I, University Hospital Carl Gustav Carus and Medical Faculty of the TU Dresden, Dresden, Germany
| | - Malte von Bonin
- Medical Clinic and Policlinic I, University Hospital Carl Gustav Carus and Medical Faculty of the TU Dresden, Dresden, Germany
| | - Raphael Teipel
- Medical Clinic and Policlinic I, University Hospital Carl Gustav Carus and Medical Faculty of the TU Dresden, Dresden, Germany
| | - Cornelia Link-Rachner
- Medical Clinic and Policlinic I, University Hospital Carl Gustav Carus and Medical Faculty of the TU Dresden, Dresden, Germany
| | - Kalina Brandt
- Medical Clinic and Policlinic I, University Hospital Carl Gustav Carus and Medical Faculty of the TU Dresden, Dresden, Germany
| | - Frank Kroschinsky
- Medical Clinic and Policlinic I, University Hospital Carl Gustav Carus and Medical Faculty of the TU Dresden, Dresden, Germany
| | - Mathias Hänel
- Department of Medicine III, Chemnitz Hospital, Chemnitz, Germany
| | - Anke Morgner
- Department of Medicine III, Chemnitz Hospital, Chemnitz, Germany
| | | | - Gerhard Ehninger
- Medical Clinic and Policlinic I, University Hospital Carl Gustav Carus and Medical Faculty of the TU Dresden, Dresden, Germany
| | - Uwe Platzbecker
- Department of Hematology, Cellular Therapy and Hemostaseology, Leipzig University Hospital, Leipzig, Germany
| | - Martin Bornhäuser
- Medical Clinic and Policlinic I, University Hospital Carl Gustav Carus and Medical Faculty of the TU Dresden, Dresden, Germany
| | - Johannes Schetelig
- Medical Clinic and Policlinic I, University Hospital Carl Gustav Carus and Medical Faculty of the TU Dresden, Dresden, Germany
- Clinical Trials Unit, DKMS, Dresden, Germany
| | - Jan Moritz Middeke
- Medical Clinic and Policlinic I, University Hospital Carl Gustav Carus and Medical Faculty of the TU Dresden, Dresden, Germany
- Correspondence: Jan Moritz Middeke, Medical Clinic and Policlinic I, University Hospital Carl Gustav Carus and Medical Faculty of the TU Dresden, Fetscherstr. 74, Dresden, 01307, Germany, Tel +49-0351-458-15603, Fax +49-0351-458-4373, Email
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7
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Ali H, Bacigalupo A. 2021 Update on allogeneic hematopoietic stem cell transplant for myelofibrosis: A review of current data and applications on risk stratification and management. Am J Hematol 2021; 96:1532-1538. [PMID: 34536293 PMCID: PMC9293100 DOI: 10.1002/ajh.26349] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/08/2021] [Accepted: 09/11/2021] [Indexed: 12/13/2022]
Abstract
The number of patients with myelofibrosis (MF) undergoing an allogeneic hemopoietic stem cell transplantation (HSCT) is increasing: in the analysis of the European Group for Blood and Marrow Transplantation (EBMT) the number of MF has increased from 515 in 2014 to 748 in 2018 . This reflects the fact that HSCT is currently the only curative treatment, capable of inducing prolonged disease‐free survival. Nevertheless, several problems prevent more patients from undergoing an allogeneic HSCT: we will be discussing indications for HSCT, comorbidities, splenomegaly, older age and disease phase. Donor type and stem cell source are less of a problem. Several transplant platforms exist, including different strategies for graft versus host disease (GvHD) prophylaxis, Age tailored conditioning regimens need to be implemented, to allow older and fragile patients to undergo an allogeneic HSCT.
