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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-Transplantation 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 PMCID: PMC9253073 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] [MESH Headings] [Grants] [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
Post-transplantation 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). Although PT-CY has met with great success in the haplo-BMT arena by suppressing GVHD, patients without acute GVHD have high relapse rates. One strategy to reduce relapse rates being explored by others is a dosage reduction of PT-CY. We have taken a different approach in evaluating whether partially replacing PT-CY with post-transplantation bendamustine (PT-BEN) would be advantageous, an idea based on our preclinical research identifying several beneficial immunomodulatory properties of BEN. We therefore initiated and completed a Phase Ia trial to evaluate the progressive substitution of PT-CY with PT-BEN (ClinicalTrials.gov identifier NCT02996773). We compared outcomes between 13 patients with high-risk hematologic malignancies who received PT-CY/BEN and 31 contemporaneous haplo-BMT recipients treated with the same myeloablative conditioning regimens but receiving only PT-CY. We found that partial replacement of PT-CY with PT-BEN (PT-CY/BEN) on day +4 was well tolerated and associated with significantly earlier trilineage engraftment. We also report favorable trends toward significant improvements on univariate and multivariate analyses with PT-CY/BEN compared with PT-CY with respect to rates of chronic GVHD (hazard ratio [HR], .08; 95% confidence interval [CI], .005 to 1.11; P = .06), and GVHD-free relapse-free survival (GRFS) (HR, .22; 95% CI, .05 to .86; P = .039). Our human trial has now 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 experience to 31 patients, demonstrating overall survival, progression-free survival, and GRFS at 3 years of 85.6%, 76.1%, and 58.2%, respectively, in a largely racial/ethnic minority cohort. 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, Arizona; Department of Immunobiology, University of Arizona, Tucson, Arizona; Department of Medicine, University of Arizona, Tucson, Arizona; Department of Pathology, University of Arizona, Tucson, Arizona; The University of Arizona Cancer Center, Tucson, Arizona; Banner University Medical Center, Tucson, Arizona.
| | - Baldassarre Stea
- Department of Radiation Oncology, University of Arizona, Tucson, Arizona; The University of Arizona Cancer Center, Tucson, Arizona; Banner University Medical Center, Tucson, Arizona
| | | | - Laurel Truscott
- Department of Pediatrics, University of Arizona, Tucson, Arizona; The University of Arizona Cancer Center, Tucson, Arizona; Banner University Medical Center, Tucson, Arizona
| | - Muhammad Husnain
- Department of Medicine, University of Arizona, Tucson, Arizona; The University of Arizona Cancer Center, Tucson, Arizona; Banner University Medical Center, Tucson, Arizona
| | - Sharad Khurana
- Department of Medicine, University of Arizona, Tucson, Arizona; The University of Arizona Cancer Center, Tucson, Arizona; Banner University Medical Center, Tucson, Arizona
| | - Denise J Roe
- Department of Epidemiology and Biostatistics, University of Arizona, Tucson, Arizona; The University of Arizona Cancer Center, Tucson, Arizona
| | - Richard J Simpson
- Department of Pediatrics, University of Arizona, Tucson, Arizona; Department of Immunobiology, University of Arizona, Tucson, Arizona; School of Nutritional Sciences and Wellness, University of Arizona, Tucson, Arizona; The University of Arizona Cancer Center, Tucson, Arizona
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Stokes J, Simpson RJ, Katsanis E. Commentary: Post-Transplantation Cyclophosphamide Uniquely Restrains Alloreactive CD4+ T-Cell Proliferation and Differentiation After Murine MHC-Haploidentical Hematopoietic Cell Transplantation. Front Immunol 2022; 13:887648. [PMID: 35493453 PMCID: PMC9046566 DOI: 10.3389/fimmu.2022.887648] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 03/28/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jessica Stokes
- 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
- The University of Arizona Cancer Center, 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 Immunobiology, University of Arizona, Tucson, AZ, United States
