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Arnold DE, Emoto C, Fukuda T, Dong M, Vinks AA, Lane A, McIntosh K, Neumeier L, Lankester AC, Achini F, Teusink-Cross A, Chandra S, Jordan MB, Nelson AS, Myers KC, Davies SM, Mehta PA, Marsh RA. A prospective pilot study of a novel alemtuzumab target concentration intervention strategy. Bone Marrow Transplant 2021; 56:3029-3031. [PMID: 34548626 DOI: 10.1038/s41409-021-01460-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 08/03/2021] [Accepted: 09/01/2021] [Indexed: 11/09/2022]
Abstract
Alemtuzumab is used as part of reduced-intensity and reduced-toxicity transplant conditioning regimens for nonmalignant diseases. Prior studies identified an ideal target concentration range of 0.15-0.6 mcg/mL at day 0. However, only 24% of patients fall within this window using standard intermediate dosing. We performed a pilot study of a novel target concentration intervention strategy to target day 0 alemtuzumab concentrations to 0.15-0.6 mcg/mL. Twelve patients received model-informed alemtuzumab dosing of 0.5-0.6 mcg/kg divided over days -14 to -12. Alemtuzumab concentrations were measured, and pharmacokinetic (PK) modeling was performed on day -5 to predict day 0 concentrations. If the day 0 alemtuzumab concentration was predicted to fall below 0.15 mcg/mL, simulations were performed to identify the individual "top-up" dose needed to achieve the target day 0 concentration window. Six (50%) patients achieved day 0 alemtuzumab concentrations between 0.15 and 0.6 mcg/mL (4 received a top-up dose). Five patients had day 0 concentrations above the target window (no top-up doses). One patient had a day 0 concentration below the target range in the presence of anti-alemtuzumab antibodies. A concentration intervention strategy approach to alemtuzumab treatment can successfully target a greater proportion of patients into the ideal therapeutic window. Additional dose-reduction studies are needed to further optimize the initial dosing and achieve target attainment in all patients.
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Affiliation(s)
- Danielle E Arnold
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Chie Emoto
- Division of Pharmacology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Tsuyoshi Fukuda
- Division of Pharmacology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Min Dong
- Division of Pharmacology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Alexander A Vinks
- Division of Pharmacology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Adam Lane
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Kelly McIntosh
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Lisa Neumeier
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Arjan C Lankester
- Division of Stem Cell Transplantation, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Federica Achini
- Lab of Pediatric Immunology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Ashley Teusink-Cross
- Division of Pharmacology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Sharat Chandra
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Michael B Jordan
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Adam S Nelson
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Kasiani C Myers
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Stella M Davies
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Parinda A Mehta
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Rebecca A Marsh
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
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Sommer C, Boldajipour B, Kuo TC, Bentley T, Sutton J, Chen A, Geng T, Dong H, Galetto R, Valton J, Pertel T, Juillerat A, Gariboldi A, Pascua E, Brown C, Chin SM, Sai T, Ni Y, Duchateau P, Smith J, Rajpal A, Van Blarcom T, Chaparro-Riggers J, Sasu BJ. Preclinical Evaluation of Allogeneic CAR T Cells Targeting BCMA for the Treatment of Multiple Myeloma. Mol Ther 2019; 27:1126-1138. [PMID: 31005597 DOI: 10.1016/j.ymthe.2019.04.001] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 04/02/2019] [Accepted: 04/02/2019] [Indexed: 12/21/2022] Open
Abstract
Clinical success of autologous CD19-directed chimeric antigen receptor T cells (CAR Ts) in acute lymphoblastic leukemia and non-Hodgkin lymphoma suggests that CAR Ts may be a promising therapy for hematological malignancies, including multiple myeloma. However, autologous CAR T therapies have limitations that may impact clinical use, including lengthy vein-to-vein time and manufacturing constraints. Allogeneic CAR T (AlloCAR T) therapies may overcome these innate limitations of autologous CAR T therapies. Unlike autologous cell therapies, AlloCAR T therapies employ healthy donor T cells that are isolated in a manufacturing facility, engineered to express CARs with specificity for a tumor-associated antigen, and modified using gene-editing technology to limit T cell receptor (TCR)-mediated immune responses. Here, transcription activator-like effector nuclease (TALEN) gene editing of B cell maturation antigen (BCMA) CAR Ts was used to confer lymphodepletion resistance and reduced graft-versus-host disease (GvHD) potential. The safety profile of allogeneic BCMA CAR Ts was further enhanced by incorporating a CD20 mimotope-based intra-CAR off switch enabling effective CAR T elimination in the presence of rituximab. Allogeneic BCMA CAR Ts induced sustained antitumor responses in mice supplemented with human cytokines, and, most importantly, maintained their phenotype and potency after scale-up manufacturing. This novel off-the-shelf allogeneic BCMA CAR T product is a promising candidate for clinical evaluation.