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Affiliation(s)
- Haris Ali
- Divison of Leukemia, Department of Hematology and Hemopoietic Cell Transplantation City of Hope Duarte California USA
| | - Andrea Bacigalupo
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia Fondazione Policlinico Universitario A. Gemelli IRCCS Rome Italy
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche Università Cattolica del Sacro Cuore Rome Italy
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8
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Rosko AE, Cordoba R, Abel G, Artz A, Loh KP, Klepin HD. Advances in Management for Older Adults With Hematologic Malignancies. J Clin Oncol 2021; 39:2102-2114. [PMID: 34043442 PMCID: PMC8260925 DOI: 10.1200/jco.21.00242] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 02/23/2021] [Accepted: 03/10/2021] [Indexed: 12/11/2022] Open
Affiliation(s)
- Ashley E. Rosko
- Division of Hematology, The Ohio State University, Columbus, OH
| | - Raul Cordoba
- Lymphoma Unit, Department of Hematology, Fundacion Jimenez Diaz University Hospital, Health Research Institute IIS-FJD, Madrid, Spain
| | - Gregory Abel
- Leukemia Program, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Andrew Artz
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA
| | - Kah Poh Loh
- James P. Wilmot Cancer Center, Division of Hematology/Oncology, Department of Medicine, University of Rochester Medical Center, Rochester, NY
| | - Heidi D. Klepin
- Section on Hematology and Oncology, Wake Forest Baptist Health, Winston-Salem, NC
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9
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Foster J, Moore H, Preussler JM, Burns LJ, Umar JH, Glotzbecker B, Johnson S, MacDougall H, Mau LW, Murphy EA, Ustun C, Ferguson SS, Denzen E. Information Needs for Treatment Decision-making of Hematopoietic Cell Transplant Patients 65 Years or Older and Caregivers. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2020; 35:651-660. [PMID: 30877651 DOI: 10.1007/s13187-019-01506-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Hematopoietic cell transplantation (HCT) is a complex and potentially life-threatening treatment option for patients with hematologic malignant and non-malignant diseases. Advances have made HCT a potentially curative treatment option for patients 65 years of age and older (older patients), and patient education resources should be adapted to meet their needs. To better understand the information needs of older patients and their caregivers for HCT treatment decision-making, the National Marrow Donor Program® (NMDP)/Be The Match® conducted a qualitative comprehensive needs assessment. Focus groups, offered in person or by phone, were conducted with older HCT patients and primary caregivers of older HCT patients at three transplant centers in the USA that were selected based on the number of older adults treated and geographic diversity. The one-hour, semi-structured discussions were recorded and transcribed verbatim. The analysis was performed with the NVivo 10 software for identification of conceptual themes. Five telephone and six in person focus groups of patients (n = 35) and caregivers (n = 10) were conducted. Themes that emerged included the following: (1) the need for tailored resources with age-specific recovery expectations; (2) the need for the right amount of information at the right times; and (3) the benefit of peer support. Effective patient education supports learning and treatment decision-making. As HCT increasingly becomes a treatment option for older patients, tailored educational resources are needed. These focus group results can inform and guide the development of new educational resources for older adults with hematologic diseases considering and planning for HCT.
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Affiliation(s)
- Jackie Foster
- National Marrow Donor Program®/Be The Match®, 500 N 5th Street, Minneapolis, MN, 55401-1206, USA.
| | - Heather Moore
- National Marrow Donor Program®/Be The Match®, 500 N 5th Street, Minneapolis, MN, 55401-1206, USA
| | - Jaime M Preussler
- National Marrow Donor Program®/Be The Match®, 500 N 5th Street, Minneapolis, MN, 55401-1206, USA
- Center for International Blood and Marrow Transplant Research, 500 N 5th Street, Minneapolis, MN, 55401-1206, USA
| | - Linda J Burns
- National Marrow Donor Program®/Be The Match®, 500 N 5th Street, Minneapolis, MN, 55401-1206, USA
- Center for International Blood and Marrow Transplant Research, 500 N 5th Street, Minneapolis, MN, 55401-1206, USA
| | - Jenna Hullerman Umar
- National Marrow Donor Program®/Be The Match®, 500 N 5th Street, Minneapolis, MN, 55401-1206, USA
