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Munshi PN, McCurdy SR. Age barriers in allogeneic hematopoietic cell transplantation: Raising the silver curtain. Am J Hematol 2024; 99:922-937. [PMID: 38414188 DOI: 10.1002/ajh.27228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 12/13/2023] [Accepted: 01/01/2024] [Indexed: 02/29/2024]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) is no longer exclusively for the young. With an aging population, development of non-intensive remission-inducing strategies for hematologic malignancies, and novel graft-versus-host disease-prevention platforms, an older population of patients is pursuing HCT. The evolving population of HCT recipients requires an overhaul in the way we risk-stratify and optimize patients prior to HCT. Here, we review the history and current state of HCT for older adults and propose an assessment and intervention flow to bridge the gaps in today's clinical guidelines.
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Affiliation(s)
- Pashna N Munshi
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Shannon R McCurdy
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Evolving Therapeutic Approaches for Older Patients with Acute Myeloid Leukemia in 2021. Cancers (Basel) 2021; 13:cancers13205075. [PMID: 34680226 PMCID: PMC8534216 DOI: 10.3390/cancers13205075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 09/29/2021] [Accepted: 10/04/2021] [Indexed: 02/06/2023] Open
Abstract
Simple Summary The better understanding of disease biology, the availability of new effective drugs and the increased awareness of patients’ heterogeneity in terms of fitness and personal expectations has made the current treatment paradigm of AML in the elderly very challenging. Here, we discuss the evolving criteria used to define eligibility for induction chemotherapy and transplantation, the introduction of new agents in the treatment of patients with very different clinical conditions, the implications of precision medicine and the importance of quality of life and supportive care, proposing a simplified algorithm that we follow in 2021. Abstract Acute myeloid leukemia (AML) in older patients is characterized by unfavorable prognosis due to adverse disease features and a high rate of treatment-related complications. Classical therapeutic options range from intensive chemotherapy in fit patients, potentially followed by allogeneic hematopoietic cell transplantation (allo-HCT), to hypomethylating agents or palliative care alone for unfit/frail ones. In the era of precision medicine, the treatment paradigm of AML is rapidly changing. On the one hand, a plethora of new targeted drugs with good tolerability profiles are becoming available, offering the possibility to achieve a prolonged remission to many patients not otherwise eligible for more intensive therapies. On the other hand, better tools to assess patients’ fitness and improvements in the selection and management of those undergoing allo-HCT will hopefully reduce treatment-related mortality and complications. Importantly, a detailed genetic characterization of AML has become of paramount importance to choose the best therapeutic option in both intensively treated and unfit patients. Finally, improving supportive care and quality of life is of major importance in this age group, especially for the minority of patients that are still candidates for palliative care because of very poor clinical conditions or unwillingness to receive active treatments. In the present review, we discuss the evolving approaches in the treatment of older AML patients, which is becoming increasingly challenging following the advent of new effective drugs for a very heterogeneous and complex population.
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Haen SP, Eyb V, Mirza N, Naumann A, Peter A, Löffler MW, Faul C, Vogel W, Bethge WA, Rammensee HG, Kanz L, Heni M. Uric acid as a novel biomarker for bone-marrow function and incipient hematopoietic reconstitution after aplasia in patients with hematologic malignancies. J Cancer Res Clin Oncol 2017; 143:759-771. [PMID: 28210842 DOI: 10.1007/s00432-017-2348-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 01/24/2017] [Indexed: 01/29/2023]
Abstract
PURPOSE Prolonged aplasia and graft failure (GF) represent life-threatening complications after hematopoietic cell transplantation (HCT) requiring suitable biomarkers for early detection and differentiation between GF and poor graft function (PGF). Uric acid (UA) is a strong immunological danger signal. METHODS Laboratory results were analyzed from patients undergoing either allogeneic or autologous HCT or induction chemotherapy for acute leukemia (n = 50 per group, n = 150 total). RESULTS During therapy, UA levels declined from normal values to hypouricemic values (all p < 0.001). Alongside hematopoietic recovery, UA serum levels returned to baseline values. During aplasia, UA levels remained low and started steadily increasing (defined as >two consecutive days, median one 2-day increase) at a median of 1 day before rising leukocytes in allogeneic HCT (p = 0.01) and together with leukocytes in autologous HCT (median one 2-day increase). During induction chemotherapy, a UA increase was also observed alongside rising leukocytes/neutrophils but also several times during aplasia (median 3 increases). Most HCT patients had no detectable leukocytes during aplasia, while some leukocytes remained detectable after induction therapy. No increase in UA levels was observed without concomitant or subsequent rise of leukocytes. CONCLUSIONS Changes in UA serum levels can indicate incipient or remaining immunological activity after HCT or induction therapy. They may, therefore, help to differentiate between PGF and GF.
