1
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von dem Borne PA, Kemps-Mols BM, de Wreede LC, van Beek AA, Snijders TJF, van Lammeren D, Tijmensen J, Sijs-Szabó A, Oudshoorn MA, Halkes CJM, van Balen P, Marijt WAE, Tjon JML, Vermaat JSP, Veelken H. The degree of HLA matching determines the incidence of cytokine release syndrome and associated nonrelapse mortality in matched related and unrelated allogeneic stem cell transplantation with post-transplant cyclophosphamide. Leuk Lymphoma 2024; 65:1270-1280. [PMID: 38710017 DOI: 10.1080/10428194.2024.2344060] [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: 11/01/2023] [Revised: 04/10/2024] [Accepted: 04/12/2024] [Indexed: 05/08/2024]
Abstract
Cytokine release syndrome (CRS) occurs frequently after haplo-identical allogeneic stem cell transplantation (alloSCT) with post-transplant cyclophosphamide (PTCy), increasing nonrelapse mortality (NRM) and decreasing survival. Data on CRS in HLA-matched alloSCT are limited and effects of specific HLA-mismatches on CRS development unknown. We hypothesized that in HLA-matched alloSCT increasing degrees of HLA-mismatching influence CRS incidence, NRM and survival. Retrospective analysis of 126 HLA-matched PTCy-alloSCT patients showed that higher degrees of HLA-mismatching significantly increased CRS incidence (26%, 75% and 90% CRS with 12/12, 10/10 and 9/10 matched donors, respectively). Maximum temperature during CRS increased with higher HLA-mismatch. Specific associations between HLA-mismatches and CRS could be determined. Grade 2 CRS and CRS-induced grade 3 fever were associated with significantly increased NRM (p < 0.001 and p = 0.003, respectively) and inferior survival (p < 0.001 and p = 0.005, respectively). NRM was mainly caused by disease conditions that may be considered CRS-induced inflammatory responses (encephalopathy, cryptogenic organizing pneumonia and multi-organ failure).
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Affiliation(s)
| | - Berit M Kemps-Mols
- Department of Immunology, Leiden University Medical Center, Leiden, the Netherlands
| | - Liesbeth C de Wreede
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Adriaan A van Beek
- Department of Immunology, Leiden University Medical Center, Leiden, the Netherlands
| | - Tjeerd J F Snijders
- Department of Hematology, Medisch Spectrum Twente, Enschede, the Netherlands
| | | | - Janneke Tijmensen
- Department of Hematology, Reinier de Graaf Gasthuis, Delft, the Netherlands
| | - Aniko Sijs-Szabó
- Department of Hematology, Leiden University Medical Center, Leiden, the Netherlands
| | - Mirjam A Oudshoorn
- Department of Hematology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Peter van Balen
- Department of Hematology, Leiden University Medical Center, Leiden, the Netherlands
| | - W A Erik Marijt
- Department of Hematology, Leiden University Medical Center, Leiden, the Netherlands
| | - Jennifer M L Tjon
- Department of Hematology, Leiden University Medical Center, Leiden, the Netherlands
| | - Joost S P Vermaat
- Department of Hematology, Leiden University Medical Center, Leiden, the Netherlands
| | - Hendrik Veelken
- Department of Hematology, Leiden University Medical Center, Leiden, the Netherlands
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2
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Elmariah H, Otoukesh S, Kumar A, Haris Ali, Shukaib Arslan, Dimaggio E, Gonzalez R, Shouse G, Pourhassan H, Taiga Nishihori, Faramand R, Mishra A, Khimani F, Fernandez H, Lazaryan A, Nieder M, Perez L, Liu H, Ryotaro Nakamura, Pidala J, Guido Marcucci, Stephen J Forman, Anasetti C, Bejanyan N, Monzr M Al Malki. Lower Weight-Based Mycophenolate Mofetil Dosing is Associated with Superior Outcomes after Haploidentical Hematopoietic Cell Transplant with Post-transplant Cyclophosphamide. Transplant Cell Ther 2024:S2666-6367(24)00554-2. [PMID: 39102983 DOI: 10.1016/j.jtct.2024.07.024] [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: 06/09/2024] [Revised: 07/12/2024] [Accepted: 07/28/2024] [Indexed: 08/07/2024]
Abstract
Mycophenolate mofetil (MMF) is commonly included in post-transplant cyclophosphamide (PTCy) based graft-versus-host disease (GVHD) prophylaxis after haploidentical (haplo) hematopoietic cell transplant (HCT). In the non-PTCy setting, higher MMF dose/kg has been shown to reduce rates of acute graft-versus-host disease (GVHD). When used in conjunction with PTCy, MMF is dosed at 15 mg/kg three times daily up to a maximum dose of 3 g/day. Thus, patients who weigh ≥67 kg receive 3 g/day and a variable dose/kg of MMF. We investigated the impact of MMF dose/kg on clinical outcomes following haploidentical PBSCT with PTCy-based GVHD prophylaxis. All consecutive adult patients with hematologic malignancies receiving haploidentical T cell replete peripheral blood stem cell transplant (PBSCT) with PTCy/MMF and either tacrolimus or sirolimus at the Moffitt Cancer Center or City of Hope between April 2014-August 2020 were included. For analyses, MMF dose relative to patient actual body weight (mg/kg/day), was stratified into categories of low (<29 mg/kg/day), low intermediate (29-34 mg/kg/day), high intermediate (35-41 mg/kg/day), and high (>41 mg/kg/day). Three hundred eighty-six patients were included. Of these, 54 patients received low dose, 73 low intermediate, 137 high intermediate and 122 high dose MMF by relative weight exposure. In multivariate analysis, low MMF dose exposure was associated with reduced rates of relapse in comparison to the high dose group (HR = 0.45, 95% CI: 0.21 to 0.94, P = .03). This led to superior PFS among patients with low compared to high MMF dose exposure (HR = 0.58, 95% CI: 0.34 to 0.99, P = .045). MMF relative dose exposure was not associated with engraftment, GVHD, nonrelapse mortality, or OS. In this study of patients receiving haploidentical PBSCT with PTCy based GVHD prophylaxis, low MMF dose/kg was associated with improved rates of relapse and PFS. Future prospective studies should investigate optimal dosing strategies of MMF when given with the PTCy regimen.