- The University of Arizona Cancer Center, Tucson, AZ, United States
- Department of Medicine, University of Arizona, Tucson, AZ, United States
- Department of Pathology, University of Arizona, Tucson, AZ, United States
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Hadjis AD, Nunes NS, Khan SM, Fletcher RE, Pohl ADP, Venzon DJ, Eckhaus MA, Kanakry CG. Post-Transplantation Cyclophosphamide Uniquely Restrains Alloreactive CD4 + T-Cell Proliferation and Differentiation After Murine MHC-Haploidentical Hematopoietic Cell Transplantation. Front Immunol 2022; 13:796349. [PMID: 35242129 PMCID: PMC8886236 DOI: 10.3389/fimmu.2022.796349] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 01/06/2022] [Indexed: 12/25/2022] Open
Abstract
Post-transplantation cyclophosphamide (PTCy) reduces the incidence and severity of graft-versus-host disease (GVHD), thereby improving the safety and accessibility of allogeneic hematopoietic cell transplantation (HCT). We have shown that PTCy works by inducing functional impairment and suppression of alloreactive T cells. We also have identified that reduced proliferation of alloreactive CD4+ T cells at day +7 and preferential recovery of CD4+CD25+Foxp3+ regulatory T cells (Tregs) at day +21 are potential biomarkers associated with optimal PTCy dosing and timing in our B6C3F1→B6D2F1 MHC-haploidentical murine HCT model. To understand whether the effects of PTCy are unique and also to understand better the biology of GVHD prevention by PTCy, here we tested the relative impact of cyclophosphamide compared with five other optimally dosed chemotherapeutics (methotrexate, bendamustine, paclitaxel, vincristine, and cytarabine) that vary in mechanisms of action and drug resistance. Only cyclophosphamide, methotrexate, and cytarabine were effective in preventing fatal GVHD, but cyclophosphamide was superior in ameliorating both clinical and histopathological GVHD. Flow cytometric analyses of blood and spleens revealed that these three chemotherapeutics were distinct in constraining conventional T-cell numerical recovery and facilitating preferential Treg recovery at day +21. However, cyclophosphamide was unique in consistently reducing proliferation and expression of the activation marker CD25 by alloreactive CD4+Foxp3- conventional T cells at day +7. Furthermore, cyclophosphamide restrained the differentiation of alloreactive CD4+Foxp3- conventional T cells at both days +7 and +21, whereas methotrexate and cytarabine only restrained differentiation at day +7. No chemotherapeutic selectively eliminated alloreactive T cells. These data suggest that constrained alloreactive CD4+Foxp3- conventional T-cell numerical recovery and associated preferential CD4+CD25+Foxp3+ Treg reconstitution at day +21 may be potential biomarkers of effective GVHD prevention. Additionally, these results reveal that PTCy uniquely restrains alloreactive CD4+Foxp3- conventional T-cell proliferation and differentiation, which may explain the superior effects of PTCy in preventing GVHD. Further study is needed to determine whether these findings also hold true in clinical HCT.
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Affiliation(s)
- Ashley D. Hadjis
- Experimental Transplantation and Immunotherapy Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, United States
| | - Natalia S. Nunes
- Experimental Transplantation and Immunotherapy Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, United States
| | - Shanzay M. Khan
- Experimental Transplantation and Immunotherapy Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, United States
| | - Rochelle E. Fletcher
- Experimental Transplantation and Immunotherapy Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, United States
| | - Alessandra de Paula Pohl
- Experimental Transplantation and Immunotherapy Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, United States
| | - David J. Venzon
- Biostatistics and Data Management Section, Office of the Clinical Director, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, United States
| | - Michael A. Eckhaus
- Division of Veterinary Resources, Office of Research Services, National Institutes of Health, Bethesda, MD, United States
| | - Christopher G. Kanakry
- Experimental Transplantation and Immunotherapy Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, United States
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