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Affiliation(s)
- Cesar Sommer
- Allogene Therapeutics, Inc., 210 E. Grand Avenue, South San Francisco, CA 94080, USA.
| | - Bijan Boldajipour
- Pfizer Cancer Immunology Discovery, Pfizer Worldwide Research and Development, 230 E. Grand Avenue, South San Francisco, CA 94080, USA
| | - Tracy C Kuo
- Pfizer Cancer Immunology Discovery, Pfizer Worldwide Research and Development, 230 E. Grand Avenue, South San Francisco, CA 94080, USA
| | - Trevor Bentley
- Allogene Therapeutics, Inc., 210 E. Grand Avenue, South San Francisco, CA 94080, USA
| | - Janette Sutton
- Allogene Therapeutics, Inc., 210 E. Grand Avenue, South San Francisco, CA 94080, USA
| | - Amy Chen
- Pfizer Cancer Immunology Discovery, Pfizer Worldwide Research and Development, 230 E. Grand Avenue, South San Francisco, CA 94080, USA
| | - Tao Geng
- Pfizer Cancer Immunology Discovery, Pfizer Worldwide Research and Development, 230 E. Grand Avenue, South San Francisco, CA 94080, USA
| | - Holly Dong
- Pfizer Cancer Immunology Discovery, Pfizer Worldwide Research and Development, 230 E. Grand Avenue, South San Francisco, CA 94080, USA
| | - Roman Galetto
- Cellectis SA, 8 rue de la Croix Jarry, 75013 Paris, France
| | - Julien Valton
- Cellectis, Inc., 430 East 29th Street, New York, NY 10016, USA
| | - Thomas Pertel
- Allogene Therapeutics, Inc., 210 E. Grand Avenue, South San Francisco, CA 94080, USA
| | | | | | - Edward Pascua
- Pfizer Cancer Immunology Discovery, Pfizer Worldwide Research and Development, 230 E. Grand Avenue, South San Francisco, CA 94080, USA
| | - Colleen Brown
- Pfizer Cancer Immunology Discovery, Pfizer Worldwide Research and Development, 230 E. Grand Avenue, South San Francisco, CA 94080, USA
| | - Sherman M Chin
- Pfizer Cancer Immunology Discovery, Pfizer Worldwide Research and Development, 230 E. Grand Avenue, South San Francisco, CA 94080, USA
| | - Tao Sai
- Pfizer Cancer Immunology Discovery, Pfizer Worldwide Research and Development, 230 E. Grand Avenue, South San Francisco, CA 94080, USA
| | - Yajin Ni
- Allogene Therapeutics, Inc., 210 E. Grand Avenue, South San Francisco, CA 94080, USA
| | | | - Julianne Smith
- Cellectis, Inc., 430 East 29th Street, New York, NY 10016, USA
| | - Arvind Rajpal
- Pfizer Cancer Immunology Discovery, Pfizer Worldwide Research and Development, 230 E. Grand Avenue, South San Francisco, CA 94080, USA
| | - Thomas Van Blarcom
- Allogene Therapeutics, Inc., 210 E. Grand Avenue, South San Francisco, CA 94080, USA
| | - Javier Chaparro-Riggers
- Pfizer Cancer Immunology Discovery, Pfizer Worldwide Research and Development, 230 E. Grand Avenue, South San Francisco, CA 94080, USA
| | - Barbra J Sasu
- Allogene Therapeutics, Inc., 210 E. Grand Avenue, South San Francisco, CA 94080, USA.
