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Sala E, Neagoie AM, Lewerenz J, Saadati M, Benner A, Gantner A, Wais V, Döhner H, Bunjes D. Neurologic Complications of the Central Nervous System after Allogeneic Stem Cell Transplantation: The Role of Transplantation-Associated Thrombotic Microangiopathy as a Potential Underreported Cause. Transplant Cell Ther 2024; 30:586.e1-586.e11. [PMID: 38508452 DOI: 10.1016/j.jtct.2024.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 03/12/2024] [Accepted: 03/15/2024] [Indexed: 03/22/2024]
Abstract
Neurologic complications (NCs), especially those of the central nervous system (CNS), represent a severe complication after allogeneic stem cell transplantation (allo-HSCT) and are associated with relevant morbidity and mortality. We aimed to characterize the potential risk factors for the development of CNS-NC, with a special focus on the role of calcineurin inhibitors (CNIs) as a predisposing factor. For this purpose, we compared cyclosporin A (CsA) versus tacrolimus (TAC) with respect to their influence on the incidence and type of CNS-NC after allo-HSCT. We retrospectively analyzed the incidence, risk factors, and impact on outcomes of CNS-NC diagnosed during the post-transplantation follow-up in patients with different high-risk hematologic malignancies who underwent allo-HSCT at our institution over a 20-year period. All patients included in the analysis received CNI (CsA or TAC) as graft-versus-host disease (GVHD) prophylaxis. We evaluated a total of 739 consecutive patients who underwent transplantation between December 1999 and April 2019. During a median follow-up of 6.8 years, we observed a CNS-NC incidence of 17%. The development of CNS-NC was associated with decreased overall survival (OS) and increased transplantation-related mortality (TRM). The most frequent CNS-NCs were infections (30%) and neurologic adverse events related to the administration of CNI, TAC, or CsA as GVHD prophylaxis (42%). In the multivariable analysis, age, total body irradiation (TBI), and severe acute GVHD and chronic GVHD were significant risk factors in the development of CNS-NCs. TAC compared with CsA emerged as an independent predisposing factor for CNS-NCs. The TAC-associated risk of CNS-NCs was related mostly to the occurrence of transplantation-associated thrombotic microangiopathy (TA-TMA) with neurologic manifestations (neuro-TA-TMA), although the general TA-TMA incidence was comparable in the 2 CNI subgroups. CNS-NCs are associated with poor prognosis after allo-HSCT, with TAC emerging as a potential yet insufficiently characterized predisposing factor.
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Affiliation(s)
- Elisa Sala
- Department of Internal Medicine III, University Hospital Ulm, Ulm, Germany.
| | - Adela M Neagoie
- Department of Internal Medicine III, University Hospital Ulm, Ulm, Germany
| | - Jan Lewerenz
- Department of Neurology, University Hospital Ulm, Ulm, Germany
| | - Maral Saadati
- Division of Biostatistics, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Axel Benner
- Division of Biostatistics, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Andrea Gantner
- Department of Internal Medicine III, University Hospital Ulm, Ulm, Germany
| | - Verena Wais
- Department of Internal Medicine III, University Hospital Ulm, Ulm, Germany
| | - Hartmut Döhner
- Department of Internal Medicine III, University Hospital Ulm, Ulm, Germany
| | - Donald Bunjes
- Department of Internal Medicine III, University Hospital Ulm, Ulm, Germany
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Henig I, Isenberg J, Yehudai-Ofir D, Leiba R, Ringelstein-Harlev S, Ram R, Avni B, Amit O, Grisariu S, Azoulay T, Slouzkey I, Zuckerman T. Third BNT162b2 mRNA SARS-CoV-2 Vaccine Dose Significantly Enhances Immunogenicity in Recipients of Allogeneic Hematopoietic Stem Cell Transplantation. Vaccines (Basel) 2023; 11:vaccines11040775. [PMID: 37112688 PMCID: PMC10145595 DOI: 10.3390/vaccines11040775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 03/22/2023] [Accepted: 03/27/2023] [Indexed: 04/03/2023] Open
Abstract
COVID-19-related mortality among hematopoietic stem cell transplantation (HSCT) recipients in the pre-vaccine era ranged between 22 and 33%. The Pfizer/BioNTech BNT162b2 vaccine demonstrated significant immunogenicity and efficacy in the healthy population; however, its long-term effects on allogeneic HSCT recipients remained unclear. Our study longitudinally evaluated humoral and cellular responses to the BNT162b2 vaccine in adult allogeneic HSCT patients. A positive response was defined as antibody titers ≥ 150 AU/mL post-second vaccination. Among 77 included patients, 51 (66.2%) responded to vaccination. Response-associated factors were female gender, recent anti-CD20 therapy, and a longer interval between transplant and vaccination. Response rates reached 83.7% in patients vaccinated >12 months post-transplant. At 6 months post-second vaccination, antibody titers dropped, but were significantly increased with the booster dose. Moreover, 43% (6/14) of non-responders to the second vaccination acquired sufficient antibody titers after booster administration, resulting in an overall response rate of 79.5% for the entire cohort. The BNT162b2 vaccine was effective in allogeneic transplant recipients. Although antibody titers decreased with time, the third vaccination led to their significant elevation, with 93% of third-dose responders maintaining titers above 150 AU/mL at 3 months post-administration.
