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Filioglou D, Truscott L, Reddivalla N, Katsanis E. Outcomes of haploidentical bone marrow transplantation in infant acute leukemia: a single center experience. Bone Marrow Transplant 2024:10.1038/s41409-024-02281-8. [PMID: 38594510 DOI: 10.1038/s41409-024-02281-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 03/22/2024] [Accepted: 04/04/2024] [Indexed: 04/11/2024]
Affiliation(s)
| | - Laurel Truscott
- Department of Pediatrics, University of Arizona, Tucson, AZ, USA
- The University of Arizona Cancer Center, Tucson, AZ, USA
| | | | - Emmanuel Katsanis
- Department of Pediatrics, University of Arizona, Tucson, AZ, USA.
- The University of Arizona Cancer Center, Tucson, AZ, USA.
- Department of Medicine, University of Arizona, Tucson, AZ, USA.
- Department of Immunobiology, University of Arizona, Tucson, AZ, USA.
- Department of Pathology, University of Arizona, Tucson, AZ, USA.
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Filioglou D, Husnain M, Khurana S, Simpson RJ, Katsanis E. Has the shortage of fludarabine altered the current paradigm of lymphodepletion in favor of bendamustine? Front Immunol 2023; 14:1329850. [PMID: 38077398 PMCID: PMC10702755 DOI: 10.3389/fimmu.2023.1329850] [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: 10/30/2023] [Accepted: 11/08/2023] [Indexed: 12/18/2023] Open
Abstract
The most common lymphodepletion regimen used prior to infusion of chimeric antigen receptor-T cells (CAR-T) is cyclophosphamide (CY) in combination with fludarabine (Flu) (CY-FLU). While cyclophosphamide (CY) possesses lymphotoxic effects, it concurrently preserves regulatory T cell activity, potentially affecting the efficacy of CAR-T cells. Moreover, the use of fludarabine (FLU) has been linked to neurotoxicity, which could complicate the early detection of immune effector cell-associated neurotoxicity syndrome (ICANS) observed in CAR-T cell therapy. Given the ongoing shortage of FLU, alternative lymphodepleting agents have become necessary. To date, only a limited number of studies have directly compared different lymphodepleting regimens, and most of these comparisons have been retrospective in nature. Herein, we review the current literature on lymphodepletion preceding CAR-T cell therapies for lymphoid hematologic malignancies, with a specific focus on the use of bendamustine (BEN). Recent evidence suggests that administering BEN before CAR-T cell infusion yields comparable efficacy, possibly with a more favorable toxicity profile when compared to CY-FLU. This warrants further investigation through randomized prospective studies.
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Affiliation(s)
| | - Muhammad Husnain
- Department of Medicine, University of Arizona, Tucson, AZ, United States
- The University of Arizona Cancer Center, Tucson, AZ, United States
| | - Sharad Khurana
- Department of Medicine, University of Arizona, Tucson, AZ, United States
- The University of Arizona Cancer Center, Tucson, AZ, United States
| | - Richard J. Simpson
- Department of Pediatrics, University of Arizona, Tucson, AZ, United States
- Department of Immunobiology, University of Arizona, Tucson, AZ, United States
- School of Nutritional Sciences and Wellness, University of Arizona, Tucson, AZ, United States
| | - Emmanuel Katsanis
- Department of Pediatrics, University of Arizona, Tucson, AZ, United States
- Department of Medicine, University of Arizona, Tucson, AZ, United States
- The University of Arizona Cancer Center, Tucson, AZ, United States
- Department of Immunobiology, University of Arizona, Tucson, AZ, United States
- Department of Pathology, University of Arizona, Tucson, AZ, United States
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Fierro-Pineda JC, Tsai HL, Blackford A, Cluster A, Caywood E, Dalal J, Davis J, Egeler M, Huo J, Hudspeth M, Keating A, Kelly SS, Krueger J, Lee D, Lehmann L, Madden L, Oshrine B, Pulsipher MA, Fry T, Symons HJ. Prospective PTCTC trial of myeloablative haplo-BMT with posttransplant cyclophosphamide for pediatric acute leukemias. Blood Adv 2023; 7:5639-5648. [PMID: 37257193 PMCID: PMC10546347 DOI: 10.1182/bloodadvances.2023010281] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 05/08/2023] [Accepted: 05/08/2023] [Indexed: 06/02/2023] Open
Abstract
Promising results have been reported for adult patients with high-risk hematologic malignancies undergoing haploidentical bone marrow transplant (haploBMT) with posttransplant cyclophosphamide (PTCy). To our knowledge, we report results from the first multicenter trial for pediatric and young adult patients with high-risk acute leukemias and myelodysplastic syndrome (MDS) in the Pediatric Transplantation and Cellular Therapy Consortium. Nine centers performed transplants in 32 patients having acute leukemias or MDS, with myeloablative conditioning (MAC), haploBMT with PTCy, mycophenolate mofetil, and tacrolimus. The median patient age was 12 years. Diagnoses included AML (15), ALL (11), mixed-lineage leukemia (1), and MDS (5). Transplant-related mortality (TRM) at 180 days was 0%. The cumulative incidence (CuI) of grade 2 acute graft-versus-host disease (aGVHD) on day 100 was 13%. No patients developed grades 3-4 aGVHD. The CuI of moderate-to-severe chronic GVHD (cGVHD) at 1 year was 4%. Donor engraftment occurred in 27 patients (84%). Primary graft failures included 3 patients who received suboptimal bone marrow grafts; all successfully engrafted after second transplants. The CuI of relapse at 1 year was 32%, with more relapse among patients MRD positive pre-BMT vs MRD negative. Overall survival rates at 1 and 2 years were 77% and 73%, and event-free survival rate at 1 and 2 years were 68% and 64%. There was no TRM or severe aGVHD, low cGVHD, and favorable relapse and survival rates. This successful pilot trial has led to a phase 3 trial comparing MAC haploBMT vs HLA-matched unrelated donor BMT in the Children's Oncology Group. This trial was registered at www.clinicaltrials.gov as #NCT02120157.
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Affiliation(s)
- Juan C. Fierro-Pineda
- Department of Oncology and the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Hua-Ling Tsai
- Department of Oncology and the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Amanda Blackford
- Department of Oncology and the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Andrew Cluster
- Division of Pediatric Hematology/Oncology, Washington University in St. Louis, St. Louis, MO
| | - Emi Caywood
- Nemours Center for Cancer and Blood Disorders, Nemours Children’s Health, Wilmington, DE; Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Jignesh Dalal
- Division of Pediatric Hematology/Oncology/Bone Marrow Transplant, Rainbow Babies and Children’s Hospital, Case Western Reserve University, Cleveland, OH
| | - Jeffrey Davis
- Division of Hematology/Oncology/BMT, Department of Pediatrics, BC Children’s Hospital, University of British Columbia, Vancouver, BC
| | | | - Jeffrey Huo
- Pediatric Blood and Marrow Transplant and Cellular Therapies, Atrium Health Levine Children's Hospital, Charlotte, NC
| | - Michelle Hudspeth
- Division of Pediatric Hematology, Oncology, and BMT, Medical University of South Carolina, Charleston, SC
| | - Amy Keating
- Pediatric Blood and Marrow Transplant and Cellular Therapeutics, University of Colorado School of Medicine, and The Children’s Hospital of Colorado, Denver, CO
| | | | - Joerg Krueger
- Division of Hematology/Oncology, Bone Marrow Transplant/Cell Therapy Section, SickKids, Toronto, ON, Canada
| | - Dean Lee
- Division of Hematology, Oncology, and BMT, Nationwide Children’s Hospital and Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
| | - Leslie Lehmann
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA
| | | | - Benjamin Oshrine
- Cancer and Blood Disorders Institute, Johns Hopkins All Children’s Hospital, Saint Petersburg, FL
| | - Michael A. Pulsipher
- Intermountain Primary Children’s Hospital Division of Hematology, Oncology, and BMT, Huntsman Cancer Institute, Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, UT
| | - Terry Fry
- Pediatric Blood and Marrow Transplant and Cellular Therapeutics, University of Colorado School of Medicine, and The Children’s Hospital of Colorado, Denver, CO
| | - Heather J. Symons
- Department of Oncology and the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
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Huo WX, Wen Q, Zhang XH, Xu LP, Wang Y, Yan CH, Chen H, Chen YH, Han W, Wang FR, Wang JZ, Huang XJ, Mo XD. Outcomes of haploidentical haematopoietic stem cell transplantation for adolescent and young adults with acute myeloid leukaemia. Br J Haematol 2023; 202:856-865. [PMID: 37365147 DOI: 10.1111/bjh.18937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/29/2023] [Accepted: 06/05/2023] [Indexed: 06/28/2023]
Abstract
We aimed to identify the efficacy of haploidentical related donor (HID) haematopoietic stem cell transplantation (HSCT) in adolescent and young adults (AYAs) with acute myeloid leukaemia (AML) in a large cohort. Consecutive AML AYAs (15-39 years old, n = 599) receiving HID HSCT in complete remission (CR) were included. The 3-year cumulative incidence of measurable residual disease occurrence, relapse and non-relapse mortality after HID HSCT was 28.6% (95% CI: 25.0-32.2), 11.6% (95% CI: 9.0-14.2) and 6.7% (95% CI: 4.7-8.7) respectively. The 3-year probability of event-free survival, leukaemia-free survival (LFS) and overall survival (OS) after HID HSCT was 60.7% (95% CI: 56.9-64.8), 81.7% (95% CI: 78.7-84.9) and 85.6% (95% CI: 82.8-88.4) respectively. In multivariable analysis, AML risk category at diagnosis and comorbidity burdens before HID HSCT were independently associated with LFS and OS. Compared to the older adults (≥ 40 years, n = 355) with AML receiving HID HSCT in CR during the same time period, AYAs have a lower incidence of non-relapse mortality and higher probabilities of LFS and OS. Thus, we firstly confirmed the safety and efficacy of HID HSCT in AYAs with AML-CR.