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3
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Robin M, Raj K, Chevret S, Gauthier J, de Lavallade H, Michonneau D, McLornan D, Peffault de Latour R, Potter V, Kulasekararaj A, Sicre de Fontbrune F, Pagliuca A, Yakoub-Agha I, Socié G, Mufti GJ. Alemtuzumab vs anti-thymocyte globulin in patients transplanted from an unrelated donor after a reduced intensity conditioning. Eur J Haematol 2018; 101:466-474. [PMID: 29714032 DOI: 10.1111/ejh.13085] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Relapse and graft-vs-host disease (GVHD) are still the main complications after allogeneic hematopoietic stem cell transplantation, especially in the setting of reduced intensity regimen (RIC) and unrelated donor. We compared here anti-thymocyte globulin (ATG) or alemtuzumab as GVHD prophylaxis in patients with myeloid disease transplanted after RIC and from an unrelated donor. METHOD ATG and alemtuzumab patients have been matched by age, gender, HLA matching, comorbidities and cytogenetics risk (119 patients in each group). RESULTS After matching, we found that ATG decreased the risk of relapse (HR: 0.55, P = .0049) and improved relapse-free survival (RFS, HR: 0.70, P = .042). The improved RFS with ATG was more pronounced in CMV-positive patients but was not influenced by disease risk. Regarding overall survival, GVHD-free relapse-free survival and transplant-related mortality, the risk was similar using ATG or alemtuzumab. CONCLUSION Even if GVHD risk is lowered by alemtuzumab use, it does not translate in better outcome due to higher risk of relapse.
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Affiliation(s)
- Marie Robin
- Service d'hématologie greffe, Hôpital Saint-Louis, APHP, Paris, France.,INSERM 1131 Université Paris 7, Paris, France
| | - Kavita Raj
- Department of Haematological Medicine, Kings College Hospital and Kings College London, London, UK
| | - Sylvie Chevret
- Service de biostatistique, Hôpital Saint-Louis, APHP, Université Paris 7, Paris, France
| | - Jordan Gauthier
- CHU de Lille, LIRIC INSERM U955, Université Lille2, Paris, France
| | - Hugues de Lavallade
- Department of Haematological Medicine, Kings College Hospital and Kings College London, London, UK
| | - David Michonneau
- Service d'hématologie greffe, Hôpital Saint-Louis, APHP, Paris, France.,INSERM 1160 Université Paris 7, Paris, France
| | - Donal McLornan
- Department of Haematological Medicine, Kings College Hospital and Kings College London, London, UK
| | | | - Victoria Potter
- Department of Haematological Medicine, Kings College Hospital and Kings College London, London, UK
| | - Austin Kulasekararaj
- Department of Haematological Medicine, Kings College Hospital and Kings College London, London, UK
| | | | - Antonio Pagliuca
- Department of Haematological Medicine, Kings College Hospital and Kings College London, London, UK
| | - Ibrahim Yakoub-Agha
- Service de biostatistique, Hôpital Saint-Louis, APHP, Université Paris 7, Paris, France
| | - Gérard Socié
- Service d'hématologie greffe, Hôpital Saint-Louis, APHP, Paris, France.,INSERM 1160 Université Paris 7, Paris, France
| | - Ghulam J Mufti
- Department of Haematological Medicine, Kings College Hospital and Kings College London, London, UK
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Guilcher GMT, Shah R, Shenoy S. Principles of alemtuzumab immunoablation in hematopoietic cell transplantation for non-malignant diseases in children: A review. Pediatr Transplant 2018; 22. [PMID: 29352515 DOI: 10.1111/petr.13142] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/29/2017] [Indexed: 12/19/2022]
Abstract
Alemtuzumab is a humanized mAb targeted to CD52. Alemtuzumab is highly immunosuppressive with the ability to deplete T and B cells (in addition to other immune cell lines). A growing understanding of the PKs, dosing, and timing of administration of alemtuzumab has allowed for the study of its use as a conditioning agent for allogeneic HCT. The highly immunosuppressive properties of the drug are particularly appealing in the setting of non-malignant HCT, where GVHD provides no clinical benefit and relapse of malignancy is not applicable. In addition, the degree of immune suppression achieved with alemtuzumab has allowed for a reduction in the intensity of myeloablative cytotoxic agents included in some HCT conditioning regimens, allowing for fewer acute and late toxicities. This review paper will provide a comprehensive summary of the mechanism of action, PKs, dosing, and timing of alemtuzumab, a brief description of its use in various allogeneic HCT protocols for non-malignant conditions and a summary of the data regarding its use for GVHD therapy. The goal of this review was to provide an understanding as to how alemtuzumab might be safely incorporated into HCT conditioning regimens for children with non-malignant disease, allowing for expanded access to curative HCT therapy.