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Management of Acute Myeloid Leukemia: A Review for General Practitioners in Oncology. Curr Oncol 2022; 29:6245-6259. [PMID: 36135060 PMCID: PMC9498246 DOI: 10.3390/curroncol29090491] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 08/16/2022] [Accepted: 08/17/2022] [Indexed: 12/04/2022] Open
Abstract
Acute myeloid leukemia (AML) is a hematologic malignancy that most frequently develops in older adults. Overall, AML is associated with a high mortality although advancements in genetic risk stratification and new treatments are leading to improvements in outcomes for some subgroups. In this review, we discuss an individualized approach to intensive therapy with a focus on the role of recently approved novel therapies as well as the selection of post-remission therapies for patients in first remission. We discuss the management of patients with relapsed and refractory AML, including the role of targeted treatment and allogeneic stem cell transplant. Next, we review non-intensive treatment for older and unfit AML patients including the use of azacitidine and venetoclax. Finally, we discuss the integration of palliative care in the management of patients with AML.
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Kliman D, Tran S, Kennedy G, Curley C, McLean A, Gottlieb D, Kwan J, Ritchie D, Chee L, Spencer A, Purtill D, Bardy P, Larsen S, Chien N, Perera T, Greenwood M, Hamad N, Moore J. The improvement in overall survival from unrelated donor transplantation in Australia and New Zealand is driven by a reduction in non-relapse mortality: A study from the ABMTRR. Bone Marrow Transplant 2022; 57:982-989. [PMID: 35440804 DOI: 10.1038/s41409-022-01683-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 04/04/2022] [Accepted: 04/06/2022] [Indexed: 11/09/2022]
Abstract
Unrelated donors (UDs) are the commonest source for allogeneic transplantation (alloSCT), with higher non-relapse mortality (NRM) than siblings. We analyzed data from the Australasian Bone Marrow Transplant Recipient Registry from adults receiving a first UD alloSCT during 2001-2015, to determine whether and how NRM has changed. Predictors of outcome were determined using cox regression, accounting for time-interactions and competing risks. A total of 2308 patients met inclusion criteria. Changes over time included increasing age, utilization of peripheral blood cells, reduced intensity conditioning, and T-cell depletion. Three-year OS increased significantly from 44% in 2001-2005 to 58% in 2011-2015 (p < 0.001). This was attributed to a reduction in NRM from 35% to 24% (p < 0.001) with no change in relapse. Factors associated with increased NRM included age, male sex, CMV seropositivity, HLA mismatch, transplant more than 6 months from diagnosis, and T-cell depletion when administered during 2001-2005. Survival following UD SCT has improved by almost 15% over the past decade, driven by improvements in NRM. This has occurred despite increasing recipient age and appears to be due to better donor selection, reduced delays to transplantation, and improved prevention and management of GVHD.
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Affiliation(s)
- David Kliman
- Department of Haematology and Stem Cell Transplantation, St Vincent's Hospital, Sydney, NSW, Australia.
| | - Steven Tran
- Australasian Bone Marrow Transplant Recipient Registry, Sydney, NSW, Australia
| | - Glen Kennedy
- Haematology and Bone Marrow Transplant Service, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Cameron Curley
- Haematology and Bone Marrow Transplant Service, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Angela McLean
- Haematology and Bone Marrow Transplant Service, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - David Gottlieb
- Blood Transplant and Cell Therapies Program, Westmead Hospital, Sydney, NSW, Australia
| | - John Kwan
- Blood Transplant and Cell Therapies Program, Westmead Hospital, Sydney, NSW, Australia
| | - David Ritchie
- Department of Haematology and BMT, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Lynette Chee
- Department of Haematology and BMT, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Andrew Spencer
- Malignant Haematology and Stem Cell Transplantation Service, Alfred Hospital, Melbourne, VIC, Australia
| | - Duncan Purtill
- Blood and Marrow Transplant Program, Fiona Stanley Hospital, Perth, WA, Australia
| | - Peter Bardy
- Haematology and Bone Marrow Transplant Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Stephen Larsen
- Institute of Haematology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Nicole Chien
- Clinical Haematology Service and Stem Cell Transplant Program, Auckland City Hospital, Auckland, New Zealand
| | - Travis Perera
- Wellington Blood and Cancer Centre, Wellington Hospital, Wellington, New Zealand
| | - Matthew Greenwood
- Department of Haematology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Nada Hamad
- Department of Haematology and Stem Cell Transplantation, St Vincent's Hospital, Sydney, NSW, Australia
| | - John Moore
- Department of Haematology and Stem Cell Transplantation, St Vincent's Hospital, Sydney, NSW, Australia
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