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Affiliation(s)
- Hany Elmariah
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Salman Otoukesh
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California
| | | | - Haris Ali
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California
| | - Shukaib Arslan
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California
| | - Elizabeth Dimaggio
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Rebecca Gonzalez
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Geoffrey Shouse
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California
| | - Hoda Pourhassan
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California
| | - Taiga Nishihori
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Rawan Faramand
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Asmita Mishra
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Farhad Khimani
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Hugo Fernandez
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Aleksandr Lazaryan
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Michael Nieder
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Lia Perez
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Hien Liu
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Ryotaro Nakamura
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California
| | - Joseph Pidala
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Guido Marcucci
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California
| | - Stephen J Forman
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California
| | - Claudio Anasetti
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Nelli Bejanyan
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida.
| | - Monzr M Al Malki
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California
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Shibata S, Arai Y, Kondo T, Mizuno S, Yamasaki S, Akasaka T, Doki N, Ota S, Maruyama Y, Matsuoka KI, Nagafuji K, Eto T, Tanaka T, Ohigashi H, Nakamae H, Onizuka M, Fukuda T, Atsuta Y, Yanada M. Prognostic factors in haploidentical transplantation with post-transplant cyclophosphamide for acute myeloid leukemia. Cytotherapy 2024; 26:592-598. [PMID: 38466265 DOI: 10.1016/j.jcyt.2024.02.010] [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: 09/27/2023] [Revised: 02/02/2024] [Accepted: 02/16/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND AIMS Haploidentical hematopoietic stem cell transplantation (haplo-HCT) is an appropriate option when an HLA-matched related or unrelated donor is not available. Haplo-HCT using post-transplant cyclophosphamide (PTCy) is being increasingly performed worldwide due to its effective suppression of GVHD and its safety. METHODS We conducted a large nationwide cohort study to retrospectively analyze 366 patients with acute myeloid leukemia undergoing haplo-HCT with PTCy between 2010 and 2019 and to identify prognostic factors. RESULTS A multivariate Cox analysis revealed that an older recipient age (≥60 years), a male donor to a male recipient, a cytomegalovirus IgG-negative donor to a cytomegalovirus IgG-positive recipient, a poor cytogenetic risk, a noncomplete remission status at the time of transplantation, and a history of HCT were independently associated with worse overall survival (OS). Based on each hazard ratio, these factors were scored (1-2 points) and stratified by their total score into three groups: favorable (0-1 points), intermediate (2-3 points), and poor (4 points or more) groups, and 2-year OS rates were 79.9%, 49.2%, and 25.1%, respectively (P < 0.001). CONCLUSIONS The present study revealed significant prognostic factors in haplo-HCT with PTCy, and a scoring system based on these factors may be used to predict outcomes.
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Affiliation(s)
- Sho Shibata
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yasuyuki Arai
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan; Center for Research and Application of Cellular Therapy, Kyoto University Hospital, Kyoto, Japan.
| | - Tadakazu Kondo
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan; Department of Hematology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Shohei Mizuno
- Division of Hematology, Department of Internal Medicine, Aichi Medical University, Nagakute, Japan
| | - Satoshi Yamasaki
- Department of Internal Medicine, Kyushu University Beppu Hospital, Beppu, Japan
| | | | - Noriko Doki
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Shuichi Ota
- Department of Hematology, Sapporo Hokuyu Hospital, Sapporo, Japan
| | - Yumiko Maruyama
- Department of Hematology, University of Tsukuba Hospital, Tsukuba, Japan
| | - Ken-Ichi Matsuoka
- Department of Hematology and Oncology, Okayama University Hospital, Okayama, Japan
| | - Koji Nagafuji
- Division of Hematology and Oncology, Department of Medicine, Kurume University Hospital, Kurume, Japan
| | - Tetsuya Eto
- Department of Hematology, Hamanomachi Hospital, Fukuoka, Japan
| | - Takashi Tanaka
- Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroyuki Ohigashi
- Department of Hematology, Hokkaido University Hospital, Sapporo, Japan
| | - Hirohisa Nakamae
- Department of Hematology, Osaka Metropolitan University Hospital, Osaka, Japan
| | - Makoto Onizuka
- Department of Hematology/Oncology, Tokai University School of Medicine, Isehara, Japan
| | - Takahiro Fukuda
- Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Yoshiko Atsuta
- Japanese Data Center for Hematopoietic Cell Transplantation, Nagakute, Japan; Department of Registry Science for Transplant and Cellular Therapy, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Masamitsu Yanada
- Department of Hematology and Oncology, Nagoya City University East Medical Center, Nagoya, Japan
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4