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Affiliation(s)
- Gregory M T Guilcher
- Section of Paediatric Oncology/BMT, Departments of Oncology and Paediatrics, University of Calgary, Calgary, AB, Canada
| | - Ravi Shah
- Department of Paediatric Haematology/BMT, Great Ormond Street Hospital, NHS Foundation Trust, London, UK
| | - Shalini Shenoy
- Division of Pediatric Hematology/Oncology, Washington University School of Medicine, St. Louis, MO, USA
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5
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Marsh RA, Fukuda T, Emoto C, Neumeier L, Khandelwal P, Chandra S, Teusink-Cross A, Vinks AA, Mehta PA. Pretransplant Absolute Lymphocyte Counts Impact the Pharmacokinetics of Alemtuzumab. Biol Blood Marrow Transplant 2017; 23:635-641. [DOI: 10.1016/j.bbmt.2017.01.071] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 01/11/2017] [Indexed: 10/20/2022]
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Zhao Y, Su H, Shen X, Du J, Zhang X, Zhao Y. The immunological function of CD52 and its targeting in organ transplantation. Inflamm Res 2017; 66:571-578. [PMID: 28283679 DOI: 10.1007/s00011-017-1032-8] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Revised: 02/18/2017] [Accepted: 02/22/2017] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION CD52 (Campath-1 antigen), a glycoprotein of 12 amino acids anchored to glycosylphosphatidylinositol, is widely expressed on the cell surface of immune cells, such as mature lymphocytes, natural killer cells (NK), eosinophils, neutrophils, monocytes/macrophages, and dendritic cells (DCs). The anti-CD52 mAb, alemtuzumab, was used widely in clinics for the treatment of patients such as organ transplantation. In the present manuscript, we will briefly summarize the immunological function of CD52 and discuss the application of anti-CD52 mAb in transplantation settings. FINDINGS We reviewed studies published until July 2016 to explore the role of CD52 in immune cell function and its implication in organ transplantation. We showed that ligation of cell surface CD52 molecules may offer costimulatory signals for T-cell activation and proliferation. However, soluble CD52 molecules will interact with the inhibitory sialic acid-binding immunoglobulin-like lectin 10 (Siglec10) to significantly inhibit T cell proliferation and activation. Although the physiological and pathological significances of CD52 molecules are still poorly understood, the anti-CD52 mAb, alemtuzumab, was used widely for the treatment of patients with chronic lymphocytic leukemia, autoimmune diseases as well as cell and organ transplantation in clinics. CONCLUSION Studies clearly showed that CD52 can modulate T-cell activation either by its intracellular signal pathways or by the interaction of soluble CD52 and Siglec-10 expressing on T cells. However, the regulatory functions of CD52 on other immune cell subpopulations in organ transplantation require to be studied in the near future.
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Affiliation(s)
- Yang Zhao
- Transplantation Biology Research Division, State Key Laboratory of Membrane Biology, Institute of Zoology, Chinese Academy of Sciences, Beichen West Road 1-5, Chaoyang District, Beijing, 100101, China
- University of Chinese Academy of Sciences, Beijing, China
| | - Huiting Su
- Transplantation Biology Research Division, State Key Laboratory of Membrane Biology, Institute of Zoology, Chinese Academy of Sciences, Beichen West Road 1-5, Chaoyang District, Beijing, 100101, China
- University of Chinese Academy of Sciences, Beijing, China
| | - Xiaofei Shen
- Transplantation Biology Research Division, State Key Laboratory of Membrane Biology, Institute of Zoology, Chinese Academy of Sciences, Beichen West Road 1-5, Chaoyang District, Beijing, 100101, China
- Department of General Surgery, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Junfeng Du
- Department of General Surgery, PLA Army General Hospital, Dongsishitiao Namencang 5, Dongcheng District, Beijing, 100007, China.