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Affiliation(s)
- Wen-Xuan Huo
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Qi Wen
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Xiao-Hui Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Lan-Ping Xu
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Yu Wang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Chen-Hua Yan
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Huan Chen
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Yu-Hong Chen
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Wei Han
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Feng-Rong Wang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Jing-Zhi Wang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Xiao-Jun Huang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Peking-Tsinghua Center for Life Sciences, Academy for Advanced Interdisciplinary Studies, Peking University, Beijing, China
- Research Unit of Key Technique for Diagnosis and Treatments of Hematologic Malignancies (2019RU029), Chinese Academy of Medical Sciences, Beijing, China
| | - Xiao-Dong Mo
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Research Unit of Key Technique for Diagnosis and Treatments of Hematologic Malignancies (2019RU029), Chinese Academy of Medical Sciences, Beijing, China
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Tannumsaeung S, Anurathapan U, Pakakasama S, Pongpitcha P, Songdej D, Sirachainan N, Andersson BS, Hongeng S. Effective T-cell replete haploidentical stem cell transplantation for pediatric patients with high-risk hematologic disorders. Eur J Haematol Suppl 2023; 110:305-312. [PMID: 36451282 DOI: 10.1111/ejh.13906] [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: 10/04/2022] [Revised: 11/25/2022] [Accepted: 11/28/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVES Patients with high-risk hematologic diseases require intensive modalities, including high-dose chemotherapy and allogeneic hematopoietic stem cell transplantation (allo-HSCT). Haploidentical T-cell-replete transplantation is a logical choice because of the limited availability of matched sibling donors and the prolonged time needed to identify matched unrelated donors in Thailand. METHODS The clinical outcomes data of 43 patients undergoing allo-HSCT were reviewed. All patients had high-risk hematologic malignancies, were younger than 20 years, and were in complete cytological remission at the time of allo-HSCT. We used two different conditioning regimens: total body irradiation (TBI) combined with cyclophosphamide, fludarabine, and melphalan (n = 23) and thiotepa combined with fludarabine and busulfan (n = 20). All patients received a graft-versus-host disease prophylaxis regimen consisting of cyclophosphamide, mycophenolate mofetil, and a calcineurin inhibitor or sirolimus. RESULTS There was no difference in engraftment between patients receiving either of the regimens. After a median follow-up of 35.8 (range, 0.6-106.2) months, the overall survival (OS) and event-free survival (EFS) rates were 62.4% and 54.7%, respectively. OS and EFS were comparable between the respective regimens. CONCLUSIONS We conclude that thiotepa-based conditioning has similar efficacy and tolerability as TBI-based conditioning for haploidentical HSCT with post-transplant cyclophosphamide.
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Affiliation(s)
- Supavich Tannumsaeung
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Krung Thep Maha Nakhon (Bangkok), Thailand
| | - Usanarat Anurathapan
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Krung Thep Maha Nakhon (Bangkok), Thailand
| | - Samart Pakakasama
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Krung Thep Maha Nakhon (Bangkok), Thailand
| | - Pongpak Pongpitcha
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Krung Thep Maha Nakhon (Bangkok), Thailand
| | - Duantida Songdej
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Krung Thep Maha Nakhon (Bangkok), Thailand
| | - Nongnuch Sirachainan
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Krung Thep Maha Nakhon (Bangkok), Thailand
| | - Borje S Andersson
- Department of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Suradej Hongeng
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Krung Thep Maha Nakhon (Bangkok), Thailand
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Truscott L, Pariury H, Hanmod S, Davini M, de la Maza M, Sapp LN, Staples K, Proytcheva M, Katsanis E. Busulfan, fludarabine, and melphalan are effective conditioning for pediatric and young adult patients with myeloid malignancies underdoing matched sibling or alternative donor transplantation. Pediatr Blood Cancer 2023; 70:e30102. [PMID: 36394072 DOI: 10.1002/pbc.30102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 10/12/2022] [Accepted: 10/24/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Allogeneic hematopoietic cell transplantation (allo-HCT) remains a curative option for patients with high-risk myeloid malignancies. PROCEDURE We present our 10-year experience (October 2012 to October 2021) of consecutive allo-HCT in patients with myeloid malignancies treated on the pediatric HCT service and conditioned with myeloablative targeted dose-busulfan (BU), fludarabine (FLU), and melphalan (MEL). Twenty-three children, adolescents, and young adult patients (CAYA) (median age 15.4 years) with acute myeloid leukemia (AML, n = 17), myelodysplastic syndrome (MDS, n = 4), or chronic myeloid leukemia (CML, n = 2) underwent allo-HCT post-BU-FLU-MEL. Four patients had treatment-related AML/MDS. Donor/stem cell source was matched sibling donor (MSD) PBSC (n = 7), matched unrelated donor (MUD) PBSC (n = 2), umbilical cord blood (UCB) (n = 3), or haploidentical-BMT (n = 11). Risk stratification was low (n = 2), intermediate (n = 15), high (n = 3), and very high risk (n = 1). The two patients with CML had failed tyrosine kinase inhibitor therapies. RESULTS With a median follow-up of 41.6 months, the relapse rate is only 4.5% with an overall survival (OS) 100%, progression-free survival (PFS) 95.5%, and graft-versus-host-free-relapse-free survival (GRFS) 67.8%. The donor source and the acute graft-versus-host disease (GvHD) prophylaxis regimen significantly impacted grade II-IV aGvHD 66.7% versus 19.2% (p = .039) and chronic graft-versus-host-disease (cGvHD) 66.7% versus 0% (p = .002) in the patients receiving MSD or MUD PBSC compared to haplo-BMT, respectively, resulting in improved GRFS in haplo-BMT, 83.3% compared to 40% matched donor peripheral blood stem cell transplant (PBSCT) (p = .025). CONCLUSIONS Our results demonstrate that BU-FLU-MEL is efficacious conditioning for disease control in young patients with myeloid malignancies undergoing MSD or alternative donor allo-HCT, but in the setting of PBSC grafts with cyclosporine A-methotrexate (CSA-MTX) GvHD prophylaxis, it results in an unacceptably high incidence of GvHD.
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Affiliation(s)
- Laurel Truscott
- Department of Pediatrics, University of Arizona, Tucson, Arizona, USA.,The University of Arizona Cancer Center, Tucson, Arizona, USA.,Banner University Medical Center, Tucson, Arizona, USA
| | - Holly Pariury
- Department of Pediatrics, University of Arizona, Tucson, Arizona, USA.,The University of Arizona Cancer Center, Tucson, Arizona, USA.,Banner University Medical Center, Tucson, Arizona, USA
| | - Santosh Hanmod
- Department of Pediatrics, University of Arizona, Tucson, Arizona, USA.,Banner Desert Medical Center, Mesa, Arizona, USA
| | - Monica Davini
- Department of Pediatrics, University of Arizona, Tucson, Arizona, USA.,The University of Arizona Cancer Center, Tucson, Arizona, USA.,Banner University Medical Center, Tucson, Arizona, USA
| | - Michelina de la Maza
- Department of Pediatrics, University of Arizona, Tucson, Arizona, USA.,The University of Arizona Cancer Center, Tucson, Arizona, USA.,Banner University Medical Center, Tucson, Arizona, USA
| | - Lauren N Sapp
- Department of Pediatrics, University of Arizona, Tucson, Arizona, USA.,Banner University Medical Center, Tucson, Arizona, USA
| | - Kyleigh Staples
- Department of Pediatrics, University of Arizona, Tucson, Arizona, USA.,Banner University Medical Center, Tucson, Arizona, USA
| | - Maria Proytcheva
- Department of Pediatrics, University of Arizona, Tucson, Arizona, USA.,The University of Arizona Cancer Center, Tucson, Arizona, USA.,Banner University Medical Center, Tucson, Arizona, USA.,Department of Pathology, University of Arizona, Tucson, Arizona, USA
| | - Emmanuel Katsanis
- Department of Pediatrics, University of Arizona, Tucson, Arizona, USA.,The University of Arizona Cancer Center, Tucson, Arizona, USA.,Banner University Medical Center, Tucson, Arizona, USA.,Department of Pathology, University of Arizona, Tucson, Arizona, USA.,Department of Immunobiology, University of Arizona, Tucson, Arizona, USA.,Department of Medicine, University of Arizona, Tucson, Arizona, USA
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Gilman KE, Cracchiolo MJ, Matiatos AP, Davini DW, Simpson RJ, Katsanis E. Partially replacing cyclophosphamide with bendamustine in combination with cyclosporine A improves survival and reduces xenogeneic graft-versus-host-disease. Front Immunol 2023; 13:1045710. [PMID: 36700195 PMCID: PMC9868157 DOI: 10.3389/fimmu.2022.1045710] [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: 09/15/2022] [Accepted: 12/19/2022] [Indexed: 01/11/2023] Open
Abstract
Introduction The use of allogeneic hematopoietic cell transplantation (allo-HCT) for treating hematological disorders is increasing, but the development of graft-versus-host disease (GvHD) remains a major cause of morbidity and mortality. The use of post-transplant cyclophosphamide (CY) has significantly improved outcomes following allo-HCT, but complications of viral reactivation due to delayed immune reconstitution or relapse remain. Other laboratories are evaluating the potential benefit of lowering the dose of CY given post-transplant, whereas our laboratory has been focusing on whether partially replacing CY with another DNA alkylating agent, bendamustine (BEN) may be advantageous in improving outcomes with allo-HCT. Methods Here, we utilized a xenogeneic GvHD (xGvHD) model in which immunodeficient NSG mice are infused with human peripheral blood mononuclear cells (PBMCs). Results We show that a lower dose of CY (25 mg/kg) given on days +3 and +4 or CY (75 mg/kg) given on only day +3 post-PBMC infusion is not sufficient for improving survival from xGvHD, but can be improved with the addition of BEN (15 mg/kg) on day +4 to day +3 CY (75 mg/kg). CY/BEN treated mice when combined with cyclosporine A (CSA) (10mg/kg daily from days +5 to +18 and thrice weekly thereafter), had improved outcomes over CY/CY +CSA treated mice. Infiltration of GvHD target organs was reduced in both CY/CY and CY/BEN treatment groups versus those receiving no treatment. CY/CY +CSA mice exhibited more severe xGvHD at day 10, marked by decreased serum albumin and increased intestinal permeability. CY/BEN treated mice had reductions in naïve, effector memory and Th17 polarized T cells. RNAseq analysis of splenocytes isolated from CY/CY and CY/BEN treated animals revealed increased gene set enrichment in multiple KEGG pathways related to cell migration, proliferation/differentiation, and inflammatory pathways, among others with CY/BEN treatment. Conclusion Together, we illustrate that the use of CY/BEN is safe and shows similar control of xGvHD to CY/CY, but when combined with CSA, survival with CY/BEN is significantly prolonged compared to CY/CY.