- Center for International Blood and Marrow Transplant Research, 500 N 5th Street, Minneapolis, MN, 55401-1206, USA
| | - Brett Glotzbecker
- Dana Farber Cancer Institute, 400 Brookline Ave, Boston, MA, 02215, USA
| | - Shirley Johnson
- City of Hope Comprehensive Cancer Center, 1500 East Durate Road, Durate, CA, 91010, USA
| | - Hannah MacDougall
- University of Minnesota, 420 Delaware Street SE, Minneapolis, MN, 55455, USA
| | - Lih-Wen Mau
- National Marrow Donor Program®/Be The Match®, 500 N 5th Street, Minneapolis, MN, 55401-1206, USA
- Center for International Blood and Marrow Transplant Research, 500 N 5th Street, Minneapolis, MN, 55401-1206, USA
| | - Elizabeth A Murphy
- National Marrow Donor Program®/Be The Match®, 500 N 5th Street, Minneapolis, MN, 55401-1206, USA
| | - Celalettin Ustun
- University of Minnesota, 420 Delaware Street SE, Minneapolis, MN, 55455, USA
| | - Stacy Stickney Ferguson
- National Marrow Donor Program®/Be The Match®, 500 N 5th Street, Minneapolis, MN, 55401-1206, USA
| | - Ellen Denzen
- National Marrow Donor Program®/Be The Match®, 500 N 5th Street, Minneapolis, MN, 55401-1206, USA
- Center for International Blood and Marrow Transplant Research, 500 N 5th Street, Minneapolis, MN, 55401-1206, USA
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10
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Mei M, Tsai NC, Mokhtari S, Al Malki MM, Ali H, Salhotra A, Sandhu K, Khaled S, Smith E, Snyder D, Marcucci G, Forman SJ, Pullarkat V, Stein A, Aldoss I, Nakamura R. Long-Term Outcomes of Allogeneic Hematopoietic Cell Transplant with Fludarabine and Melphalan Conditioning and Tacrolimus/Sirolimus as Graft-versus-Host Disease Prophylaxis in Patients with Acute Lymphoblastic Leukemia. Biol Blood Marrow Transplant 2020; 26:1425-1432. [PMID: 32416253 DOI: 10.1016/j.bbmt.2020.04.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 04/14/2020] [Accepted: 04/14/2020] [Indexed: 11/30/2022]
Abstract
Acute lymphoblastic leukemia (ALL) is associated with poor survival in older adults, and allogeneic hematopoietic cell transplant (HCT) with reduced-intensity conditioning (RIC) has been an increasingly used strategy in this population. At City of Hope we conducted a retrospective analysis of 72 patients who underwent allogeneic HCT with fludarabine and melphalan (FluMel) as the conditioning regimen between 2005 and 2018, from either a matched sibling or fully matched unrelated donor while in complete remission. Tacrolimus and sirolimus (T/S) were used as graft-versus-host disease (GVHD) prophylaxis. Overall survival and progression-free survival at 4 years post-HCT were 58% and 44%, respectively. The cumulative incidences of relapse/progression and nonrelapse mortality at 4 years were 34% and 22%, respectively. Patients with Philadelphia chromosome-positive (Ph+) ALL had a significantly lower cumulative incidence of relapse/progression (20% versus 48% for patients with Ph-negative status, P = .007). In conclusion, RIC HCT with FluMel conditioning and T/S GVHD prophylaxis was associated with favorable outcomes in patients with Ph+ ALL and should be considered as a viable consolidative therapy for adult patients with ALL.
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Affiliation(s)
- Matthew Mei
- Department of Hematology and HCT, City of Hope, Duarte, California
| | - Ni-Chun Tsai
- Department of Computational Quantitative Medicine/BRI, City of Hope, Duarte, California
| | - Sally Mokhtari
- Department of Clinical Translational Project Development, City of Hope, Duarte, California
| | - Monzr M Al Malki
- Department of Hematology and HCT, City of Hope, Duarte, California
| | - Haris Ali
- Department of Hematology and HCT, City of Hope, Duarte, California
| | | | - Karamjeet Sandhu
- Department of Hematology and HCT, City of Hope, Duarte, California
| | - Samer Khaled
- Department of Hematology and HCT, City of Hope, Duarte, California
| | - Eileen Smith
- Department of Hematology and HCT, City of Hope, Duarte, California
| | - David Snyder
- Department of Hematology and HCT, City of Hope, Duarte, California
| | - Guido Marcucci
- Department of Hematology and HCT, City of Hope, Duarte, California
| | - Stephen J Forman
- Department of Hematology and HCT, City of Hope, Duarte, California
| | - Vinod Pullarkat
- Department of Hematology and HCT, City of Hope, Duarte, California
| | - Anthony Stein
- Department of Hematology and HCT, City of Hope, Duarte, California
| | - Ibrahim Aldoss
- Department of Hematology and HCT, City of Hope, Duarte, California
| | - Ryotaro Nakamura
- Department of Hematology and HCT, City of Hope, Duarte, California; Department of Computational Quantitative Medicine/BRI, City of Hope, Duarte, California.