| | - Xiaodong Zhang
- Department of Urology, Beijing Chaoyang Hospital, Capital Medical University, 8 Gong Ti Nan Road, Chaoyang District, Beijing, 100020, China.
| | - Yong Zhao
- Transplantation Biology Research Division, State Key Laboratory of Membrane Biology, Institute of Zoology, Chinese Academy of Sciences, Beichen West Road 1-5, Chaoyang District, Beijing, 100101, China.
- University of Chinese Academy of Sciences, Beijing, China.
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7
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Alemtuzumab levels impact acute GVHD, mixed chimerism, and lymphocyte recovery following alemtuzumab, fludarabine, and melphalan RIC HCT. Blood 2015; 127:503-12. [PMID: 26644451 DOI: 10.1182/blood-2015-07-659672] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 11/21/2015] [Indexed: 01/02/2023] Open
Abstract
Reduced intensity conditioning (RIC) allogeneic hematopoietic cell transplantation (HCT) with alemtuzumab, fludarabine, and melphalan is an effective approach for patients with nonmalignant disorders. Mixed chimerism and graft-versus-host-disease (GVHD) remain limitations on success. We hypothesized that higher levels of alemtuzumab at day 0 would result in a low risk of acute GVHD, a higher risk of mixed chimerism, and delayed early lymphocyte recovery and that alemtuzumab level thresholds for increased risks of these outcomes would be definable. We collected data from 105 patients to examine the influence of peritransplant alemtuzumab levels on acute GVHD, mixed chimerism, and lymphocyte recovery. The cumulative incidences of initial grades I-IV, II-IV, and III-IV acute GVHD in patients with alemtuzumab levels ≤0.15 vs ≥0.16 μg/mL were 68% vs 18% (P < .0001), 47% vs 13% (P = .0002), and 32% vs 8%, respectively (P = .005). The cumulative incidence of mixed chimerism in patients with an alemtuzumab level ≤0.15 μg/mL was 21%, vs 42% with levels of 0.16 to 4.35 μg/mL, and 100% with levels >4.35 μg/mL (P = .003). Patients with alemtuzumab levels ≤0.15 or 0.16 to 0.56 μg/mL had higher lymphocyte counts at day +30 and higher T-cell counts at day +100 compared with patients with levels ≥0.57 μg/mL (all P < .05). We conclude that peritransplant alemtuzumab levels impact acute GVHD, mixed chimerism, and lymphocyte recovery following RIC HCT with alemtuzumab, fludarabine, and melphalan. Precision dosing trials are warranted. We recommend a day 0 therapeutic range of 0.2 to 0.4 μg/mL.
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8
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Pingali SR, Champlin RE. Pushing the envelope-nonmyeloablative and reduced intensity preparative regimens for allogeneic hematopoietic transplantation. Bone Marrow Transplant 2015; 50:1157-67. [PMID: 25985053 PMCID: PMC4809137 DOI: 10.1038/bmt.2015.61] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Accepted: 11/17/2014] [Indexed: 12/30/2022]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) was originally developed to allow delivery of myeloablative doses of chemotherapy and radiotherapy. With better understanding of disease pathophysiology, the graft vs malignancy (GVM) effect of allogeneic hematopoietic transplantation and toxicities associated with myeloablative conditioning (MAC) regimens, the focus shifted to developing less toxic conditioning regimens to reduce treatment-related morbidity without compromising survival. Although HCT with MAC is preferred to reduced intensity conditioning (RIC) for most patients ⩽60 years with AML/myelodysplastic syndrome and ALL, RIC and nonmyeloablative (NMA) regimens allow HCT for many otherwise ineligible patients. Reduced intensity preparative regimens have produced high rates of PFS for diagnoses, which are highly sensitive to GVM. Relapse of the malignancy is the major cause of treatment failure with RIC/NMA HCT. Incorporation of novel agents like bortezomib or lenalidomide, addition of cellular immunotherapy and use of targeted radiation therapies could further improve outcome. In this review, we discuss commonly used RIC/NMA regimens and promising novel regimens.