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Affiliation(s)
- Kristy E. Gilman
- Department of Pediatrics, University of Arizona, Tucson, AZ, United States
| | | | - Andrew P. Matiatos
- Department of Pediatrics, University of Arizona, Tucson, AZ, United States
| | - Dan W. Davini
- Department of Pediatrics, University of Arizona, Tucson, AZ, United States
| | - Richard J. Simpson
- Department of Pediatrics, University of Arizona, Tucson, AZ, United States,Department of Immunobiology, University of Arizona, Tucson, AZ, United States,Department of Medicine, University of Arizona, Tucson, AZ, United States,Department of Pathology, University of Arizona, Tucson, AZ, United States
| | - Emmanuel Katsanis
- Department of Pediatrics, University of Arizona, Tucson, AZ, United States,Department of Immunobiology, University of Arizona, Tucson, AZ, United States,School of Nutritional Sciences and Wellness, University of Arizona, Tucson, AZ, United States,The University of Arizona Cancer Center, Tucson, AZ, United States,Department of Pathology, University of Arizona, Tucson, AZ, United States,*Correspondence: Emmanuel Katsanis,
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Dufort Y Alvarez G. Myeloablative Conditioning Regimen in Haploidentical Stem Cell Transplantation With Posttransplant Cyclophosphamide in Children With High-risk Hematologic Malignancies. J Pediatr Hematol Oncol 2022; 44:e930-e938. [PMID: 35091515 DOI: 10.1097/mph.0000000000002406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 12/23/2021] [Indexed: 11/25/2022]
Abstract
Limited information is available on outcomes of haploidentical stem cell transplantation (haploSCT) with posttransplant cyclophosphamide using myeloablative conditioning regimens in children and adolescents. We report the results of a single-institution retrospective study of myeloablative haploSCT in 36 children and adolescents (median age, 8 y; range, 9 mo to 22 y) with high-risk hematologic malignancies. Donor engraftment occurred in 31 of 33 evaluable patients (94%). Recovery of neutrophils and platelets occurred at a median of 15 and 20 days. Cumulative incidence of acute graft-versus-host-disease (GVHD) grades II to IV and grades III to IV at 100 days was 36±8.7% and 10±5.4% and of chronic GVHD at 1 year was 55±9.2%, with 31±8.6% moderate to severe. Nonrelapse mortality was 16±6.1% and 22±6.9% at 100 days and 1 year. The cumulative incidence of relapse at 4 years was 32±8.8%. With a median follow-up of 57 months (range, 8 to 89 mo), the overall survival and event-free survival at 4 years was 55.6±8.7% and 44.8±8.5%. Myeloablative conditioning T-replete haploSCT with posttransplant cyclophosphamide is a viable alternative to matched unrelated transplantation for children and adolescents with high-risk hematologic malignancies. The high rates of nonrelapse mortality and chronic GVHD is a concern and deserves careful consideration.
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Epperly R, Talleur AC, Li Y, Schell S, Tuggle M, Métais JY, Huang S, Pei D, Cheng C, Madden R, Mamcarz E, Naik S, Qudeimat A, Sharma A, Srinivasan A, Suliman A, Gottschalk S, Triplett BM. Sub-myeloablative Second Transplantations with Haploidentical Donors and Post-Transplant Cyclophosphamide have limited Anti-Leukemic Effects in Pediatric Patients. Transplant Cell Ther 2022; 28:262.e1-262.e10. [PMID: 35151936 PMCID: PMC9081211 DOI: 10.1016/j.jtct.2022.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 02/01/2022] [Accepted: 02/06/2022] [Indexed: 10/19/2022]
Abstract
Pediatric patients with high-risk hematologic malignancies who experience relapse after a prior allogeneic hematopoietic cell transplant (HCT) have an exceedingly poor prognosis. A second allogeneic HCT offers the potential for long-term cure but carries high risks of both subsequent relapse and HCT-related morbidity and mortality. Using haploidentical donors for HCT (haploHCT) can expand the donor pool and potentially enhance the graft-versus-leukemia effect but is accompanied by a risk of graft-versus-host disease (GVHD). The goal of this protocol was to intensify the antileukemia effect of haploHCT for pediatric patients with hematologic malignancies that relapsed after prior allogeneic HCT, while limiting regimen-associated toxicities. This phase II clinical trial evaluated a sub-myeloablative preparative regimen consisting of anti-thymocyte globulin, clofarabine, cytarabine, busulfan, and cyclophosphamide, in combination with plerixafor to sensitize leukemic blasts. Participants received a mobilized peripheral blood unmanipulated haploidentical donor graft with one dose of post-transplant cyclophosphamide as GVHD prophylaxis, followed by natural killer (NK) cell addback. Here we report the clinical outcomes and immune reconstitution of 17 participants treated on the study and 5 additional patients treated on similar single-patient treatment plans. Of the 22 participants analyzed, 12 (55%) had active disease at the time of HCT. The regimen provided robust immune reconstitution, with 21 participants (95%) experiencing neutrophil engraftment at a median of 14 days after HCT. In this high-risk population, the overall survival was 45% (95% confidence interval [CI], 24%-64%), with a 12-month event-free survival of 31% (95% CI, 14%-51%) and cumulative incidence of relapse at 12 months of 50% (95% CI, 27%-69%). Four participants (18%) remain in remission at >5 years follow-up. Expected HCT-related organ-specific toxicities were observed, and 13 participants (59%) experienced acute or chronic GVHD. This intensified but sub-myeloablative regimen, followed by a high-dose unmanipulated haploidentical graft, post-transplantation cyclophosphamide, and NK cell infusion, resulted in adequate immune reconstitution but failed to overcome the elevated risks of relapse and treatment-related morbidity in this high-risk population.
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Affiliation(s)
- Rebecca Epperly
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Aimee C Talleur
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Ying Li
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Sarah Schell
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - MaCal Tuggle
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Jean-Yves Métais
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Sujuan Huang
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Deqing Pei
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Cheng Cheng
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Renee Madden
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Ewelina Mamcarz
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Swati Naik
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Amr Qudeimat
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Akshay Sharma
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Ashok Srinivasan
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Ali Suliman
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee; Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Stephen Gottschalk
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Brandon M Triplett
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee.
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10
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Katsanis E, Stea B, Kovacs K, Truscott L, Husnain M, Khurana S, Roe DJ, Simpson RJ. Feasibility and efficacy of partially replacing post-transplant cyclophosphamide with bendamustine in pediatric and young adult patients undergoing haploidentical bone marrow transplantation. Transplant Cell Ther 2022; 28:390.e1-390.e10. [PMID: 35460929 DOI: 10.1016/j.jtct.2022.04.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 04/11/2022] [Accepted: 04/12/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Post-transplant cyclophosphamide (PT-CY) is the most widely applied graft-versus-host disease (GvHD) prophylaxis regimen in T-cell replete haploidentical bone marrow transplantation (haplo-BMT). While PT-CY has been met with great success in the haplo-BMT arena by suppressing GvHD, patients without acute GvHD have high relapse rates. OBJECTIVE One of the strategies being explored by others to lessen relapse rates is the dose reduction of PT-CY. We have taken a different approach in evaluating whether partially replacing PT-CY with post-transplant bendamustine (PT-BEN) would be advantageous, which is based on our pre-clinical research that delineated several beneficial immunomodulatory properties of BEN. STUDY DESIGN We therefore initiated and completed a Phase Ia trial which evaluated the progressive substitution of PT-CY with PT-BEN (NCT02996773). Thirteen patients with high-risk hematologic malignancies have received PT-CY/BEN and their outcomes compared to 31 contemporaneous haplo-BMT recipients treated with the same myeloablative conditioning (MAC) regimens but receiving only PT-CY. RESULTS We demonstrate that partial replacement of PT-CY with PT-BEN on day +4 (PT-CY/BEN) is well tolerated and associated with significantly earlier trilineage engraftment. We also show favorable trends to significant improvements in univariate and multivariate analyses, with PT-CY/BEN compared to PT-CY, with respect to chronic GvHD (HR, 0.08; 95% CI, 0.005, 1.11; P=0.06), and GvHD-free-relapse-free survival (GRFS) (HR, 0.22; 95% CI, 0.05, 0.86; P=0.039). Our human trial has transitioned to Phase Ib which will further evaluate the safety and potential benefits of PT-CY/BEN. Herein, we also expand our pediatric, adolescent, and young adult (AYA) experience to 31 patients demonstrating an overall survival (OS), progression-free survival (PFS) and GRFS at 3 years of 85.6%, 76.1% and 58.2%, respectively in a largely racial/ethnic minority cohort. CONCLUSIONS PT-CY/BEN appears to be a promising treatment option that requires further evaluation.