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Affiliation(s)
- Sebastian P Haen
- Medizinische Universitaetsklinik, Abteilung II fuer Onkologie, Haematologie, Immunologie, Rheumatologie und Pulmologie, Otfried Mueller Str. 10, 72076, Tuebingen, Germany. .,Interfakultaeres Institut fuer Zellbiologie, Abteilung Immunologie, Auf der Morgenstelle 15, 72076, Tuebingen, Germany.
| | - Vicky Eyb
- Medizinische Universitaetsklinik, Abteilung II fuer Onkologie, Haematologie, Immunologie, Rheumatologie und Pulmologie, Otfried Mueller Str. 10, 72076, Tuebingen, Germany
| | - Nora Mirza
- Medizinische Universitaetsklinik, Abteilung II fuer Onkologie, Haematologie, Immunologie, Rheumatologie und Pulmologie, Otfried Mueller Str. 10, 72076, Tuebingen, Germany.,Interfakultaeres Institut fuer Zellbiologie, Abteilung Immunologie, Auf der Morgenstelle 15, 72076, Tuebingen, Germany
| | - Aline Naumann
- Institut fuer klinische Epidemiologie und angewandte Biometrie, Silcherstr. 5, 72076, Tuebingen, Germany
| | - Andreas Peter
- Medizinische Universitaetsklinik, Abteilung IV fuer Endokrinologie, Diabetologie, Angiologie, Nephrologie und Klinische Chemie, Otfried Mueller Str. 10, 72076, Tuebingen, Germany.,Institute of Diabetes Research and Metabolic Diseases (IDM) of the Helmholtz Center Munich at the University of Tuebingen, Tuebingen, Germany.,German Center for Diabetes Research (DZD), Muenchen-Neuherberg, Germany
| | - Markus W Löffler
- Interfakultaeres Institut fuer Zellbiologie, Abteilung Immunologie, Auf der Morgenstelle 15, 72076, Tuebingen, Germany
| | - Christoph Faul
- Medizinische Universitaetsklinik, Abteilung II fuer Onkologie, Haematologie, Immunologie, Rheumatologie und Pulmologie, Otfried Mueller Str. 10, 72076, Tuebingen, Germany
| | - Wichard Vogel
- Medizinische Universitaetsklinik, Abteilung II fuer Onkologie, Haematologie, Immunologie, Rheumatologie und Pulmologie, Otfried Mueller Str. 10, 72076, Tuebingen, Germany
| | - Wolfgang A Bethge
- Medizinische Universitaetsklinik, Abteilung II fuer Onkologie, Haematologie, Immunologie, Rheumatologie und Pulmologie, Otfried Mueller Str. 10, 72076, Tuebingen, Germany
| | - Hans-Georg Rammensee
- Interfakultaeres Institut fuer Zellbiologie, Abteilung Immunologie, Auf der Morgenstelle 15, 72076, Tuebingen, Germany
| | - Lothar Kanz
- Medizinische Universitaetsklinik, Abteilung II fuer Onkologie, Haematologie, Immunologie, Rheumatologie und Pulmologie, Otfried Mueller Str. 10, 72076, Tuebingen, Germany
| | - Martin Heni
- Medizinische Universitaetsklinik, Abteilung IV fuer Endokrinologie, Diabetologie, Angiologie, Nephrologie und Klinische Chemie, Otfried Mueller Str. 10, 72076, Tuebingen, Germany.,Institute of Diabetes Research and Metabolic Diseases (IDM) of the Helmholtz Center Munich at the University of Tuebingen, Tuebingen, Germany.,German Center for Diabetes Research (DZD), Muenchen-Neuherberg, Germany
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