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Affiliation(s)
- S R Pingali
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - R E Champlin
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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10
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Marsh RA, Rao MB, Gefen A, Bellman D, Mehta PA, Khandelwal P, Chandra S, Jodele S, Myers KC, Grimley M, Dandoy C, El-Bietar J, Kumar AR, Leemhuis T, Zhang K, Bleesing JJ, Jordan MB, Filipovich AH, Davies SM. Experience with Alemtuzumab, Fludarabine, and Melphalan Reduced-Intensity Conditioning Hematopoietic Cell Transplantation in Patients with Nonmalignant Diseases Reveals Good Outcomes and That the Risk of Mixed Chimerism Depends on Underlying Disease, Stem Cell Source, and Alemtuzumab Regimen. Biol Blood Marrow Transplant 2015; 21:1460-70. [PMID: 25865646 DOI: 10.1016/j.bbmt.2015.04.009] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Accepted: 04/02/2015] [Indexed: 10/23/2022]
Abstract
Alemtuzumab, fludarabine, and melphalan reduced-intensity conditioning (RIC) regimens are increasingly used for the hematopoietic cell transplantation (HCT) of pediatric and young adult patients with nonmalignant diseases. Early experience suggests that these regimens are associated with good survival but a high incidence of mixed chimerism, which we have previously shown to be influenced by the alemtuzumab schedule. We hypothesized that the underlying diagnosis and donor graft source would also affect the development of mixed chimerism and that the majority of patients would survive RIC HCT without graft loss. To examine this, we conducted a retrospective study of 206 patients with metabolic diseases, non-Fanconi anemia marrow failure disorders, and primary immune deficiencies who underwent 210 consecutive RIC HCT procedures at Cincinnati Children's Hospital. Ninety-seven percent of the patients engrafted. Mixed donor and recipient chimerism developed in 46% of patients. Patients with marrow failure had a low risk of mixed chimerism (hazard ratio [HR], .208; 95% confidence interval [CI], .061 to .709; P = .012). The risk of mixed chimerism was high in patients who received a cord blood graft (HR, 3.122; 95% CI, 1.236 to 7.888; P = .016). As expected, patients who received a proximal or higher dose per kilogram of alemtuzumab schedule also experienced higher rates of mixed chimerism (all HR > 2, all P < .05). At the time of last follow-up (median, 654 days; range, 13 to 3337), over 75% of patients had greater than 90% whole blood donor chimerism. A second transplantation was performed in 5% of patients. Three-year survival without retransplantation was 84% (95% CI, 71% to 98%) for patients who underwent transplantation with an HLA-matched sibling donor. Survival without retransplantation was negatively affected by lack of a matched related donor, increasing age, and development of grades III and IV acute graft-versus-host disease. We conclude that alemtuzumab, fludarabine, and melphalan RIC HCT offers good results for many patients and that the risk of developing mixed chimerism is influenced by underlying diagnosis, graft source, and alemtuzumab dosing.