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Affiliation(s)
- Emmanuel Katsanis
- Department of Pediatrics, University of Arizona, Tucson, AZ, USA; Department of Immunobiology, University of Arizona, Tucson, AZ, USA; Department of Medicine, University of Arizona, Tucson, AZ, USA; Department of Pathology, University of Arizona, Tucson, AZ, USA; The University of Arizona Cancer Center, Tucson, AZ, USA; Banner University Medical Center, Tucson, AZ, USA.
| | - Baldassarre Stea
- Department of Radiation Oncology, University of Arizona, Tucson, AZ, USA; The University of Arizona Cancer Center, Tucson, AZ, USA; Banner University Medical Center, Tucson, AZ, USA
| | | | - Laurel Truscott
- Department of Pediatrics, University of Arizona, Tucson, AZ, USA; The University of Arizona Cancer Center, Tucson, AZ, USA; Banner University Medical Center, Tucson, AZ, USA
| | - Muhammad Husnain
- Department of Medicine, University of Arizona, Tucson, AZ, USA; The University of Arizona Cancer Center, Tucson, AZ, USA; Banner University Medical Center, Tucson, AZ, USA
| | - Sharad Khurana
- Department of Medicine, University of Arizona, Tucson, AZ, USA; The University of Arizona Cancer Center, Tucson, AZ, USA; Banner University Medical Center, Tucson, AZ, USA
| | - Denise J Roe
- Department of Epidemiology and Biostatistics, University of Arizona, Tucson, AZ, USA; The University of Arizona Cancer Center, Tucson, AZ, USA
| | - Richard J Simpson
- Department of Pediatrics, University of Arizona, Tucson, AZ, USA; Department of Immunobiology, University of Arizona, Tucson, AZ, USA; School of Nutritional Sciences and Wellness, University of Arizona, Tucson, AZ, USA; The University of Arizona Cancer Center, Tucson, AZ, USA
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11
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Katsanis E, Hanley PJ, Simpson RJ. Editorial: Advances in Pediatric Hematopoietic Cell Therapies and Transplantation. Front Pediatr 2022; 10:847288. [PMID: 35155311 PMCID: PMC8832116 DOI: 10.3389/fped.2022.847288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Accepted: 01/07/2022] [Indexed: 11/20/2022] Open
Affiliation(s)
- Emmanuel Katsanis
- Department of Pediatrics, University of Arizona, Tucson, AZ, United States
| | - Patrick J Hanley
- Center for Cancer and Immunology Research, Children's National Hospital, The George Washington University, Washington, DC, United States
| | - Richard J Simpson
- Department of Pediatrics, University of Arizona, Tucson, AZ, United States.,School of Nutritional Sciences and Wellness, University of Arizona, Tucson, AZ, United States
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12
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Smith J, Alfonso JH, Reddivalla N, Angulo P, Katsanis E. Case Report: Haploidentical Bone Marrow Transplantation in Two Brothers With Wiskott-Aldrich Syndrome Using Their Father as the Donor. Front Pediatr 2021; 9:647505. [PMID: 34778119 PMCID: PMC8578118 DOI: 10.3389/fped.2021.647505] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 09/23/2021] [Indexed: 12/31/2022] Open
Abstract
Wiskott-Aldrich syndrome (WAS) is an X-linked genetic disorder with a variable phenotypic expression that includes thrombocytopenia, eczema, and immunodeficiency. Some patients may also exhibit autoimmune manifestations. Patients with WAS are at increased risk of developing malignancies such as lymphoma. Allogeneic hematopoietic cell transplantation remains the only curative treatment. Haploidentical bone marrow transplantation (haplo-BMT) with post-transplant cyclophosphamide (PT-CY) has more recently been applied in WAS. Here, we report two brothers who underwent successful T-cell replete haplo-BMT with PT-CY at ages 9 months and 4 years using their father as the donor. Our myeloablative regimen was well-tolerated with minimal organ toxicity and no acute or chronic graft vs. host disease (GvHD). Haplo-BMT may be considered as a safe and effective option for patients with WAS who do not have available human leukocyte antigen (HLA) matched donors.
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Affiliation(s)
- Jasmine Smith
- Department of Pediatrics, University of Arizona, Tucson, AZ, United States
- Banner University Medical Center, Tucson, AZ, United States
| | - Jessica Hass Alfonso
- Department of Pediatrics, University of Arizona, Tucson, AZ, United States
- Banner University Medical Center, Tucson, AZ, United States
| | - Naresh Reddivalla
- Department of Pediatrics, University of Arizona, Tucson, AZ, United States
- Banner Children's at Desert, Mesa, AZ, United States
| | - Pablo Angulo
- Department of Pediatrics, University of Arizona, Tucson, AZ, United States
- Banner Children's at Desert, Mesa, AZ, United States
| | - Emmanuel Katsanis
- Department of Pediatrics, University of Arizona, Tucson, AZ, United States
- Banner University Medical Center, Tucson, AZ, United States
- Department of Immunobiology, University of Arizona, Tucson, AZ, United States
- Department of Medicine, University of Arizona, Tucson, AZ, United States
- Department of Pathology, University of Arizona, Tucson, AZ, United States
- The University of Arizona Cancer Center, Tucson, AZ, United States
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13
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Pariury H, Truscott L, Katsanis E. Have CD19-directed immunotherapy and haploidentical hematopoietic cell transplantation transformed pediatric B-cell acute lymphoblastic leukemia into a chronic disease? Oncoimmunology 2021; 10:1956125. [PMID: 34367735 PMCID: PMC8312595 DOI: 10.1080/2162402x.2021.1956125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The treatment of pediatric B-cell acute lymphoblastic leukemia (B-ALL) has undergone several recent advancements, leading to an increased amount of treatment options for relapsed patients. The development of immunotherapies such as anti-CD19 chimeric antigen receptor(CAR) T cells and bispecific T-cell engagers has given clinicians therapeutic options with less expected toxicity when compared to standard re-induction chemotherapy. This is especially beneficial in patients with toxicities from their prior treatment. Along with this, the emergence of haploidentical hematopoietic cell transplantation (HCT) has increased opportunity for patients to receive HCT who may not have had an available matched donor. We present four patients who have received all of these therapies in different combinations to treat multiple relapses. Because of the success of achieving remission as well as decreasing toxicity, the patients are alive and well up to 15 y after the original B-ALL diagnosis, rendering this as a chronic disease for them.
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Affiliation(s)
- Holly Pariury
- Department of Pediatrics, University of Arizona, Tucson, Arizona, USA.,The University of Arizona Cancer Center, Tucson, Arizona, USA.,Banner University Medical Center, Tucson, AZ, USA
| | - Laurel Truscott
- Department of Pediatrics, University of Arizona, Tucson, Arizona, USA.,The University of Arizona Cancer Center, Tucson, Arizona, USA.,Banner University Medical Center, Tucson, AZ, USA
| | - Emmanuel Katsanis
- Department of Pediatrics, University of Arizona, Tucson, Arizona, USA.,The University of Arizona Cancer Center, Tucson, Arizona, USA.,Banner University Medical Center, Tucson, AZ, USA.,Department of Immunobiology, University of Arizona, Tucson, Arizona, USA.,Department of Medicine, University of Arizona, Tucson, Arizona, USA.,Department of Pathology, University of Arizona, Tucson, Arizona, USA
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14
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Moiseev I, Bondarenko S, Morozova E, Vlasova Y, Dotsenko A, Epifanovskaya O, Babenko E, Botina A, Baykov V, Surkova E, Lapin S, Beynarovich A, Borzenkova E, Golosgchapov O, Kanunnikov M, Kudyasheva O, Ovechkina V, Pirogova O, Porunova V, Rudakova T, Smikova O, Smirnova A, Afansyev B. Graft-versus-Host Disease Prophylaxis with Post-Transplantation Bendamustine in Patients with Refractory Acute Leukemia: A Dose-Ranging Study. Transplant Cell Ther 2021; 27:601.e1-601.e7. [PMID: 33845259 DOI: 10.1016/j.jtct.2021.03.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Revised: 02/20/2021] [Accepted: 03/31/2021] [Indexed: 11/18/2022]
Abstract
The prognosis of acute leukemia refractory to induction chemotherapy or immunotherapy is dismal. Salvage allogeneic hematopoietic stem cell transplantation (HSCT) is widely used option for these patients, but only 10% to 15% of patients are cured by the procedure. Preclinical studies indicate that substitution of post-transplantation cyclophosphamide with bendamustine (PTB) in a prophylaxis regimen may be associated with an augmented graft-versus-leukemia (GVL) reaction. The aim of this study was to establish the optimal dose of PTB and evaluate the antileukemic effect of HSCT with this type of graft-versus-host disease (GVHD) prophylaxis. In the prospective trial (NCT02799147), PTB was administered in doses of 140, 100, and 70 mg/m2 on days +3 and +4. Myeloablative conditioning with fludarabine and oral busulfan was provided to all patients. The first 12 patients received single-agent PTB, and subsequent patients received combination therapy with tacrolimus and mycophenolate mofetil (MMF). Inclusion criteria were acute myelogenous leukemia (AML) or acute lymphoblastic leukemia (ALL) refractory to at least one induction course of chemotherapy or target therapy and ≥5% clonal blasts in the bone marrow. The study cohort comprised 22 patients with AML and 5 with ALL. Seven patients were enrolled in the 140 mg/m2 group (due to a stopping rule), and 10 each were enrolled in the 100 mg/m2 and 70 mg/m2 groups. Primary refractory disease was documented in 41% of the patients, and secondary refractory was documented in 59%. The median blast count in the bone marrow at the start of the conditioning was 18% (range, 6% to 97%). Transplantation was performed with a matched sibling donor in 5 patients, a matched or mismatched unrelated donor in 15, and a haploidentical donor in 7. Engraftment was documented in 93% of the patients, including 89% with complete remission and 63% without measurable residual disease. After PTB prophylaxis, we observed an unusual complication, a cytokine release syndrome (CRS), in 70% of the patients, including grade 3 to 5 CRS in 44%. The most frequent clinical symptoms included high fever in 67% of patients, abnormal liver function tests in 67%, pancreatitis in 63%, skin vasculitis in 56%, enterocolitis in 48%, inflammation of oral mucosa in 37%, disseminated intravascular coagulation in 37%, and central nervous system toxicity in 26%. The development of CRS was associated with use of an HLA-mismatched donor (75% versus 20%; P = .0043). Classic acute GVHD was documented in 44% of the patients. Grade II-IV acute GVHD was associated with grade 3 to 5 CRS (67% versus 25%; P = .031). Moderate and severe chronic GVHD in the 100-day survivors were more often observed after single-agent PTB than after the combination immunosuppression (100% versus 18%; P = .002). A relatively low relapse rate was observed for this patient population. Three-year overall survival was 28% (95% confidence interval [CI], 13% to 46%), and event-free survival was 29% (95% CI, 13% to 46%). Nonrelapse mortality was 46% (95% CI, 25% to 64%), and the cumulative incidence of relapse was 26% (95% CI, 11% to 44%). No relapses were documented after day +100. There were no statistically significant differences among the dose groups (P = .3481); however, survival was higher in the 100 mg/kg group. Survival was higher in patients with AML compared with those with ALL (35% versus 0%; P = .0157). PTB represents a promising option to augment the GVL effect in refractory AML; however, the high CRS-associated mortality necessitates additional studies to reduce the risk of this complication. Thus, routine clinical application of PTB cannot be currently recommended. Combination immunosuppression with tacrolimus and MMF partially ameliorates these complications, at least in the setting of HLA-matched allografts. Biological mechanisms of CRS and GVL after PTB require further elucidation.