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Tang J, Jensen RR, Bryan B, Hoda D, Hunter BD. Reduced Cytokine Release Syndrome and Improved Outcomes with Earlier Immunosuppressive Therapy in Haploidentical Stem Cell Transplantation. Transplant Cell Ther 2024; 30:438.e1-438.e11. [PMID: 38281591 DOI: 10.1016/j.jtct.2024.01.076] [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: 09/22/2023] [Revised: 01/22/2024] [Accepted: 01/22/2024] [Indexed: 01/30/2024]
Abstract
The optimal timing of immunosuppression and post-transplantation cyclophosphamide (PTCy) in haploidentical hematopoietic stem cell transplantation (haplo-HSCT) is unknown. However, cytokine release syndrome (CRS) following haplo-HSCT is associated with worse transplantation outcomes, and the incidence of CRS may be affected by the timing of immunosuppression and PTCy. In this study, we compared CRS and other transplantation outcomes in 2 cohorts receiving different immunosuppression and PTCy schedules following haplo-HSCT. This was a retrospective cohort study of 91 patients who underwent haplo-HSCT at the Intermountain Health Blood and Marrow Transplant Program. The original or standard haplo-HSCT GVHD prophylaxis regimen included PTCy on days +3 and +4, with mycophenolate mofetil (MMF) and tacrolimus starting on day +5. The modified regimen adopted in November 2020 changed PTCy to days +3 and +5, with earlier introduction of tacrolimus and MMF, on day -1 and day 0, respectively. Grade ≥1 CRS occurred in 32% of patients in the modified regimen, in 82% of patients in the standard regimen (P <.0001), and 65% overall. Likewise, grade ≥2 CRS was lower with the modified regimen (16% versus 57%; P = .0002). The mean duration of CRS symptoms was longer with the standard regimen (3.14 days versus 1.44 days; P = .0003). The incidence of acute graft-versus-host disease grade III-IV or extensive chronic GVHD (cGVHD) at 1 year was lower in the modified regimen (6% versus 32%; P = .0068). No differences between the standard and modified regimens were seen in overall survival, relapse, or GVHD-free relapse-free survival (GRFS), although there appeared to be a trend toward improved GRFS with the modified regimen. Post hoc analysis comparing GRFS in patients with CRS and those without CRS found that CRS was associated with lower GRFS at 1 year (36% versus 63%; P = .0138). The duration of broad-spectrum antibiotic therapy was decreased by 7.5 days (P = .0017) and the time to hospital discharge was reduced by 7.1 days (P = .0241) with the modified regimen. This is the first analysis to evaluate and find a difference in CRS with early initiation of immunosuppressive therapy in haplo-HSCT. Our results suggest that this modified GVHD regimen benefits patients by reducing CRS and high-grade GVHD compared to the standard PTCy-based GVHD prophylaxis regimen in haplo-HSCT. Additionally, this novel regimen did not appear to negatively impact outcomes.
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5
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Elmariah H, Otoukesh S, Kumar A, Ali H, Arslan S, Shouse G, Pourhassan H, Nishihori T, Faramand R, Mishra A, Khimani F, Fernandez H, Lazaryan A, Nieder M, Perez L, Liu H, Nakamura R, Pidala J, Marcucci G, Forman SJ, Anasetti C, Locke F, Bejanyan N, Al Malki MM. Sirolimus Is an Acceptable Alternative to Tacrolimus for Graft-versus-Host Disease Prophylaxis after Haploidentical Peripheral Blood Stem Cell Transplantation with Post-Transplantation Cyclophosphamide. Transplant Cell Ther 2024; 30:229.e1-229.e11. [PMID: 37952648 DOI: 10.1016/j.jtct.2023.11.010] [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: 05/14/2023] [Revised: 10/25/2023] [Accepted: 11/07/2023] [Indexed: 11/14/2023]
Abstract
Graft-versus-host disease (GVHD) prophylaxis with post-transplantation cyclophosphamide (PTCy), tacrolimus (Tac), and mycophenolate mofetil (MMF) for allogeneic haploidentical donor (haplo) hematopoietic cell transplantation (HCT) results in comparable outcomes to matched unrelated donor HCT. A phase II study from the Moffitt Cancer Center substituting sirolimus (Siro) for Tac in this prophylactic regimen reported comparable rates of grade II-IV acute GVHD (aGVHD). Many centers have substituted Siro for Tac in this setting based on a preferable side effect profile, although comparative data are limited. In this study, we retrospectively compared outcomes in haplo-HCT with PTCy/Siro/MMF versus haplo-HCT with PTCy/Tac/MMF. The study cohort included all consecutive patients receiving haploidentical donor T cell-replete peripheral blood stem cell (PBSC) HCT for hematologic malignancies at Moffitt Cancer Center or the City of Hope National Medical Center between 2014 and 2019. A total of 423 patients were included, of whom 84 (20%) received PTCy/Siro/MMF and 339 (80%) received PTCy/Tac/MMF. The median age for the entire cohort was 54 years (range, 18 to 78 years), and the median follow-up was 30 months. The Siro group had a higher proportion of patients age ≥60 years (58% versus 34%; P < .01), and the groups also differed in diagnosis type, conditioning regimen, and cytomegalovirus serostatus. There were no significant differences in the rates of grade II-IV aGVHD (45% versus 47%; P = .6) at day +100 or chronic GVHD (cGVHD) (47% versus 54%; P = .79) at 2 years post-HCT. In multivariate analysis, neutrophil engraftment at day +30 was significantly better in the Tac group (odds ratio, .30; 95% confidence interval, .1 to .83; P = .02), with a median time to engraftment of 17 days versus 18 days in the Siro group, but platelet engraftment was similar in the 2 groups. Otherwise, in multivariate analysis, GVHD prophylaxis type had no significant influence on aGVHD or cGVHD, nonrelapse mortality, relapse, GVHD-free relapse-free survival, disease-free survival, or overall survival after PBSC haplo-HCT. These findings suggest that Siro is a comparable alternative to Tac in combination with PTCy/MMF for GVHD prophylaxis, with overall similar clinical outcomes despite delayed engraftment after peripheral blood stem cell haplo-HCT. Although Tac remains the standard of care, Siro may be substituted based on the side effect profile of these medications, with consideration of patient medical comorbidities at HCT.