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11
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Is there an optimal conditioning for older patients with AML receiving allogeneic hematopoietic cell transplantation? Blood 2020; 135:449-452. [PMID: 31826244 PMCID: PMC8212356 DOI: 10.1182/blood.2019003662] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 11/28/2019] [Indexed: 02/03/2023] Open
Abstract
The optimal conditioning regimen for older patients with acute myeloid leukemia (AML) remains unclear. In this study, we compared outcomes of AML patients >60 years of age undergoing allogenic hematopoietic stem cell transplantation at our institution. All 404 consecutively treated patients received 1 of the following conditioning regimens: (1) fludarabine+melphalan 100 mg/m2 (FM100), (2) fludarabine+melphalan 140 mg/m2 (FM140), (3) fludarabine+IV busulfan AUC ≥ 5000/d × 4 d (Bu≥20000), and (4) fludarabine+IV busulfan AUC 4000/d × 4 d (Bu16000). A propensity score analysis (PSA) was used to compare outcomes between these 4 groups. Among the 4 conditioning regimens, the FM100 group had a significantly better long-term survival with 5-year progression-free survival of 49% vs 30%, 34%, and 23%, respectively. The benefit of the FM100 regimen resulted primarily from the lower nonrelapse mortality associated with this regimen, an effect more pronounced in patients with lower performance status. The PSA confirmed that FM100 was associated with better posttransplantation survival, whereas no significant differences were seen between the other regimen groups. In summary, older patients with AML benefited from a reduced-intensity conditioning regimen with lower melphalan doses (FM100), which was associated with better survival, even though it was primarily used in patients who could not receive a more intense conditioning regimen.
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12
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MIPSS70+ v2.0 predicts long-term survival in myelofibrosis after allogeneic HCT with the Flu/Mel conditioning regimen. Blood Adv 2020; 3:83-95. [PMID: 30622146 DOI: 10.1182/bloodadvances.2018026658] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 12/07/2018] [Indexed: 01/14/2023] Open
Abstract
Although allogeneic hematopoietic cell transplantation (allo-HCT) is the only curative treatment for myelofibrosis (MF), data are limited on how molecular markers predict transplantation outcomes. We retrospectively evaluated transplantation outcomes of 110 consecutive MF patients who underwent allo-HCT with a fludarabine/melphalan (Flu/Mel) conditioning regimen at our center and assessed the impact of molecular markers on outcomes based on a 72-gene next-generation sequencing panel and Mutation-Enhanced International Prognostic Scoring System 70+ v2.0 (MIPSS70+ v2.0). With a median follow-up of 63.7 months, the 5-year overall survival (OS) rate was 65% and the nonrelapse mortality (NRM) rate was 17%. In mutational analysis, JAK2 V617F and ASXL1 mutations were the most common. By univariable analysis, higher Dynamic International Prognostic Scoring System scores, unrelated donor type, and very-high-risk cytogenetics were significantly associated with lower OS. Only CBL mutations were significantly associated with lower OS (hazard ratio [HR], 2.64; P = .032) and increased NRM (HR, 3.68; P = .004) after allo-HCT, but CALR, ASXL1, and IDH mutations did not have an impact on transplantation outcomes. Patient classification per MIPSS70 showed worse OS for high-risk (HR, 0.49; P = .039) compared with intermediate-risk patients. Classification per MIPSS70+ v2.0 demonstrated better OS when intermediate-risk patients were compared with high-risk patients (HR, 0.291) and much lower OS when very-high-risk patients were compared with high-risk patients (HR, 5.05; P ≤ .001). In summary, we present one of the largest single-center experiences of Flu/Mel-based allo-HCT, demonstrating that revised cytogenetic changes and MIPSS70+ v2.0 score predict transplantation outcomes, and thus can better inform physicians and patients in making decisions about allo-HCT.