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Affiliation(s)
- Rebecca A Marsh
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
| | - Marepalli B Rao
- Division of Epidemiology and Biostatistics, Department of Environmental Health, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Aharon Gefen
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Denise Bellman
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Parinda A Mehta
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Pooja Khandelwal
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Sharat Chandra
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Sonata Jodele
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kasiani C Myers
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Michael Grimley
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Christopher Dandoy
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Javier El-Bietar
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Ashish R Kumar
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Tom Leemhuis
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kejian Zhang
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jack J Bleesing
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Michael B Jordan
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Division of Immunobiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Alexandra H Filipovich
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Stella M Davies
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Jardine L, Publicover A, Bigley V, Hale G, Pearce K, Dickinson A, Jackson G, Collin M. A comparative study of reduced dose alemtuzumab in matched unrelated donor and related donor reduced intensity transplants. Br J Haematol 2015; 168:874-81. [PMID: 25640315 PMCID: PMC4737113 DOI: 10.1111/bjh.13239] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Accepted: 10/15/2014] [Indexed: 11/29/2022]
Abstract
In vivo T cell depletion with 100 mg alemtuzumab prevents graft-versus-host disease (GVHD) in reduced intensity conditioned transplants but is associated with delayed immune reconstitution, a higher risk of infection and relapse. De-escalation studies have shown that a reduced dose of 30 mg is as effective as 100 mg in preventing GVHD in matched related donor (MRD) transplants. Dose reduction in matched unrelated donor (MUD) transplants is feasible but the comparative efficacy of alemtuzumab in this setting is not known and opinions vary widely concerning the optimal level of GVHD prophylaxis that should be achieved. Through retrospective analysis we made an objective comparison of MUD transplants receiving an empirically reduced dose of 60 mg, with MRD transplants receiving a 30 mg dose. We observed proportionate levels of alemtuzumab according to dose but an inverse relationship with body surface area particularly in MRD transplants. MUD transplants experienced more acute and chronic GVHD, higher T cell chimerism, more sustained use of ciclosporin and less need for donor lymphocyte infusion than MRD transplants. Thus, doubling the dose of alemtuzumab to 60 mg did not provide equivalent prevention of GVHD after MUD transplant although there was no difference in non-relapse mortality or survival compared with MRD transplants.
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Affiliation(s)
- Laura Jardine
- Institute of Cellular MedicineNewcastle UniversityNewcastle upon TyneUK
- Newcastle upon Tyne Hospitals NHS Foundation TrustNewcastle upon TyneUK
| | | | - Venetia Bigley
- Institute of Cellular MedicineNewcastle UniversityNewcastle upon TyneUK
- Newcastle upon Tyne Hospitals NHS Foundation TrustNewcastle upon TyneUK
| | | | - Kim Pearce
- Institute of Cellular MedicineNewcastle UniversityNewcastle upon TyneUK
| | - Anne Dickinson
- Institute of Cellular MedicineNewcastle UniversityNewcastle upon TyneUK
| | - Graham Jackson
- Newcastle upon Tyne Hospitals NHS Foundation TrustNewcastle upon TyneUK
| | - Matthew Collin
- Institute of Cellular MedicineNewcastle UniversityNewcastle upon TyneUK
- Newcastle upon Tyne Hospitals NHS Foundation TrustNewcastle upon TyneUK
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Impact of serotherapy on immune reconstitution and survival outcomes after stem cell transplantations in children: thymoglobulin versus alemtuzumab. Biol Blood Marrow Transplant 2014; 21:473-82. [PMID: 25485863 DOI: 10.1016/j.bbmt.2014.11.674] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2014] [Accepted: 11/13/2014] [Indexed: 01/24/2023]
Abstract
The outcome of allogeneic hematopoietic stem cell transplantation (HSCT) is strongly affected by the kinetics of reconstitution of the immune system. This study compared the effects of antithymocyte globulin (ATG) and alemtuzumab on various outcome parameters after HSCT. The study cohort consisted of 148 children, with a median age of 9.6 years (range, .4 to 19.0), who underwent HSCT for malignant and benign hematological disorders in a single HSCT unit. Conditioning included ATG (n = 110) or alemtuzumab (n = 38). Cox proportional hazard regression analysis showed that alemtuzumab significantly delayed the recovery of CD3(+) T cells and CD4(+)as well as CD8(+) T cell subsets (P ≤ .001) and natural killer (NK) cells (P = .008) compared with ATG. In both ATG- and alemtuzumab-treated patients, shorter drug exposure lead to significantly faster recovery of T cells. Alemtuzumab was associated with lower donor chimerism 3 and 6 months after transplantation and a higher risk of disease relapse (P = .001). The overall survival and event-free survival risks were significantly lower for alemtuzumab-treated patients (P = .020 and P < .001, respectively). Patients who received alemtuzumab showed a trend to lower risk of acute graft-versus-host disease, more human adenovirus, and less Epstein-Barr virus reactivations compared with patients who received ATG. These data indicate that children treated with alemtuzumab as part of the conditioning regimen have a slower T cell and NK cell reconstitution compared with those treated with ATG, which compromises the overall and event-free survival. Prolonged length of lympholytic drug exposure delayed the T cell recovery in both ATG- and alemtuzumab-treated patients. Therefore, we recommend detailed pharmacokinetic/pharmacodynamic (PK/PD) analyses in a larger cohort of patients to develop an algorithm aiming at optimization of the serotherapy containing conditioning regimen.