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Affiliation(s)
- Hany Elmariah
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Salman Otoukesh
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California
| | | | - Haris Ali
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California
| | - Shukaib Arslan
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California
| | - Geoffrey Shouse
- City of Hope Comprehensive Cancer Center, Duarte, California
| | - Hoda Pourhassan
- City of Hope Comprehensive Cancer Center, Duarte, California
| | - Taiga Nishihori
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Rawan Faramand
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Asmita Mishra
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Farhad Khimani
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Hugo Fernandez
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Aleksandr Lazaryan
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Michael Nieder
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Lia Perez
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Hien Liu
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Ryotaro Nakamura
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California
| | - Joseph Pidala
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Guido Marcucci
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California
| | - Stephen J Forman
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California
| | - Claudio Anasetti
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Frederick Locke
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Nelli Bejanyan
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida.
| | - Monzr M Al Malki
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California
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6
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Duléry R, Brissot E, Mohty M. Combining post-transplant cyclophosphamide with antithymocyte globulin for graft-versus-host disease prophylaxis in hematological malignancies. Blood Rev 2023; 62:101080. [PMID: 37085459 DOI: 10.1016/j.blre.2023.101080] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 04/10/2023] [Indexed: 04/23/2023]
Abstract
In search of an ideal partner or alternative to conventional immunosuppressive agents, rabbit anti-thymocyte globulin (ATG) and, more recently, post-transplant cyclophosphamide (PT-Cy) have both emerged as valid and efficient options for preventing graft-versus-host disease (GvHD). To further reduce the risk of GvHD, strategies combining ATG and PT-Cy have recently been investigated. In a haploidentical setting, retrospective studies suggest that combining PT-Cy and ATG may result in a lower incidence of chronic GvHD without increasing the risks of infection or relapse, when compared to PT-Cy without ATG. In haploidentical or unrelated donor settings, adding reduced doses of PT-Cy to ATG may reduce the risk of acute and chronic GvHD and improve survival, particularly GvHD-free, relapse-free survival (GRFS), when compared to ATG without PT-Cy. Overall, the combination of PT-Cy and ATG is a safe and promising approach for patients with hematological malignancies undergoing allogeneic hematopoietic stem cell transplantation (HSCT).
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Affiliation(s)
- Rémy Duléry
- Sorbonne University, Department of Clinical Hematology and Cellular Therapy, Saint Antoine Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France; INSERM, UMRs 938, Centre de recherche Saint Antoine (CRSA), Paris, France
| | - Eolia Brissot
- Sorbonne University, Department of Clinical Hematology and Cellular Therapy, Saint Antoine Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France; INSERM, UMRs 938, Centre de recherche Saint Antoine (CRSA), Paris, France
| | - Mohamad Mohty
- Sorbonne University, Department of Clinical Hematology and Cellular Therapy, Saint Antoine Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France; INSERM, UMRs 938, Centre de recherche Saint Antoine (CRSA), Paris, France.
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7
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Ram R, Amit O, Adler A, Bar-On Y, Beyar-Katz O, Avivi I, Shasha D, Ben-Ami R. Early Antibiotic Deescalation and Discontinuation in Patients with Febrile Neutropenia after Cellular Therapy: A Single-Center Prospective Unblinded Randomized Trial. Transplant Cell Ther 2023; 29:708.e1-708.e8. [PMID: 37591446 DOI: 10.1016/j.jtct.2023.08.013] [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: 06/14/2023] [Revised: 08/08/2023] [Accepted: 08/09/2023] [Indexed: 08/19/2023]
Abstract
The optimal duration of empiric antimicrobial therapy of febrile neutropenia in patients after cellular therapy is unclear. Early deescalation has been suggested by some authorities; however, data are lacking for cellular therapy recipients. We performed a randomized controlled study of cellular therapy recipients with febrile neutropenia to evaluate the safety and noninferiority of an early deescalation and discontinuation antibiotic strategy (EDD arm) versus standard broad-spectrum antibiotic treatment until recovery of neutropenia (standard duration arm). The primary outcome was the fraction of antibiotic-free neutropenia days. We randomized 110 patients to the standard duration arm (n = 51) or EDD arm (n = 59). The fraction of antibiotic-free neutropenia days was higher in the EDD arm compared to the standard duration arm (median, .8 [interquartile range (IQR), .62 to .86] versus .51 [IQR, .17 to .86]; P = .016). This was true for the per-protocol, allogeneic hematopoietic cell transplantation (HCT), autologous HCT, and anti-CD19 chimeric antigen receptor T cell therapy subgroups. Treatment success rate, subsequent fever, death within 30 days, and other common cellular therapy-related toxicities were all similar between the 2 study arms. An EDD antibiotic strategy in patients after cellular therapy was safe and associated with a substantial reduction in broad-spectrum antibiotic utilization without compromising cellular therapy outcomes.