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13
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Bacigalupo A. Antithymocyte globulin and cyclosporin: standard of care also for older patients with aplastic anemia. Haematologica 2019; 104:215-216. [PMID: 30705112 DOI: 10.3324/haematol.2018.207167] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- Andrea Bacigalupo
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Universita' Cattolica del Sacro Cuore, Rome, Italy
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14
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Srour SA, Saliba RM, Bittencourt MCB, Perez JMR, Kongtim P, Alousi A, Al‐Atrash G, Olson A, Betul O, Mehta R, Popat U, Hosing C, Bashir Q, Khouri I, Kebriaei P, Masarova L, Short N, Jabbour E, Daver N, Konopleva M, Ravandi F, Kantarjian H, Champlin RE, Ciurea SO. Haploidentical transplantation for acute myeloid leukemia patients with minimal/measurable residual disease at transplantation. Am J Hematol 2019; 94:1382-1387. [PMID: 31595538 DOI: 10.1002/ajh.25647] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 09/02/2019] [Accepted: 09/26/2019] [Indexed: 01/09/2023]
Abstract
There have been conflicting results regarding the impact of minimal/measurable disease at transplant on acute myeloid leukemia (AML) outcomes after haploidentical transplantation (haplo-SCT). We assessed the impact of pre-transplant disease status on post-transplant outcomes of 143 patients treated with haplo-SCT using fludarabine-melphalan (FM) conditioning and post-transplant cyclophosphamide (PTCy). With a median follow-up of 29 months, the two-year PFS for all patients was 41%. Compared to patients in complete remission (CR) at transplant, those with active disease (n = 29) and CR with incomplete count recovery (CRi) (n = 39) had worse PFS. They had hazard ratios (HR) of 3.5 (95% CI: 2.05-6.1; P < .001) and 2.3 (95% CI: 1.3-3.9; P = .002), respectively. Among patients who were in CR at transplant, there were no differences in PFS between those who had minimal residual disease (MRD) positive (n = 24), and MRD negative (n = 41) (HR 1.85, 95%CI: 0.9-4.0; P = .1). In multivariable analysis for patients in CR, only age was predictive for outcomes, while MRD status at transplant did not influence the treatment outcomes. Our findings suggest that haplo-SCT with FM conditioning regimen and PTCy-based GVHD prophylaxis has a protective effect, and may potentially abrogate the inferior outcomes of MRD positivity for patients with AML. Patients with positive MRD may benefit from proceeding urgently to a haplo-SCT, as this does not appear to negatively impact transplant outcomes.
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Affiliation(s)
- Samer A. Srour
- Department of Stem Cell Transplantation and Cellular Therapy The University of Texas MD Anderson Cancer Center Houston Texas
| | - Rima M. Saliba
- Department of Stem Cell Transplantation and Cellular Therapy The University of Texas MD Anderson Cancer Center Houston Texas
| | - Maria C. B. Bittencourt
- Department of Stem Cell Transplantation and Cellular Therapy The University of Texas MD Anderson Cancer Center Houston Texas
| | - Jorge M. R. Perez
- Department of Stem Cell Transplantation and Cellular Therapy The University of Texas MD Anderson Cancer Center Houston Texas
| | - Piyanuch Kongtim
- Department of Stem Cell Transplantation and Cellular Therapy The University of Texas MD Anderson Cancer Center Houston Texas
| | - Amin Alousi
- Department of Stem Cell Transplantation and Cellular Therapy The University of Texas MD Anderson Cancer Center Houston Texas
| | - Gheath Al‐Atrash
- Department of Stem Cell Transplantation and Cellular Therapy The University of Texas MD Anderson Cancer Center Houston Texas
| | - Amanda Olson
- Department of Stem Cell Transplantation and Cellular Therapy The University of Texas MD Anderson Cancer Center Houston Texas
| | - Oran Betul
- Department of Stem Cell Transplantation and Cellular Therapy The University of Texas MD Anderson Cancer Center Houston Texas
| | - Rohtesh Mehta
- Department of Stem Cell Transplantation and Cellular Therapy The University of Texas MD Anderson Cancer Center Houston Texas
| | - Uday Popat
- Department of Stem Cell Transplantation and Cellular Therapy The University of Texas MD Anderson Cancer Center Houston Texas
| | - Chitra Hosing
- Department of Stem Cell Transplantation and Cellular Therapy The University of Texas MD Anderson Cancer Center Houston Texas
| | - Qaiser Bashir
- Department of Stem Cell Transplantation and Cellular Therapy The University of Texas MD Anderson Cancer Center Houston Texas
| | - Issa Khouri