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Affiliation(s)
- Ivan Moiseev
- RM Gorbacheva Research Institute, Pavlov University, Saint-Petersburg, Russian Federation.
| | - Sergey Bondarenko
- RM Gorbacheva Research Institute, Pavlov University, Saint-Petersburg, Russian Federation
| | - Elena Morozova
- RM Gorbacheva Research Institute, Pavlov University, Saint-Petersburg, Russian Federation
| | - Yulia Vlasova
- RM Gorbacheva Research Institute, Pavlov University, Saint-Petersburg, Russian Federation
| | - Anna Dotsenko
- RM Gorbacheva Research Institute, Pavlov University, Saint-Petersburg, Russian Federation
| | - Olga Epifanovskaya
- RM Gorbacheva Research Institute, Pavlov University, Saint-Petersburg, Russian Federation
| | - Elena Babenko
- RM Gorbacheva Research Institute, Pavlov University, Saint-Petersburg, Russian Federation
| | - Anna Botina
- RM Gorbacheva Research Institute, Pavlov University, Saint-Petersburg, Russian Federation
| | - Vadim Baykov
- RM Gorbacheva Research Institute, Pavlov University, Saint-Petersburg, Russian Federation
| | - Elena Surkova
- Laboratory of Autoimmune Diagnostics, Pavlov University, Saint-Petersburg, Russian Federation
| | - Sergey Lapin
- Laboratory of Autoimmune Diagnostics, Pavlov University, Saint-Petersburg, Russian Federation
| | - Anastasiya Beynarovich
- RM Gorbacheva Research Institute, Pavlov University, Saint-Petersburg, Russian Federation
| | - Evgeniya Borzenkova
- RM Gorbacheva Research Institute, Pavlov University, Saint-Petersburg, Russian Federation
| | - Oleg Golosgchapov
- RM Gorbacheva Research Institute, Pavlov University, Saint-Petersburg, Russian Federation
| | - Mikhail Kanunnikov
- RM Gorbacheva Research Institute, Pavlov University, Saint-Petersburg, Russian Federation
| | - Olga Kudyasheva
- RM Gorbacheva Research Institute, Pavlov University, Saint-Petersburg, Russian Federation
| | - Varvara Ovechkina
- RM Gorbacheva Research Institute, Pavlov University, Saint-Petersburg, Russian Federation
| | - Olga Pirogova
- RM Gorbacheva Research Institute, Pavlov University, Saint-Petersburg, Russian Federation
| | - Valentina Porunova
- RM Gorbacheva Research Institute, Pavlov University, Saint-Petersburg, Russian Federation
| | - Tatyana Rudakova
- RM Gorbacheva Research Institute, Pavlov University, Saint-Petersburg, Russian Federation
| | - Olesya Smikova
- RM Gorbacheva Research Institute, Pavlov University, Saint-Petersburg, Russian Federation
| | - Anna Smirnova
- RM Gorbacheva Research Institute, Pavlov University, Saint-Petersburg, Russian Federation
| | - Boris Afansyev
- RM Gorbacheva Research Institute, Pavlov University, Saint-Petersburg, Russian Federation
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15
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Stanley K, Hanmod S, Simpson RJ, Katsanis E. Haploidentical hematopoietic cell transplantation is even more advantageous during the COVID-19 pandemic. Pediatr Transplant 2021; 25:e14004. [PMID: 33729657 PMCID: PMC8250374 DOI: 10.1111/petr.14004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 03/02/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Kelly Stanley
- Department of PediatricsUniversity of ArizonaTucsonAZUSA,Banner University Medical CenterTucsonAZUSA
| | - Santosh Hanmod
- Department of PediatricsUniversity of ArizonaTucsonAZUSA,Banner Children’s at DesertMesaAZUSA
| | - Richard J Simpson
- Department of PediatricsUniversity of ArizonaTucsonAZUSA,Department of Nutritional SciencesUniversity of ArizonaTucsonAZUSA,The University of Arizona Cancer CenterTucsonAZUSA,Department of ImmunobiologyUniversity of ArizonaTucsonAZUSA
| | - Emmanuel Katsanis
- Department of PediatricsUniversity of ArizonaTucsonAZUSA,Banner University Medical CenterTucsonAZUSA,Banner Children’s at DesertMesaAZUSA,The University of Arizona Cancer CenterTucsonAZUSA,Department of ImmunobiologyUniversity of ArizonaTucsonAZUSA,Department of MedicineUniversity of ArizonaTucsonAZUSA,Department of PathologyUniversity of ArizonaTucsonAZUSA
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16
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Stokes J, Molina MS, Hoffman EA, Simpson RJ, Katsanis E. Immunomodulatory Effects of Bendamustine in Hematopoietic Cell Transplantation. Cancers (Basel) 2021; 13:1702. [PMID: 33916711 PMCID: PMC8038415 DOI: 10.3390/cancers13071702] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 03/25/2021] [Accepted: 04/01/2021] [Indexed: 12/22/2022] Open
Abstract
Bendamustine (BEN) is a unique alkylating agent with efficacy against a broad range of hematological malignancies, although investigations have only recently started to delve into its immunomodulatory effects. These immunomodulatory properties of BEN in the context of hematopoietic cell transplantation (HCT) are reviewed here. Pre- and post-transplant use of BEN in multiple murine models have consistently resulted in reduced GvHD and enhanced GvL, with significant changes to key immunological cell populations, including T-cells, myeloid derived suppressor cells (MDSCs), and dendritic cells (DCs). Further, in vitro studies find that BEN enhances the suppressive function of MDSCs, skews DCs toward cDC1s, enhances Flt3 expression on DCs, increases B-cell production of IL-10, inhibits STAT3 activation, and suppresses proliferation of T- and B-cells. Overall, BEN has a broad range of immunomodulatory effects that, as they are further elucidated, may be exploited to improve clinical outcomes. As such, clinical trials are currently underway investigating new potential applications of BEN in the setting of allogeneic HCT.
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Affiliation(s)
- Jessica Stokes
- Department of Pediatrics, University of Arizona, Tucson, AZ 85721, USA; (J.S.); (M.S.M.); (E.A.H.); (R.J.S.)
| | - Megan S. Molina
- Department of Pediatrics, University of Arizona, Tucson, AZ 85721, USA; (J.S.); (M.S.M.); (E.A.H.); (R.J.S.)
- Department of Immunobiology, University of Arizona, Tucson, AZ 85721, USA
| | - Emely A. Hoffman
- Department of Pediatrics, University of Arizona, Tucson, AZ 85721, USA; (J.S.); (M.S.M.); (E.A.H.); (R.J.S.)
| | - Richard J. Simpson
- Department of Pediatrics, University of Arizona, Tucson, AZ 85721, USA; (J.S.); (M.S.M.); (E.A.H.); (R.J.S.)
- Department of Immunobiology, University of Arizona, Tucson, AZ 85721, USA
- Department of Nutritional Sciences, University of Arizona, Tucson, AZ 85721, USA
- The University of Arizona Cancer Center, Tucson, AZ 85721, USA
| | - Emmanuel Katsanis
- Department of Pediatrics, University of Arizona, Tucson, AZ 85721, USA; (J.S.); (M.S.M.); (E.A.H.); (R.J.S.)