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Affiliation(s)
- Ron Ram
- Bone Marrow Transplantation Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty Of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Odelia Amit
- Bone Marrow Transplantation Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty Of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amos Adler
- Infection Disease Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty Of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Bar-On
- Bone Marrow Transplantation Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty Of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ofrat Beyar-Katz
- Bone Marrow Transplantation Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty Of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Irit Avivi
- Bone Marrow Transplantation Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty Of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - David Shasha
- Infection Disease Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty Of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ronen Ben-Ami
- Infection Disease Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty Of Medicine, Tel Aviv University, Tel Aviv, Israel
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8
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Nawas MT, Im A, Shaffer B. Higher graft cell dose does not influence development of acute or chronic GVHD in haploidentical transplantation using PTCy. Blood Adv 2023; 7:4475-4478. [PMID: 37315168 PMCID: PMC10440450 DOI: 10.1182/bloodadvances.2023010369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 05/23/2023] [Accepted: 06/04/2023] [Indexed: 06/16/2023] Open
Affiliation(s)
- Mariam T. Nawas
- Hematopoietic Cellular Therapy Program, Department of Medicine, University of Chicago Medicine, Chicago, IL
| | - Annie Im
- University of Pittsburgh/UPMC Hillman Cancer Center, Pittsburgh, PA
| | - Brian Shaffer
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
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9
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Arora S, Upasana K, Thakkar D, Yadav A, Rastogi N, Yadav SP. Fatal Severe Cytokine Release Syndrome Post-haploidentical Stem Cell Transplant With Post-transplant Cyclophosphamide in an Infant With Severe Combined Immunodeficiency and Disseminated Bacille Calmette-Guérin Infection. J Pediatr Hematol Oncol 2023; 45:e773-e774. [PMID: 37494614 DOI: 10.1097/mph.0000000000002700] [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: 06/26/2022] [Accepted: 05/04/2023] [Indexed: 07/28/2023]
Abstract
INTRODUCTION Severe Combined Immunodeficiency (SCID) is a primary immunodeficiency disorder characterized by absent or dysfunctional T lymphocytes, leading to defective cellular and humoral immunity requiring urgent hematopoietic stem cell transplantation (HSCT). We report a case of SCID with disseminated Bacille Calmette-Guérin (BCG) infection who developed cytokine release syndrome (CRS) and possible Immune reconstitution inflammatory syndrome (IRIS) after Haploidentical HSCT with post-transplant cyclophosphamide. METHODS Data were retrospectively retrieved from electronic medical records. RESULT A 5-month-old male infant was referred with fever, cough, and generalized maculopapular rash for 15 days, and had pallor without hepatosplenomegaly or lymphadenopathy. He had a history of previous male sibling death at 6 months of age due to pneumonia. Investigations: hemoglobin: 4.7 g/dL, TLC-6.37×103/uL, absolute lymphocytes: 0.98×103/uL, platelets: 319×103/uL, bilateral patchy opacities in both lung fields, and low immunoglobulin levels. Lymphocyte subset analysis revealed T-, B+, NK- SCID. Genetic analysis showed a hemizygous mutation in IL2RG (c.314A>G). The child received intravenous (IV) antibiotics, antifungal, antitubercular drugs, irradiated blood products, and IV immunoglobulins. Urgent haploidentical HSCT from the mother was planned. Conditioning was Fludarabine-40 mg/m2/d for 4 days, cyclophosphamide: 14.5 mg/kg/d for 2 days. He received peripheral blood hematopoietic stem cells with CD34- 15×106 cells/kg and CD3- 805×106 cells/kg. Within 2 hours of stem cell infusion, he developed respiratory distress, fever, shock, and flaring of rash. Methylprednisolone was started in view of CRS. On day+2, he had sudden desaturation and bradycardia needing mechanical ventilation and inotropes. His inflammatory markers were elevated (Ferritin: 3640 ng/mL, IL-6:5000 pg/mL, CRP:255 mg/L). In view of high-grade CRS, he received an injection of tocilizumab 8 mg/kg on day +2 and day +4. He received post-transplant cyclophosphamide 5 mg/kg on day +3. The endotracheal secretion GeneXpert was positive for Mycobacterium supporting the diagnosis of disseminated tuberculosis. Our patient had disseminated BCG infection which could also be contributory in the initiation of IRIS as the mother was immunized with the BCG vaccine in childhood so she must be having cytotoxic T cells specific for BCG, which were transferred to the infant with peripheral blood stem cell product. He succumbed to severe acute respiratory distress syndrome and multiorgan dysfunction on day +5 post-transplant. CONCLUSIONS In haploidentical HSCT of SCID, post-transplant course can be complicated by CRS and IRIS as these patients are inefficient in mounting any response to infused donor lymphocytes resulting in their unregulated growth.
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Affiliation(s)
- Sunisha Arora
- Pediatric Hematology Oncology and Bone Marrow Transplant Unit, Medanta-The Medicity, Gurgaon, Haryana, India
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10
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Yao JM, Otoukesh S, Kim H, Yang D, Mokhtari S, Samara Y, Blackmon A, Arslan S, Agrawal V, Pourhassan H, Amanam I, Ball B, Koller P, Salhotra A, Becker P, Curtin P, Artz A, Aldoss I, Ali H, Stewart F, Smith E, Stein A, Marcucci G, Forman SJ, Nakamura R, Al Malki MM. Tocilizumab for Cytokine Release Syndrome Management After Haploidentical Hematopoietic Cell Transplantation With Post-Transplantation Cyclophosphamide-Based Graft-Versus-Host Disease Prophylaxis. Transplant Cell Ther 2023; 29:515.e1-515.e7. [PMID: 37182736 PMCID: PMC10527340 DOI: 10.1016/j.jtct.2023.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 04/26/2023] [Accepted: 05/08/2023] [Indexed: 05/16/2023]
Abstract
Cytokine release syndrome (CRS) is a common complication after haploidentical hematopoietic cell transplantation (HaploHCT). Severe CRS after haploHCT leads to higher risk of non-relapse mortality (NRM) and worse overall survival (OS). Tocilizumab (TOCI) is an interleukin-6 receptor inhibitor and is commonly used as first-line for CRS management after chimeric antigen receptor T cell therapy, but the impact of TOCI administration for CRS management on Haplo HCT outcomes is not known. In this single center retrospective analysis, we compared HCT outcomes in patients treated with or without TOCI for CRS management after HaploHCT with post-transplantation cyclophosphamide- (PTCy-) based graft-versus-host disease (GvHD) prophylaxis. Of the 115 patients eligible patients who underwent HaploHCT at City of Hope between 2019 to 2021 and developed CRS, we identified 11 patients who received tocilizumab for CRS management (TOCI). These patients were matched with 21 patients who developed CRS but did not receive tocilizumab (NO-TOCI) based on age at the time of HCT (≤64 years or >65 years or older), conditioning intensity (myeloablative versus reduced-intensity/nonmyeloablative), and CRS grading (1, 2, versus 3-4). Instead of 22 controls, we chose 21 patients because there was only 1 control matched with 1 TOCI treatment patient in 1 stratum. With only 11 patients in receiving tocilizumab for CRS treatment, matching with 21 patients who developed CRS but did not receive tocilizumab, we had 80% power to detect big differences (hazard ratio [HR] = 3.4 or higher) in transplantation outcomes using a 2-sided 0.05 test. The power would be reduced to about 20% to 30% if the difference was moderate (HR = 2.0) using the same test. No CRS-related deaths were recorded in either group. Median time to neutrophil engraftment was 21 days (range 16-43) in TOCI and 18 days (range 14-23) in NO-TOCI group (HR = 0.55; 95% confidence interval [CI] = 0.28-1.06, P = .08). Median time to platelet engraftment was 34 days (range 20-81) in TOCI and 28 days (range 12-94) in NO-TOCI group (HR = 0.56; 95% CI = 0.25-1.22, P = .19). Cumulative incidences of day 100 acute GvHD grades II-IV (P = .97) and grades III-IV (P = .47) were similar between the 2 groups. However, cumulative incidence of chronic GvHD at 1 year was significantly higher in patients receiving TOCI (64% versus 24%; P = .05). Rates of NRM (P = .66), relapse (P = .83), disease-free survival (P = .86), and overall survival (P = .73) were similar at 1 year after HCT between the 2 groups. Tocilizumab administration for CRS management after HaploHCT appears to be safe with no short-term adverse effect and no effect on relapse rate. However, the significantly higher cumulative incidence of chronic GvHD, negates the high efficacy of PTCy on GvHD prophylaxis in this patient population. Therefore using tocilizumab for CRS management in the HaploHCT population with PTCy maybe kept only for patients with severe CRS. The impact on such approach on long term outcome in HaploHCT with PTCy will need to be evaluated in a larger retrospective study or a prospective manner.
