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Rivinius R, Helmschrott M, Ruhparwar A, Schmack B, Klein B, Erbel C, Gleissner CA, Akhavanpoor M, Frankenstein L, Darche FF, Thomas D, Ehlermann P, Bruckner T, Katus HA, Doesch AO. Analysis of malignancies in patients after heart transplantation with subsequent immunosuppressive therapy. Drug Des Devel Ther 2014; 9:93-102. [PMID: 25552900 PMCID: PMC4277123 DOI: 10.2147/dddt.s75464] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective The aim of this study was to analyze the distribution of malignancies in patients after heart transplantation (HTX) and to evaluate the risk factors including immunosuppressive therapy with regard to the development of malignancies and survival. Special emphasis was placed on the effects of a mammalian target of rapamycin (mTOR) containing immunosuppressive regimen. Methods A total of 381 patients (age ≥18 years) receiving HTX were included in the present analysis. All patients were followed-up at the University of Heidelberg Heart Center, Heidelberg, Germany. Data were retrieved from the Heidelberg Registry for Heart Transplantation being collected between 1989 and 2014. According to center standard, all patients received induction therapy with anti-thymocyte globulin guided by T-cell monitoring since 1994. The initial immunosuppressive regimen consisting of cyclosporine A (CsA) and azathioprine (AZA) was replaced by CsA and mycophenolate mofetil (MMF) in 2001 and by tacrolimus (TAC) and MMF in 2006. Additionally, mTOR inhibitors (everolimus/sirolimus) were applied since 2003. Results Mean recipient age at HTX was 51.2±10.5 years and the mean follow-up period after HTX was 9.7±5.9 years. During follow-up, 130 patients developed a neoplasm (34.1% of total). Subgroup analysis revealed 58 patients with cutaneous malignancy only (15.2%), 56 patients with noncutaneous malignancy only (14.7%), and 16 patients with both cutaneous and noncutaneous malignancy (4.2%). Statistically significant risk factors associated with an increased risk of malignancy after HTX were older age (P<0.0001), male recipients (P=0.0008), dyslipidemia (P=0.0263), diabetes mellitus (P=0.0003), renal insufficiency (P=0.0247), and >1 treated rejection episode (TRE) in the first year after HTX (P=0.0091). Administration of CsA (P=0.0195), AZA (P=0.0008), or steroids (P=0.0018) for >1 year after HTX was associated with increased development of malignancy, whereas administration of MMF (P<0.0001) or mTOR inhibitors (P<0.0001) was associated with a lower risk for development of malignancy. Additionally, 5-year follow-up of cutaneous malignancy recurrence (P=0.0065) and noncutaneous malignancy mortality (P=0.0011) was significantly lower in patients receiving an mTOR inhibitor containing therapy after the development of a malignancy. Conclusion This study highlights the complexity of risk factors including immunosuppression with regard to the development of malignancies after HTX. mTOR-inhibitor-based immunosuppression is associated with a better outcome after HTX, particularly in cases with noncutaneous malignancy.
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Affiliation(s)
- Rasmus Rivinius
- Department of Cardiology, Angiology and Pneumology, University of Heidelberg, Heidelberg, Germany
| | - Matthias Helmschrott
- Department of Cardiology, Angiology and Pneumology, University of Heidelberg, Heidelberg, Germany
| | - Arjang Ruhparwar
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Bastian Schmack
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Berthold Klein
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Christian Erbel
- Department of Cardiology, Angiology and Pneumology, University of Heidelberg, Heidelberg, Germany
| | - Christian A Gleissner
- Department of Cardiology, Angiology and Pneumology, University of Heidelberg, Heidelberg, Germany
| | - Mohammadreza Akhavanpoor
- Department of Cardiology, Angiology and Pneumology, University of Heidelberg, Heidelberg, Germany
| | - Lutz Frankenstein
- Department of Cardiology, Angiology and Pneumology, University of Heidelberg, Heidelberg, Germany
| | - Fabrice F Darche
- Department of Cardiology, Angiology and Pneumology, University of Heidelberg, Heidelberg, Germany
| | - Dierk Thomas
- Department of Cardiology, Angiology and Pneumology, University of Heidelberg, Heidelberg, Germany
| | - Philipp Ehlermann
- Department of Cardiology, Angiology and Pneumology, University of Heidelberg, Heidelberg, Germany
| | - Tom Bruckner
- Institute for Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Hugo A Katus
- Department of Cardiology, Angiology and Pneumology, University of Heidelberg, Heidelberg, Germany
| | - Andreas O Doesch
- Department of Cardiology, Angiology and Pneumology, University of Heidelberg, Heidelberg, Germany
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Abstract
Beta cell replacement therapy has been proposed as a novel therapy for the treatment of type 1 diabetes. The proof of concept has been demonstrated with successful islet allotransplantation. Islet xenotransplantation has been proposed as an alternative, more reliable, and infinite source of beta cells. The advantages of islet xenotransplantation are the ability to transplant a well differentiated cell that is responsive to glucose and the potential for genetic modification which focuses the treatment on the donor rather than the recipient. The major hurdle remains overcoming the severe cellular rejection that affects xenografts. This review will focus on the major advances that have occurred with genetic modification and the successful therapeutic strategies that have been demonstrated in nonhuman primates. Novel approaches to overcome cell-mediated rejection including biological agents that target selectively costimulation molecules, the development of local immunosuppression through genetic manipulation, and encapsulation will be discussed. Overall, there has been considerable progress in all these areas, which eventually should lead to clinical trials.