- Department of Immunobiology, University of Arizona, Tucson, AZ 85721, USA
- The University of Arizona Cancer Center, Tucson, AZ 85721, USA
- Department of Medicine, University of Arizona, Tucson, AZ 85721, USA
- Department of Pathology, University of Arizona, Tucson, AZ 85721, USA
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17
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Contemporary haploidentical stem cell transplant strategies in children with hematological malignancies. Bone Marrow Transplant 2021; 56:1518-1534. [PMID: 33674791 DOI: 10.1038/s41409-021-01246-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 02/01/2021] [Accepted: 02/15/2021] [Indexed: 12/14/2022]
Abstract
The barriers to HLA-mismatched or haploidentical hematopoietic stem cell transplantation (HSCT), namely GvHD and graft failure, have been overcome with novel transplant platforms. Post-transplant Cyclophosphamide (PTCy) is widely available, feasible and easy to implement. TCRαβ T and B cell depletion comes with consistent GvHD preventive benefits irrespective of age and indication. Naive T-cell depletion helps prevention of severe viral reactivations. The Beijing protocol shows promising outcomes in patients with poor remission status at the time of transplantation. For children, the toxicities and late outcomes related to these transplants are truly relevant as they suffer the most in the long run from transplant-related toxicities, especially chronic GvHD. While comparing the outcomes of different Haplo-HSCT approaches, one must understand the transplant immunobiology and factors affecting the transplant outcomes. Leukemia remission status at the time of conditioning is a consistent factor affecting the transplant outcomes using any of these platforms. Prospective comparison of these platforms lacks in a homogenous population; however, the evidence is growing, and this review highlights the areas of research gaps.
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18
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Smith J, Kumar A, Stanton NA, Katsanis E. Concurrent application of blinatumomab and haploidentical donor leukocyte infusions for refractory primary mediastinal large B-cell lymphoma. Ther Adv Hematol 2021; 12:2040620721994348. [PMID: 33747421 PMCID: PMC7905714 DOI: 10.1177/2040620721994348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 01/14/2021] [Indexed: 11/15/2022] Open
Abstract
Primary mediastinal large B-cell lymphoma (PMBCL) is a rare hematologic malignancy with distinct clinical and immunopathological features. We report a case of a young male with disease refractory to multiple lines of therapy, including chimeric antigen receptor-T cells, who achieved his first complete remission after haploidentical bone marrow transplantation (haplo-BMT), following donor leukocyte infusions (DLIs) given concurrently with blinatumomab. While DLI has been used after T-replete haplo-BMT with post-transplant cyclophosphamide, there are no reports on its use for PMBCL. Similarly, blinatumomab is active against B-cell lymphomas, but literature is lacking in patients with PMBCL. Our experience illustrates that blinatumomab can be used concurrently with DLI in a haploidentical setting to achieve disease response in PMBCL. Despite our encouraging experience with this case, we would not recommend this approach outside of a clinical trial as blinatumomab may exacerbate the graft versus host disease risks of DLI, especially in a haploidentical setting. Evaluating this treatment combination in high-risk patients in the setting of a clinical trial may be meaningful.
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Affiliation(s)
- Jasmine Smith
- Department of Pediatrics, University of Arizona, Tucson, AZ, USA
- Banner University Medical Center, Tucson, AZ, USA
| | - Abhijeet Kumar
- Department of Medicine, University of Arizona, Tucson, AZ, USA
- The University of Arizona Cancer Center, Tucson, AZ, USA
- Banner University Medical Center, Tucson, AZ, USA
| | | | - Emmanuel Katsanis
- Department of Pediatrics, University of Arizona, 1501 N. Campbell Ave., PO Box 245073, Tucson, AZ 85724-5073, USA
- Department of Immunobiology, University of Arizona, Tucson, AZ, USA
- Department of Medicine, University of Arizona, Tucson, AZ, USA
- Department of Pathology, University of Arizona, Tucson, AZ, USA
- The University of Arizona Cancer Center, Tucson, AZ, USA
- Banner University Medical Center, Tucson, AZ, USA
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19
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Kleinschmidt K, Lv M, Yanir A, Palma J, Lang P, Eyrich M. T-Cell-Replete Versus ex vivo T-Cell-Depleted Haploidentical Haematopoietic Stem Cell Transplantation in Children With Acute Lymphoblastic Leukaemia and Other Haematological Malignancies. Front Pediatr 2021; 9:794541. [PMID: 35004548 PMCID: PMC8740090 DOI: 10.3389/fped.2021.794541] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 12/03/2021] [Indexed: 12/16/2022] Open
Abstract
Allogeneic haematopoietic stem cell transplantation (HSCT) represents a potentially curative option for children with high-risk or refractory/relapsed leukaemias. Traditional donor hierarchy favours a human leukocyte antigen (HLA)-matched sibling donor (MSD) over an HLA-matched unrelated donor (MUD), followed by alternative donors such as haploidentical donors or unrelated cord blood. However, haploidentical HSCT (hHSCT) may be entailed with significant advantages: besides a potentially increased graft-vs.-leukaemia effect, the immediate availability of a relative as well as the possibility of a second donation for additional cellular therapies may impact on outcome. The key question in hHSCT is how, and how deeply, to deplete donor T-cells. More T cells in the graft confer faster immune reconstitution with consecutively lower infection rates, however, greater numbers of T-cells might be associated with higher rates of graft-vs.-host disease (GvHD). Two different methods for reduction of alloreactivity have been established: in vivo T-cell suppression and ex vivo T-cell depletion (TCD). Ex vivo TCD of the graft uses either positive selection or negative depletion of graft cells before infusion. In contrast, T-cell-repleted grafts consisting of non-manipulated bone marrow or peripheral blood grafts require intense in vivo GvHD prophylaxis. There are two major T-cell replete protocols: one is based on post-transplantation cyclophosphamide (PTCy), while the other is based on anti-thymocyte globulin (ATG; Beijing protocol). Published data do not show an unequivocal benefit for one of these three platforms in terms of overall survival, non-relapse mortality or disease recurrence. In this review, we discuss the pros and cons of these three different approaches to hHSCT with an emphasis on the significance of the existing data for children with acute lymphoblastic leukaemia.
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Affiliation(s)
- Katharina Kleinschmidt
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, University Hospital of Regensburg, Regensburg, Germany
| | - Meng Lv
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, National Clinical Research Center for Hematologic Disease, Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China
| | - Asaf Yanir
- Bone Marrow Transplant Unit, Division of Haematology and Oncology, Schneider Children's Medical Center of Israel, Petach-Tikva, Israel.,The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Julia Palma
- Bone Marrow Transplant Unit, Hospital Dr. Luis Calvo Mackenna, Santiago, Chile
| | - Peter Lang
- Department of Pediatric Hematology and Oncology, University Children's Hospital, University of Tuebingen, Tuebingen, Germany
| | - Matthias Eyrich
- Department of Paediatric Haematology, Oncology and Stem Cell Transplantation, University Children's Hospital, University Medical Center, University of Würzburg, Würzburg, Germany
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20
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Zubarovskaya N, Bauer D, Ronceray L, Poetschger U, Kurzmann P, Lender C, Kuzmina Z, Lawitschka A. To Lighten the Burden of Cure: Thyroid Disease in Long-Term Survivors After TBI Conditioning for Paediatric ALL. Front Pediatr 2021; 9:798974. [PMID: 35127596 PMCID: PMC8809136 DOI: 10.3389/fped.2021.798974] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 12/20/2021] [Indexed: 01/29/2023] Open
Abstract
Thyroid disorders are well-studied after allogeneic haematopoietic stem cell transplantation (HSCT) following total body irradiation (TBI)-based conditioning, occurring in 15-30% of paediatric survivors. The toxic effect of TBI is known but data on the role of immunological dysregulation (ID) and chronic graft-versus-host-disease (cGvHD) are scarce. We studied functional and structural thyroid disorders in 97 paediatric ALL patients after TBI-based HSCT, assessing their correlation with patient/transplant characteristics including cGvHD, prolonged immunosuppression and ID. The 10- and 15-year cumulative incidence (CI) of functional disorders was 50 and 60%. Univariate analysis revealed TBI in 6 vs. 8 fractions (p = 0.01), an interval between ALL diagnosis and HSCT <1 year (p = 0.038), and the application of ATG (p = 0.044) as risk factors. The 10- and 15-year CI of structural disorders was 60 and 80%. No correlation between patient/transplant characteristics and structural disorders was observed. cGvHD, prolonged immunosuppression and additional radiotherapy were not associated with any thyroid disease. We observed a significant correlation between ID and the development of thyroid dysfunction in patients with structural changes (10-year CI: 77% for patients with ID vs. 56% without ID, p = 0.02). The impact of our results on thyroid follow-up evaluations and the significance of hormonal replacement therapy are discussed.