- Department of Stem Cell Transplantation and Cellular Therapy The University of Texas MD Anderson Cancer Center Houston Texas
| | - Partow Kebriaei
- Department of Stem Cell Transplantation and Cellular Therapy The University of Texas MD Anderson Cancer Center Houston Texas
| | - Lucia Masarova
- Department of Leukemia The University of Texas MD Anderson Cancer Center Houston Texas
| | - Nicholas Short
- Department of Leukemia The University of Texas MD Anderson Cancer Center Houston Texas
| | - Elias Jabbour
- Department of Leukemia The University of Texas MD Anderson Cancer Center Houston Texas
| | - Naval Daver
- Department of Leukemia The University of Texas MD Anderson Cancer Center Houston Texas
| | - Marina Konopleva
- Department of Leukemia The University of Texas MD Anderson Cancer Center Houston Texas
| | - Farhad Ravandi
- Department of Leukemia The University of Texas MD Anderson Cancer Center Houston Texas
| | - Hagop Kantarjian
- Department of Leukemia The University of Texas MD Anderson Cancer Center Houston Texas
| | - Richard E. Champlin
- Department of Stem Cell Transplantation and Cellular Therapy The University of Texas MD Anderson Cancer Center Houston Texas
| | - Stefan O. Ciurea
- Department of Stem Cell Transplantation and Cellular Therapy The University of Texas MD Anderson Cancer Center Houston Texas
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15
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Harada K, Yanada M, Machida S, Kanamori H, Onizuka M, Ozawa Y, Kobayashi H, Sawa M, Katayama Y, Ohashi K, Kanda J, Ichinohe T, Atsuta Y, Yano S. Prognostic impact of melphalan dose and total body irradiation use in patients with acute myeloid leukemia undergoing allogeneic stem cell transplantation with reduced-intensity conditioning. Leuk Lymphoma 2018; 60:1493-1502. [PMID: 30457400 DOI: 10.1080/10428194.2018.1535115] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
To evaluate the prognostic impact of melphalan dose and total body irradiation (TBI) use in acute myeloid leukemia patients undergoing reduced-intensity allogeneic transplantation, we retrospectively compared outcomes of patients receiving a higher-dose (120-140 mg/m2, n = 379) or lower-dose melphalan (80-110 mg/m2, n = 128) with or without TBI of ≤4 Gy. At 3 years, overall survival was 48.9% in the higher-dose group versus 40.3% in the lower-dose group (p = .013). This survival benefit was attributed to lower tumor-related mortality (23.9% vs. 31.7%; p = .049). Non-relapse mortality did not differ (24.8% vs. 23.5%, p = .59). The beneficial effect of a higher-dose melphalan was more evident when combined with TBI in younger patients, those not in complete remission, and those with good performance status. Our findings support the use of a higher-dose melphalan in combination with TBI for reduced-intensity conditioning in physically fit patients.
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Affiliation(s)
- Kaito Harada
- a Department of Hematology and Oncology , Tokai University School of Medicine , Isehara , Japan
| | - Masamitsu Yanada
- b Department of Hematology and Cell Therapy , Aichi Cancer Center , Nagoya , Japan
| | - Shinichiro Machida
- a Department of Hematology and Oncology , Tokai University School of Medicine , Isehara , Japan
| | - Heiwa Kanamori
- c Department of Hematology , Kanagawa Cancer Center , Yokohama , Japan
| | - Makoto Onizuka
- a Department of Hematology and Oncology , Tokai University School of Medicine , Isehara , Japan
| | - Yukiyasu Ozawa
- d Department of Hematology , Japanese Red Cross Nagoya First Hospital , Nagoya , Japan
| | - Hikaru Kobayashi
- e Department of Hematology , Nagano Red Cross Hospital , Nagano , Japan
| | - Masashi Sawa
- f Department of Hematology and Oncology , Anjo Kosei Hospital , Anjo , Japan
| | - Yuta Katayama
- g Department of Hematology , Hiroshima Red Cross Hospital & Atomic-bomb Survivors Hospital , Hiroshima , Japan
| | - Kazuteru Ohashi
- h Hematology Division , Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital , Tokyo , Japan
| | - Junya Kanda
- i Department of Hematology and Oncology , Graduate School of Medicine, Kyoto University , Kyoto , Japan
| | - Tatsuo Ichinohe
- j Department of Hematology and Oncology , Research Institute for Radiation Biology and Medicine, Hiroshima University , Hiroshima , Japan
| | - Yoshiko Atsuta
- k Japanese Data Center for Hematopoietic Cell Transplantation, Nagoya, Japan.,l Department of Healthcare Administration , Nagoya University Graduate School of Medicine , Nagoya , Japan
| | - Shingo Yano
- m Division of Clinical Oncology and Hematology , The Jikei University School of Medicine , Tokyo , Japan
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