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Affiliation(s)
- Philip J O'Connell
- Centre for Transplant and Renal Research, Westmead Millennium Institute, University of Sydney at Westmead Hospital, Westmead, NSW, 2145, Australia,
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Doesch AO, Müller S, Konstandin M, Celik S, Kristen A, Frankenstein L, Ehlermann P, Sack FU, Katus HA, Dengler TJ. Malignancies after heart transplantation: incidence, risk factors, and effects of calcineurin inhibitor withdrawal. Transplant Proc 2011; 42:3694-9. [PMID: 21094840 DOI: 10.1016/j.transproceed.2010.07.107] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2009] [Revised: 01/04/2010] [Accepted: 07/15/2010] [Indexed: 01/04/2023]
Abstract
The objectives of the present study were to evaluate the incidence of malignancies and to describe the effects of immunosuppression on survival and recurrence of malignancies after heart transplantation (HTX). Data were analyzed in 211 cardiac allograft recipients, in whom HTX was performed between 1989 and 2005. All of these patients survived for more than 2 years after HTX and received induction therapy with antithymocyte globulin (RATG) guided by T-cell monitoring since 1994. An immunosuppressive regimen consisting of cyclosporine A (CsA) combined with azathioprine was followed by CsA and mycophenolate mofetil (MMF) in 2001; mammalian target of rapamycin (mTOR) inhibitors (everolimus/sirolimus) were used since 2003. Mean patient age at HTX was 51.4 ± 10.5 years; mean follow-up time after HTX 9.2 ± 4.7 years. Overall incidence of neoplasias was 30.8%. Individual risk factors associated with a higher risk of malignancy after HTX were higher age at transplantation (P = .003), male gender (P = .005) and ischemic cardiomyopathy before HTX (P = .04). Administration of azathioprine (P < .0001) or a calcineurin inhibitor (CNI) (P = .02) for more than 1 year was associated with development of malignancy, whereas significantly fewer malignancies were noticed in patients receiving an mTOR-inhibitor (P < .0001). Kaplan-Meier analysis demonstrated a strong statistical trend toward an improved survival in patients with a noncutaneous neoplasia switched to a CNI-free protocol (P = .05). This study demonstrated the impact of a variety of individual risk factors and immunosuppressive drugs on development of malignancy after HTX. Markedly fewer patients with noncutaneous malignancies died after switch to a CNI-free regimen, not quite reaching statistical significance by Kaplan-Meier analysis, however.
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Affiliation(s)
- A O Doesch
- Department of Cardiology, University of Heidelberg, Germany.
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Koos D, Josephs SF, Alexandrescu DT, Chan RCF, Ramos F, Bogin V, Gammill V, Dasanu CA, De Necochea-Campion R, Riordan NH, Carrier E. Tumor vaccines in 2010: need for integration. Cell Immunol 2010; 263:138-47. [PMID: 20434139 DOI: 10.1016/j.cellimm.2010.03.019] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2010] [Accepted: 03/30/2010] [Indexed: 12/24/2022]
Abstract
Induction of tumor-specific immunity is an attractive approach to cancer therapy, however to date every major pivotal trial has resulted in failure. While the phenomena of tumor-mediated immune suppression has been known for decades, only recently have specific molecular pathways been elucidated, and for the first time, rationale means of intervening and observing results of intervention have been developed. In this review we describe major advances in our understanding of tumor escape from immunological pressure and provide some possible therapeutic scenarios for enhancement of efficacy in future cancer vaccine trials.
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