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Affiliation(s)
- Natalia Zubarovskaya
- Stem Cell Transplantation Unit, St. Anna Children's Hospital, Medical University Vienna, Vienna, Austria
| | - Dorothea Bauer
- Stem Cell Transplantation Unit, St. Anna Children's Hospital, Medical University Vienna, Vienna, Austria
| | - Leila Ronceray
- Stem Cell Transplantation Unit, St. Anna Children's Hospital, Medical University Vienna, Vienna, Austria
| | | | | | - Carina Lender
- Department of Pediatrics, St. Anna Children's Hospital, Medical University Vienna, Vienna, Austria
| | - Zoya Kuzmina
- Pulmonology Department, Ottakring Hospital, Vienna, Austria
| | - Anita Lawitschka
- Stem Cell Transplantation Unit, St. Anna Children's Hospital, Medical University Vienna, Vienna, Austria.,St. Anna Children's Cancer Research Institute, Vienna, Austria
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21
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Molina MS, Stokes J, Hoffman EA, Eremija J, Zeng Y, Simpson RJ, Katsanis E. Bendamustine Conditioning Skews Murine Host DCs Toward Pre-cDC1s and Reduces GvHD Independently of Batf3. Front Immunol 2020; 11:1410. [PMID: 32765499 PMCID: PMC7378358 DOI: 10.3389/fimmu.2020.01410] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 06/02/2020] [Indexed: 11/21/2022] Open
Abstract
Graft-versus-host disease (GvHD) remains the second leading cause of death in allogeneic hematopoietic stem cell transplantation recipients, highlighting the need for improved preventative strategies. Our laboratory has previously demonstrated in an experimental bone marrow transplantation (BMT) model that bendamustine combined with total body irradiation (BEN+TBI) is a safer alternative to cyclophosphamide with TBI (CY+TBI). The biological mechanisms of action of BEN have not been fully elucidated and likely involve multiple cell populations. Host dendritic cells (DCs) can prime naïve donor T-cells immediately following transplantation, making host DCs critical for the initiation phase of GvHD. We hypothesized that BEN+TBI conditioning favorably alters host DC composition to reduce GvHD. We demonstrate that host DCs treated with BEN+TBI induce less allogeneic T-cell proliferation than those conditioned with CY+TBI. We further show that BEN+TBI conditioning results in greater total numbers of all host DC subsets but with a more favorable composition compared to CY+TBI with significantly larger proportions of type 1 conventional DCs (cDC1), a highly regulatory DC subset capable of suppressing GvHD. Our studies using recipient Batf3 KO mice indicate that CD8α+ cDC1s are largely dispensable for the reduced GvHD following BEN+TBI conditioning. We found a higher frequency of host pre-cDC1s with BEN+TBI conditioning in both wild-type (WT) and Batf3 KO mice, which was inversely associated with GvHD. Additionally, we observed that BEN treatment results in greater expression of Flt3 receptor (CD135) on host DCs compared to CY, potentially contributing to the skewing of host DCs toward cDC1s. Further, BEN+TBI conditioning results in host cDCs with greater expression of PIR-B, an inhibitory receptor capable of preventing lethal GvHD. We conclude that BEN+TBI is a safer alternative to CY+TBI, resulting in a greater frequency of host pre-cDC1s and limiting GvHD.
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Affiliation(s)
- Megan S. Molina
- Department of Immunobiology, University of Arizona, Tucson, AZ, United States
- Department of Pediatrics, University of Arizona, Tucson, AZ, United States
| | - Jessica Stokes
- Department of Pediatrics, University of Arizona, Tucson, AZ, United States
| | - Emely A. Hoffman
- Department of Pediatrics, University of Arizona, Tucson, AZ, United States
| | - Jelena Eremija
- Department of Pediatrics, University of Arizona, Tucson, AZ, United States
| | - Yi Zeng
- Department of Pediatrics, University of Arizona, Tucson, AZ, United States
- Department of Pathology, University of Arizona, Tucson, AZ, United States
| | - Richard J. Simpson
- Department of Immunobiology, University of Arizona, Tucson, AZ, United States
- Department of Pediatrics, University of Arizona, Tucson, AZ, United States
- Department of Nutritional Science, University of Arizona, Tucson, AZ, United States
| | - Emmanuel Katsanis
- Department of Immunobiology, University of Arizona, Tucson, AZ, United States
- Department of Pediatrics, University of Arizona, Tucson, AZ, United States
- Department of Pathology, University of Arizona, Tucson, AZ, United States
- University of Arizona Cancer Center, University of Arizona, Tucson, AZ, United States
- Department of Medicine, University of Arizona, Tucson, AZ, United States
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22
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Katsanis E, Sapp LN, Reid SC, Reddivalla N, Stea B. T-Cell Replete Myeloablative Haploidentical Bone Marrow Transplantation Is an Effective Option for Pediatric and Young Adult Patients With High-Risk Hematologic Malignancies. Front Pediatr 2020; 8:282. [PMID: 32582591 PMCID: PMC7295947 DOI: 10.3389/fped.2020.00282] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 05/05/2020] [Indexed: 12/24/2022] Open
Abstract
Twenty-one pediatric and young adult patients (1.1-24.7 years) with hematologic malignancies underwent myeloablative T-cell replete haploidentical bone marrow transplant (haplo-BMT) between October 2015 to December 2019. Fifty-seven percent of the patients were ethnic or racial minorities. Thirteen patients had B-cell precursor acute lymphoblastic leukemia (B-ALL) with 10 receiving 1,200 cGy fractionated total body irradiation with fludarabine while the remaining 11 patients had targeted dose-busulfan, fludarabine, melphalan conditioning. Graft-vs.-host disease (GvHD) prophylaxis consisted of post-transplant cyclophosphamide (15 patients) or cyclophosphamide and bendamustine (six patients), with all patients receiving tacrolimus and mycophenolate mofetil. Twelve patients were in first or second remission at time of transplant with five in >2nd remission and four with measurable disease. Three patients had failed prior transplants and three CAR-T cell therapies. Only one patient developed primary graft failure but engrafted promptly after a second conditioned T-replete peripheral blood stem cell transplant from the same donor. An absolute neutrophil count of 0.5 × 109/L was achieved at a median time of 16 days post-BMT while platelet engraftment occurred at a median of 30 days. The cumulative incidence of grades III to IV acute GvHD and chronic GvHD was 15.2 and 18.1%, respectively. With a median follow-up of 25.1 months the relapse rate is 17.6% with an overall survival of 84.0% and a progression-free survival of 74.3%. The chronic graft-vs.-host-free relapse-free survival (CRFS) is 58.5% while acute and chronic graft-vs.-host-free relapse-free survival (GRFS) is 50.1%. Myeloablative conditioned T-replete haploidentical BMT is a viable alternative to matched unrelated transplantation for children and young adults with high-risk hematologic malignancies.
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Affiliation(s)
- Emmanuel Katsanis
- Department of Pediatrics, University of Arizona, Tucson, AZ, United States
- Department of Immunobiology, University of Arizona, Tucson, AZ, United States
- Department of Medicine, University of Arizona, Tucson, AZ, United States
- Department of Pathology, University of Arizona, Tucson, AZ, United States
- The University of Arizona Cancer Center, Tucson, AZ, United States
- Banner University Medical Center, Tucson, AZ, United States
- Banner Cardon Children's Medical Center, Mesa, AZ, United States
| | - Lauren N. Sapp
- Department of Pediatrics, University of Arizona, Tucson, AZ, United States
- Banner University Medical Center, Tucson, AZ, United States
| | - Susie Cienfuegos Reid
- Department of Pediatrics, University of Arizona, Tucson, AZ, United States
- Banner University Medical Center, Tucson, AZ, United States
| | - Naresh Reddivalla
- Department of Pediatrics, University of Arizona, Tucson, AZ, United States
- Banner Cardon Children's Medical Center, Mesa, AZ, United States
| | - Baldassarre Stea
- The University of Arizona Cancer Center, Tucson, AZ, United States
- Banner University Medical Center, Tucson, AZ, United States
- Department of Radiation Oncology, University of Arizona, Tucson, AZ, United States
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23
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Katsanis E, Maher K, Roe DJ, Simpson RJ. Progressive substitution of posttransplant cyclophosphamide with bendamustine: A phase I study in haploidentical bone marrow transplantation. EJHAEM 2020; 1:286-292. [PMID: 35847727 PMCID: PMC9176108 DOI: 10.1002/jha2.20] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/03/2020] [Accepted: 05/05/2020] [Indexed: 01/19/2023]
Abstract
We have initiated a single center phase I study in patients with hematologic malignancies progressively substituting day +4 posttransplant cyclophosphamide (PT‐CY) with bendamustine (PT‐BEN) following myeloablative conditioning (MAC) and T‐cell replete haploidentical bone marrow transplantation (haplo‐BMT). We report herein our interim analysis of our first three cohorts PT‐CY (mg/kg)/PT‐BEN (mg/m2): 40/20, 20/60, and 0/90. All patients have tolerated PT‐CY/BEN well with no dose limiting toxicities. Compared to contemporaneous controls undergoing haplo‐BMT with the same MAC regimens but only PT‐CY, we have observed earlier trilineage engraftment (P = .002 neutrophils, P = .014 platelets) and a lower incidence of cytomegalovirus reactivation (P = .016) in the PT‐CY/BEN cohorts. After substituting day +4 PT‐CY with PT‐BEN, the registered trial (www.clinicaltrials.gov;NCT02996773) is proceeding to replace day +3 PT‐CY with PT‐BEN with a view to identifying further evidence on the potential advantages of PT‐BEN.