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Affiliation(s)
- Janny M Yao
- Department of Pharmacy, City of Hope National Medical Center, Duarte, California
| | - Salman Otoukesh
- Department of Hematology and Hematopoietic cell transplantation, City of Hope National Medical Center, Duarte, California
| | - Hanna Kim
- Department of Pharmacy, City of Hope National Medical Center, Duarte, California
| | - Dongyun Yang
- Department of Computational and Quantitative Medicine, Division of Biostatistics, City of Hope National Medical Center, Duarte, California
| | - Sally Mokhtari
- Department of Clinical and Translational Project Development, City of Hope National Medical Center, Duarte, California
| | - Yazeed Samara
- Department of Hematology and Hematopoietic cell transplantation, City of Hope National Medical Center, Duarte, California
| | - Amanda Blackmon
- Department of Hematology and Hematopoietic cell transplantation, City of Hope National Medical Center, Duarte, California
| | - Shukaib Arslan
- Department of Hematology and Hematopoietic cell transplantation, City of Hope National Medical Center, Duarte, California
| | - Vaibhav Agrawal
- Department of Hematology and Hematopoietic cell transplantation, City of Hope National Medical Center, Duarte, California
| | - Hoda Pourhassan
- Department of Hematology and Hematopoietic cell transplantation, City of Hope National Medical Center, Duarte, California
| | - Idoroenyi Amanam
- Department of Hematology and Hematopoietic cell transplantation, City of Hope National Medical Center, Duarte, California
| | - Brian Ball
- Department of Hematology and Hematopoietic cell transplantation, City of Hope National Medical Center, Duarte, California
| | - Paul Koller
- Department of Hematology and Hematopoietic cell transplantation, City of Hope National Medical Center, Duarte, California
| | - Amandeep Salhotra
- Department of Hematology and Hematopoietic cell transplantation, City of Hope National Medical Center, Duarte, California
| | - Pamela Becker
- Department of Hematology and Hematopoietic cell transplantation, City of Hope National Medical Center, Duarte, California
| | - Peter Curtin
- Department of Hematology and Hematopoietic cell transplantation, City of Hope National Medical Center, Duarte, California
| | - Andrew Artz
- Department of Hematology and Hematopoietic cell transplantation, City of Hope National Medical Center, Duarte, California
| | - Ibrahim Aldoss
- Department of Hematology and Hematopoietic cell transplantation, City of Hope National Medical Center, Duarte, California
| | - Haris Ali
- Department of Hematology and Hematopoietic cell transplantation, City of Hope National Medical Center, Duarte, California
| | - Forrest Stewart
- Department of Hematology and Hematopoietic cell transplantation, City of Hope National Medical Center, Duarte, California
| | - Eileen Smith
- Department of Hematology and Hematopoietic cell transplantation, City of Hope National Medical Center, Duarte, California
| | - Anthony Stein
- Department of Hematology and Hematopoietic cell transplantation, City of Hope National Medical Center, Duarte, California
| | - Guido Marcucci
- Department of Hematology and Hematopoietic cell transplantation, City of Hope National Medical Center, Duarte, California
| | - Stephen J Forman
- Department of Hematology and Hematopoietic cell transplantation, City of Hope National Medical Center, Duarte, California
| | - Ryotaro Nakamura
- Department of Hematology and Hematopoietic cell transplantation, City of Hope National Medical Center, Duarte, California
| | - Monzr M Al Malki
- Department of Hematology and Hematopoietic cell transplantation, City of Hope National Medical Center, Duarte, California.