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Lee F, Luevano M, Veys P, Yong K, Madrigal A, Shaw BE, Saudemont A. The effects of CAMPATH-1H on cell viability do not correlate to the CD52 density on the cell surface. PLoS One 2014; 9:e103254. [PMID: 25050704 PMCID: PMC4106894 DOI: 10.1371/journal.pone.0103254] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Accepted: 06/30/2014] [Indexed: 11/23/2022] Open
Abstract
Graft versus host disease (GvHD) is one of the main complications after hematological stem cell transplantation (HSCT). CAMPATH-1H is used in the pre-transplant conditioning regimen to effectively reduce GvHD by targeting CD52 antigens on T cells resulting in their depletion. Information regarding CD52 expression and the effects of CAMPATH-1H on immune cells is scant and limited to peripheral blood (PB) T and B cells. To date, the effects of CAMPATH-1H on cord blood (CB) cells has not been studied. Here we aimed to analyze CD52 expression and the effects of CAMPATH-1H on fresh or frozen, resting or activated, PB mononuclear cells (PBMC) and CB mononuclear cells (CBMC). In resting state, CD52 expression was higher in CB than PB T cell subsets (653.66±26.68 vs 453.32±19.2) and B cells (622.2±20.65 vs 612.0±9.101) except for natural killer (NK) cells where CD52 levels were higher in PB (421.0±9.857) than CB (334.3±9.559). In contrast, CD52 levels were comparable across all cell types after activation. CAMPATH-1H depleted resting cells more effectively than activated cells with approximately 80–95% of apoptosis observed with low levels of necrosis. There was no direct correlation between cell surface CD52 density and depleting effects of CAMPATH-1H. In addition, no difference in cell viability was noted when different concentrations of CAMPATH-1H were used. CD52 was not expressed on HSC but began to be expressed as the cells differentiate, implying that CAMPATH-1H could potentially affect HSC differentiation and proliferation. Our study provides insightful information, which contributes to the better understanding in the use of CAMPATH-1H as part of the conditioning regime in HSCT.
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MESH Headings
- Alemtuzumab
- Antibodies, Monoclonal, Humanized/pharmacology
- Antigens, CD/analysis
- Antigens, CD/immunology
- Antigens, Neoplasm/analysis
- Antigens, Neoplasm/immunology
- Antineoplastic Agents/pharmacology
- B-Lymphocytes/drug effects
- B-Lymphocytes/immunology
- CD52 Antigen
- Cell Separation
- Cell Survival/drug effects
- Glycoproteins/analysis
- Glycoproteins/immunology
- Humans
- Killer Cells, Natural/drug effects
- Killer Cells, Natural/immunology
- Leukocytes, Mononuclear/drug effects
- Leukocytes, Mononuclear/immunology
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Affiliation(s)
- Fuiyee Lee
- University College London, Cancer Institute, London, United Kingdom
- Anthony Nolan Research Institute, London, United Kingdom
| | - Martha Luevano
- University College London, Cancer Institute, London, United Kingdom
- Anthony Nolan Research Institute, London, United Kingdom
| | - Paul Veys
- University College London, Cancer Institute, London, United Kingdom
- Anthony Nolan Research Institute, London, United Kingdom
- Great Ormond Street Hospital for Children NHS, London, United Kingdom
| | - Kwee Yong
- University College London, Cancer Institute, London, United Kingdom
| | - Alejandro Madrigal
- University College London, Cancer Institute, London, United Kingdom
- Anthony Nolan Research Institute, London, United Kingdom
| | - Bronwen E. Shaw
- University College London, Cancer Institute, London, United Kingdom
- Anthony Nolan Research Institute, London, United Kingdom
- Royal Marsden NHS Foundation Trust, Sutton, United Kingdom
| | - Aurore Saudemont
- University College London, Cancer Institute, London, United Kingdom
- Anthony Nolan Research Institute, London, United Kingdom
- * E-mail:
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