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Affiliation(s)
- Emmanuel Katsanis
- Department of PediatricsUniversity of Arizona Tucson Arizona
- Department of ImmunobiologyUniversity of Arizona Tucson Arizona
- Department of MedicineUniversity of Arizona Tucson Arizona
- Department of PathologyUniversity of Arizona Tucson Arizona
- The University of Arizona Cancer Center Tucson Arizona
| | - Keri Maher
- Department of MedicineUniversity of Arizona Tucson Arizona
- The University of Arizona Cancer Center Tucson Arizona
- Banner University Medical Center Tucson Arizona
| | - Denise J. Roe
- The University of Arizona Cancer Center Tucson Arizona
- Department of Epidemiology and BiostatisticsUniversity of Arizona Tucson Arizona
| | - Richard J. Simpson
- Department of PediatricsUniversity of Arizona Tucson Arizona
- Department of ImmunobiologyUniversity of Arizona Tucson Arizona
- The University of Arizona Cancer Center Tucson Arizona
- Department of Nutritional SciencesUniversity of Arizona Tucson Arizona
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24
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Stokes J, Hoffman EA, Molina MS, Kummet N, Simpson RJ, Zeng Y, Katsanis E. Bendamustine with total body irradiation conditioning yields tolerant T-cells while preserving T-cell-dependent graft-versus-leukemia. Oncoimmunology 2020; 9:1758011. [PMID: 32391190 PMCID: PMC7199810 DOI: 10.1080/2162402x.2020.1758011] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 04/01/2020] [Accepted: 04/15/2020] [Indexed: 12/16/2022] Open
Abstract
Graft-versus-host disease (GvHD) remains a significant impediment to allogeneic hematopoietic cell transplantation (HCT) success, necessitating studies focused on alleviating GvHD, while preserving the graft-versus-leukemia (GvL) effect. Based on our previous studies showing bendamustine with total body irradiation (BEN-TBI) conditioning reduces GvHD compared to the current clinical standard of care cyclophosphamide (CY)-TBI in a murine MHC-mismatched bone marrow transplantation (BMT) model, this study aimed to evaluate the role and fate of donor T-cells following BEN-TBI conditioning. We demonstrate that BEN-TBI reduces GvHD compared to CY-TBI independently of T regulatory cells (Tregs). BEN-TBI conditioned mice have a smaller proportion and less activated donor T-cells, with lower CD47 expression, early post-transplant, but no sustained phenotypic differences in T-cells. In BEN-TBI conditioned mice, donor T-cells gain tolerance specific to host MHC antigens. Though these T-cells are tolerant to host antigens, we demonstrate that BEN-TBI preserves a T-cell-dependent GvL effect. These findings indicate that BEN-TBI conditioning reduces GvHD without compromising GvL, warranting its further investigation as a potentially safer and more efficacious clinical alternative to CY-TBI.
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Affiliation(s)
- Jessica Stokes
- Department of Pediatrics, University of Arizona, Tucson, AZ, USA
| | - Emely A Hoffman
- Department of Pediatrics, University of Arizona, Tucson, AZ, USA
| | - Megan S Molina
- Department of Pediatrics, University of Arizona, Tucson, AZ, USA.,Department of Immunobiology, University of Arizona, Tucson, AZ, USA
| | - Nicole Kummet
- Department of Pediatrics, University of Arizona, Tucson, AZ, USA.,Department of Molecular and Cellular Biology, University of Arizona, Tucson, AZ, USA
| | - Richard J Simpson
- Department of Pediatrics, University of Arizona, Tucson, AZ, USA.,Department of Immunobiology, University of Arizona, Tucson, AZ, USA.,Department of Nutritional Sciences, University of Arizona, Tucson, AZ, USA.,The University of Arizona Cancer Center, Tucson, AZ, USA
| | - Yi Zeng
- Department of Pediatrics, University of Arizona, Tucson, AZ, USA.,The University of Arizona Cancer Center, Tucson, AZ, USA
| | - Emmanuel Katsanis
- Department of Pediatrics, University of Arizona, Tucson, AZ, USA.,Department of Immunobiology, University of Arizona, Tucson, AZ, USA.,The University of Arizona Cancer Center, Tucson, AZ, USA.,Department of Medicine, University of Arizona, Tucson, AZ, USA.,Department of Pathology, University of Arizona, Tucson, AZ, USA
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25
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Gatza E, Reddy P, Choi SW. Prevention and Treatment of Acute Graft-versus-Host Disease in Children, Adolescents, and Young Adults. Biol Blood Marrow Transplant 2020; 26:e101-e112. [PMID: 31931115 DOI: 10.1016/j.bbmt.2020.01.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 12/31/2019] [Accepted: 01/03/2020] [Indexed: 12/14/2022]
Abstract
Acute graft-versus-host disease (GVHD) continues to be a major cause of morbidity and mortality after allogeneic hematopoietic cell transplant (HCT) in pediatric patients (ie, children and adolescent and young adults) and limits broader application of the therapy. Pediatric HCT patients have faced major obstacles to access clinical trials that test new agents for GVHD prevention and treatment. According to a recent search, only 6 clinical trials of interventions for prevention or treatment of acute GVHD were conducted specifically in pediatric patients in the United States over the past decade, with 8 internationally. In this review, we summarize the studies that were performed and specifically enrolled and reported on pediatric patients after allogeneic HCT and provide a listing of studies currently under way.
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Affiliation(s)
- Erin Gatza
- Department of Pediatrics, Division of Hematology-Oncology, University of Michigan, Ann Arbor, Michigan
| | - Pavan Reddy
- Department of Internal Medicine, Division of Hematology-Oncology, Blood & Marrow Transplant Program, University of Michigan, Ann Arbor, Michigan
| | - Sung Won Choi
- Department of Pediatrics, Division of Hematology-Oncology, University of Michigan, Ann Arbor, Michigan.
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26
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Rimando J, Slade M, DiPersio JF, Westervelt P, Gao F, Liu C, Romee R. The Predicted Indirectly Recognizable HLA Epitopes (PIRCHE) Score for HLA Class I Graft-versus-Host Disparity Is Associated with Increased Acute Graft-versus-Host Disease in Haploidentical Transplantation with Post-Transplantation Cyclophosphamide. Biol Blood Marrow Transplant 2020; 26:123-131. [PMID: 31563575 PMCID: PMC7286229 DOI: 10.1016/j.bbmt.2019.09.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 09/16/2019] [Accepted: 09/18/2019] [Indexed: 11/17/2022]
Abstract
The Predicted Indirectly Recognizable HLA Epitopes (PIRCHE) score quantifies the number of PIRCHEs in patient-donor pairs and represents an in silico measure of indirect alloreactivity. This biologic process is defined as T cell recognition of epitopes derived from mismatched, allogeneic HLA peptides that are subsequently presented by shared HLA molecules. Its association with clinical outcome has not been examined in haploidentical hematopoietic cell transplantation (haplo-HCT) with post-transplantation cyclophosphamide (PTCy). We hypothesized that the PIRCHE score (PS) would correlate with indirect alloreactivity and predict graft-versus-host disease (GVHD) risk and the incidence of relapse after haplo-HCT with PTCy. We retrospectively analyzed 148 patients who underwent peripheral blood stem cell T cell-replete haplo-HCT with PTCy at a single center between 2009 and 2016. For each patient-donor pair, the PS was calculated using the PIRCHE online matching tool. PSs were categorized by class and vector. The median class I graft-versus-host (GVH) PS was 11 (range, 0 to 56), and the median class I host-versus-graft (HVG) PS was 10 (range, 0 to 51). Class I GVH PS was associated with increased risk of grade II-IV acute GVHD (adjusted hazard ratio, 1.03 per PS unit increase; 95% confidence interval, 1.01 to 1.05; P= .008) but not of chronic GVHD or relapse. Our data show that use of the PS is a novel strategy for predicting clinical outcome in haplo-HCT; further studies using registry data and prospective cohorts are warranted to validate these findings.
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Affiliation(s)
- Joseph Rimando
- BMT and Leukemia Program, Washington University School of Medicine, Saint Louis, Missouri
| | - Michael Slade
- BMT and Leukemia Program, Washington University School of Medicine, Saint Louis, Missouri
| | - John F DiPersio
- BMT and Leukemia Program, Washington University School of Medicine, Saint Louis, Missouri
| | - Peter Westervelt
- BMT and Leukemia Program, Washington University School of Medicine, Saint Louis, Missouri
| | - Feng Gao
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Chang Liu
- Department of Pathology and Immunology, Washington University School of Medicine, Saint Louis, Missouri.
| | - Rizwan Romee
- Division of Hematologic Malignancies and Transplantation, Dana Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
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27
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Macaraeg M, Proytcheva M, Katsanis E. Transfusion independence after repeated haploidentical hematopoietic cell transplants in a patient with congenital dyserythropoietic anemia type II and hemosiderosis. Pediatr Transplant 2019; 23:e13587. [PMID: 31529567 DOI: 10.1111/petr.13587] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 08/12/2019] [Accepted: 08/22/2019] [Indexed: 11/30/2022]
Abstract
Matched related or unrelated donor allogeneic HCT has occasionally been applied in patients with severe CDA type II and proven to be curative. We report on the first patient with CDA to undergo haploidentical bone marrow transplantation with PT-CY. A 12-year-old boy with severe hemosiderosis, and a, consequently, disturbed BM microenvironment, developed recurrent graft failures and required salvage with two additional haploidentical HCTs. He achieved complete donor chimerism and transfusion independence after the third HCT. Our case underscores the risks associated with performing haploidentical HCT in older pediatric patients with CDA and severe chronic iron overload.
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Affiliation(s)
- Marci Macaraeg
- Department of Pediatrics, University of Arizona, Tucson, Arizona.,Banner University Medical Center, Tucson, Arizona
| | - Maria Proytcheva
- Banner University Medical Center, Tucson, Arizona.,Department of Pathology, University of Arizona, Tucson, Arizona
| | - Emmanuel Katsanis
- Department of Pediatrics, University of Arizona, Tucson, Arizona.,Banner University Medical Center, Tucson, Arizona.,Department of Pathology, University of Arizona, Tucson, Arizona.,Department of Medicine, University of Arizona, Tucson, Arizona.,Department of Immunobiology, University of Arizona, Tucson, Arizona
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28
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Bacigalupo A, Maria Raiola A, Dominietto A, Di Grazia C, Gualandi F, Lint MTV, Chiusolo P, Laurenti L, Sora F, Giammarco S, Angelucci E. Graft versus host disease in unmanipulated haploidentical marrow transplantation with a modified post-transplant cyclophosphamide (PT-CY) regimen: an update on 425 patients. Bone Marrow Transplant 2019; 54:708-712. [DOI: 10.1038/s41409-019-0594-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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