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11
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Li Z, Wang Y, Li G, Ma N, Li M, Yuan F, Fu Y, Wang L. Clinical observation on the safety and efficacy of umbilical cord mesenchymal stem cells in the treatment of bronchiolitis obliterans after allogeneic haematopoietic stem cell transplantation. Biotechnol Genet Eng Rev 2023:1-18. [PMID: 36856529 DOI: 10.1080/02648725.2023.2183611] [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: 01/12/2023] [Accepted: 02/13/2023] [Indexed: 03/02/2023]
Abstract
Graft-versus-host disease (GVHD) is caused by a pathologic and destructive response of the organism as a result of the interaction between donor immunocompetent T lymphocytes and the recipient tisular antigens1. Graft-versus-host disease is considered a serious complication of hematopoietic stem cell transplantation. The skin, oral cavity and lungs are commonly affected organs. Among these complications bronchiolitis obliterans syndrome is a serious complication, which even can be life-threatening. Therefore, this research aims to do a clinical observation on the safety and efficacy of umbilical cord mesenchymal stem cells in the treatment of bronchiolitis obliterans after allogeneic haematopoietic stem cell transplantation. Fifteen patients were included in this study, who received allogeneic hematopoietic stem cell transplantation. Among these patients, both of them were treated with azithromycin, montelukast, glucocorticoid and pirfenidone. Two of them did not receive second line anti-rejection treatment due to economic reasons, and three of them were treated with mesenchymal stem cells. These bronchiolitis obliterans syndrome-related symptoms such as shortness of breath, chest tightness and wheezing have improved. Two of them died due to bronchiolitis obliterans syndrome related complications such as respiratory failure. Two of them not only improve the symptoms but also increased the FEV1/FVC, who were treated with mesenchymal stem cells. The comprehensive treatment regimen containing imatinib and ruxolitinib is safe and effective and mesenchymal stem cell is a promising treatment option to improve the prognosis of post-HSCT BOS.
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Affiliation(s)
- Ziye Li
- Department of Hematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Yongqi Wang
- Department of Hematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Gangping Li
- Department of Hematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Nan Ma
- Research and Transformation Center of Stem Cell And Regenearative Medicine, Henan Academy of Medical Sciences Zhengzhou, China
| | - Minghui Li
- Department of Hematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Fangfang Yuan
- Department of Hematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Yuewen Fu
- Department of Hematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Li Wang
- Research and Transformation Center of Stem Cell And Regenearative Medicine, Henan Academy of Medical Sciences Zhengzhou, China
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12
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Athale J, Busch LM, O'Grady NP. Cytokine Release Syndrome and Sepsis: Analogous Clinical Syndromes with Distinct Causes and Challenges in Management. Infect Dis Clin North Am 2022; 36:735-748. [PMID: 36328633 PMCID: PMC9641544 DOI: 10.1016/j.idc.2022.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Both cytokine release syndrome (CRS) and sepsis are clinical syndromes rather than distinct diseases and share considerable overlap. It can often be challenging to distinguish between the two, but it is important given the availability of targeted treatment options. In addition, several other clinical syndromes overlap with CRS and sepsis, further making it difficult to differentiate them. This has particularly been highlighted in the recent coronavirus disease-2019 pandemic. As we start to understand the differences in the inflammatory markers and presentations in these syndromes, hopefully we will be able to enhance treatment and improve outcomes.
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Affiliation(s)
- Janhavi Athale
- Department of Critical Care Medicine, Division of Hematology and Oncology, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Lindsay M Busch
- Department of Medicine, Emory University Hospital, 550 Peachtree Street Northeast, Atlanta, GA 30308, USA
| | - Naomi P O'Grady
- Internal Medicine Services, National Institutes of Health, Room 2-2734, Bethesda, MD 20892-1662, USA.
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13
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Total marrow and lymphoid irradiation as conditioning in haploidentical transplant with posttransplant cyclophosphamide. Blood Adv 2022; 6:4098-4106. [PMID: 35838754 PMCID: PMC9327543 DOI: 10.1182/bloodadvances.2022007264] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 04/19/2022] [Indexed: 12/18/2022] Open
Abstract
TMLI at 2000 cGy for HaploHCT with PTCy was determined to be safe in patients with high-risk leukemia and MDS. At 2000 cGy, a 1-year relapse rate of 17% was achieved without increasing GVHD or transplant-related mortality.
Posttransplant cyclophosphamide (PTCy) platform has shown low rates of graft-versus-host disease (GVHD) and nonrelapse mortality (NRM) after haploidentical hematopoietic cell transplantation (HaploHCT). However, because of the limited disease control, relapse rate remains a major cause of treatment failure in high-risk patients. Total marrow and lymphoid irradiation (TMLI) allows for delivery of high radiation to bone marrow and other targeted structures, without increasing off-target radiation exposure and toxicity to end organs. In this phase 1 trial, 31 patients with high-risk and/or active primary refractory leukemias or myelodysplastic syndrome underwent peripheral blood stem cell HaploHCT with TMLI, fludarabine, and cyclophosphamide as the conditioning regimen. Radiation dose was escalated in increments of 200 cGy (1200-2000 cGy). GVHD prophylaxis was PTCy with tacrolimus/mycophenolate mofetil. Grade 2 toxicities by the Bearman scale were mucositis (n = 1), hepatic (n = 3), gastrointestinal (n = 5), and cardiac (n = 2). One patient (1800 cGy) experienced grade 3 pulmonary toxicity (dose-limiting toxicity). At a follow-up duration of 23.9 months for the whole cohort; 2-year NRM was 13%. Cumulative incidence of day 100 grade 2 to 4 and 3 to 4 acute GVHD was 52% and 6%, respectively. Chronic GVHD at 2 years was 35%. For patients treated with 2000 cGy, with a median follow-up duration of 12.3 months, 1-year relapse/progression, progression-free survival, and overall survival rates were 17%, 74%, and 83%, respectively. In conclusion, HaploHCT-TMLI with PTCy was safe and feasible in our high-risk patient population with promising outcomes.
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14
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Piñana JL, López-Corral L, Martino R, Vazquez L, Pérez A, Martin-Martin G, Gago B, Sanz-Linares G, Sanchez-Salinas A, Villalon L, Conesa-Garcia V, Olave MT, Corona M, Marcos-Corrales S, Tormo M, Hernández-Rivas JÁ, Montoro J, Rodriguez-Fernandez A, Risco-Gálvez I, Rodríguez-Belenguer P, Hernandez-Boluda JC, García-Cadenas I, Ruiz-García M, Muñoz-Bellido JL, Solano C, Cedillo Á, Sureda A, Navarro D. SARS-CoV-2 vaccine response and rate of breakthrough infection in patients with hematological disorders. J Hematol Oncol 2022; 15:54. [PMID: 35526045 PMCID: PMC9077637 DOI: 10.1186/s13045-022-01275-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 04/25/2022] [Indexed: 12/24/2022] Open
Abstract
Background The clinical efficacy of SARS-CoV-2 vaccines according to antibody response in immunosuppressed patients such as hematological patients has not yet been established. Patients and methods A prospective multicenter registry-based cohort study conducted from December 2020 to December 2021 by the Spanish transplant and cell therapy group was used to analyze the relationship of antibody response at 3–6 weeks after full vaccination (2 doses) with breakthrough SARS-CoV-2 infection in 1394 patients with hematological disorders. Results At a median follow-up of 165 days after complete immunization, 37 out of 1394 (2.6%) developed breakthrough SARS-CoV-2 infection at median of 77 days (range 7–195) after full vaccination. The incidence rate was 6.39 per 100 persons-year. Most patients were asymptomatic (19/37, 51.4%), whereas only 19% developed pneumonia. The mortality rate was 8%. Lack of detectable antibodies at 3–6 weeks after full vaccination was the only variable associated with breakthrough infection in multivariate logistic regression analysis (Odds Ratio 2.35, 95% confidence interval 1.2–4.6, p = 0.012). Median antibody titers were lower in cases than in non-cases [1.83 binding antibody units (BAU)/mL (range 0–4854.93) vs 730.81 BAU/mL (range 0–56,800), respectively (p = 0.007)]. We identified 250 BAU/mL as a cutoff above which incidence and severity of the infection were significantly lower. Conclusions Our study highlights the benefit of developing an antibody response in these highly immunosuppressed patients. Level of antibody titers at 3 to 6 weeks after 2-dose vaccination links with protection against both breakthrough infection and severe disease for non-Omicron SARS-CoV-2 variants. Supplementary Information The online version contains supplementary material available at 10.1186/s13045-022-01275-7.
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Affiliation(s)
- José Luis Piñana
- Division of Clinical Hematology, Hematology Department, Hospital Clínico Universitario de Valencia, Avda Blasco Ibañez, 17, 46010, Valencia, Spain. .,Fundación INCLIVA, Instituto de Investigación Sanitaria Hospital Clínico Universitario de Valencia, Valencia, Spain.
| | - Lucia López-Corral
- Hematology Division, Hospital Universitario de Salamanca, Salamanca, Spain
| | - Rodrigo Martino
- Hematology Division, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Lourdes Vazquez
- Hematology Division, Hospital Universitario de Salamanca, Salamanca, Spain
| | - Ariadna Pérez
- Division of Clinical Hematology, Hematology Department, Hospital Clínico Universitario de Valencia, Avda Blasco Ibañez, 17, 46010, Valencia, Spain.,Fundación INCLIVA, Instituto de Investigación Sanitaria Hospital Clínico Universitario de Valencia, Valencia, Spain
| | | | - Beatriz Gago
- Hematology Division, Hospital Regional Universitario Carlos Haya, Malaga, Spain
| | - Gabriela Sanz-Linares
- Hematology Division, Institut Català Oncologia-Hospital Duran i Reynals, IDIBELL, Universitat de Barcelona, Barcelona, Spain
| | - Andrés Sanchez-Salinas
- Hematology Division, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Lucia Villalon
- Hematology Division, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | | | - María T Olave
- Hematology Division, Hospital Clínico Universitario Lozano Blesa, IIS Aragon, Saragossa, Spain
| | | | | | - Mar Tormo
- Division of Clinical Hematology, Hematology Department, Hospital Clínico Universitario de Valencia, Avda Blasco Ibañez, 17, 46010, Valencia, Spain.,Fundación INCLIVA, Instituto de Investigación Sanitaria Hospital Clínico Universitario de Valencia, Valencia, Spain
| | | | - Juan Montoro
- Hematology Division, Hospital universitario y politécnico La Fe, Valencia, Spain
| | | | | | - Pablo Rodríguez-Belenguer
- Research Program on Biomedical Informatics (GRIB), Department of Experimental and Health Sciences, Hospital del Mar Medical Research Institute (IMIM), Universitat Pompeu Fabra, Barcelona, Spain
| | - Juan Carlos Hernandez-Boluda
- Division of Clinical Hematology, Hematology Department, Hospital Clínico Universitario de Valencia, Avda Blasco Ibañez, 17, 46010, Valencia, Spain.,Fundación INCLIVA, Instituto de Investigación Sanitaria Hospital Clínico Universitario de Valencia, Valencia, Spain.,Department of Medicine, School of Medicine, University of Valencia, Valencia, Spain
| | | | | | | | - Carlos Solano
- Division of Clinical Hematology, Hematology Department, Hospital Clínico Universitario de Valencia, Avda Blasco Ibañez, 17, 46010, Valencia, Spain.,Fundación INCLIVA, Instituto de Investigación Sanitaria Hospital Clínico Universitario de Valencia, Valencia, Spain.,Department of Medicine, School of Medicine, University of Valencia, Valencia, Spain
| | - Ángel Cedillo
- Hematopoietic Stem Cell Transplantation and Cell Therapy Group (GETH) Office, Madrid, Spain
| | - Anna Sureda
- Hematology Division, Institut Català Oncologia-Hospital Duran i Reynals, IDIBELL, Universitat de Barcelona, Barcelona, Spain
| | - David Navarro
- Fundación INCLIVA, Instituto de Investigación Sanitaria Hospital Clínico Universitario de Valencia, Valencia, Spain.,Hospital Clinico Universitario de Valencia, Valencia, Spain
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