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Wu Y, Tang BL, Song KD, Sun GY, Pan TZ, Huang AJ, Yan BB, Zhu XY. [Single non-blood-related umbilical cord blood transplantation using a reduced-intensity conditioning regimen for the treatment of severe aplastic anemia]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2024; 45:68-73. [PMID: 38527841 PMCID: PMC10951129 DOI: 10.3760/cma.j.issn.0253-2727.121090-20230928-00146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Indexed: 03/27/2024]
Abstract
Objective: To evaluated the clinical efficacy of a reduced-intensity preconditioning regimen for single non-blood-related umbilical cord blood transplantation (sUCBT) in the treatment of severe aplastic anemia (SAA) . Methods: The clinical data of 63 patients with SAA who underwent sUCBT from January 2021 to July 2023 at the Department of Hematology of the First Affiliated Hospital of USTC were retrospectively analyzed. Fifty-two patients received total body irradiation/total bone marrow irradiation (TMI) combined with fludarabine or a cyclophosphamide- conditioning regimen (non-rATG group) , while 11 patients received rabbit anti-human thymocyte immunoglobulin (rATG) combined with TMI, fludarabine, or the cyclophosphamide-conditioning regimen (rATG group) . All patients received cyclosporine A and mycophenolate mofetil for graft-versus-host disease (GVHD) prophylaxis. Complications post-transplantation and long-term survival were compared between the two groups. Results: The baseline parameters were balanced between the two groups (P>0.05) . In the rATG group, all patients achieved stem cell engraftment, and in the non-rATG group, five patients had primary graft failure. There was no significant difference in the cumulative incidence of neutrophil engraftment at 42 days after transplantation or platelet engraftment at 60 days between the two groups. The incidence of grade Ⅱ-Ⅳ acute GVHD in the rATG group was significantly lower than in the non-rATG group (10.0% vs. 46.2% , P=0.032) , and the differences in the cumulative incidences of grade Ⅲ/Ⅳ acute GVHD and 1-year chronic GVHD were not statistically significant (P=0.367 and P=0.053, respectively) . There were no significant differences in the incidences of pre-engraftment syndrome, bacterial bloodstream infections, cytomegalovirus viremia, or hemorrhagic cystitis between the two groups (P>0.05 for all) . The median follow-up time for surviving patients was 536 (61-993) days, and the 1-year transplantation related mortality (TRM) of all patients after transplantation was 13.0% (95% CI 6.7% -24.3% ) . Among the patients in the non-rATG and rATG groups, 15.5% (95% CI 8.1% -28.6% ) and 0% (P=0.189) , respectively, had mutations. The 1-year overall survival (OS) rate of all patients after transplantation was 87.0% (95% CI 75.7% -93.3% ) . The 1-year OS rates in the rATG group and non-rATG group after transplantation were 100% and 84.5% , respectively (95% CI 71.4% -91.9% ) (P=0.198) . Conclusion: The preliminary results of sUCBT with a low-dose irradiation-based reduced-intensity conditioning regimen with fludarabine/cyclophosphamide for the treatment of patients with SAA showed good efficacy. Early application of low-dose rATG can reduce the incidence of acute GVHD after transplantation without increasing the risk of implantation failure or infection.
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Affiliation(s)
- Y Wu
- Department of Hematology, the First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230001, China Anhui Provincial Key Laboratory of Blood Research and Applications, Hefei 230001, China Blood and Cell Therapy Institute, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230001, China
| | - B L Tang
- Department of Hematology, the First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230001, China Anhui Provincial Key Laboratory of Blood Research and Applications, Hefei 230001, China Blood and Cell Therapy Institute, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230001, China
| | - K D Song
- Department of Hematology, the First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230001, China
| | - G Y Sun
- Department of Hematology, the First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230001, China
| | - T Z Pan
- Department of Hematology, the First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230001, China Anhui Provincial Key Laboratory of Blood Research and Applications, Hefei 230001, China Blood and Cell Therapy Institute, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230001, China
| | - A J Huang
- Department of Hematology, the First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230001, China Anhui Provincial Key Laboratory of Blood Research and Applications, Hefei 230001, China Blood and Cell Therapy Institute, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230001, China
| | - B B Yan
- Department of Hematology, the First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230001, China Anhui Provincial Key Laboratory of Blood Research and Applications, Hefei 230001, China Blood and Cell Therapy Institute, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230001, China
| | - X Y Zhu
- Department of Hematology, the First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230001, China Anhui Provincial Key Laboratory of Blood Research and Applications, Hefei 230001, China Blood and Cell Therapy Institute, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230001, China
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Ponce DM, Politikos I, Alousi A, Carpenter PA, Milano F, MacMillan ML, Barker JN, Horwitz ME. Guidelines for the Prevention and Management of Graft-versus-Host Disease after Cord Blood Transplantation. Transplant Cell Ther 2021; 27:540-544. [PMID: 34210500 DOI: 10.1016/j.jtct.2021.03.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 03/07/2021] [Indexed: 12/13/2022]
Abstract
The incidence of graft-versus-host disease (GVHD) after cord blood (CB) transplantation (CBT) is lower than expected given the marked degree of human leukocyte antigen (HLA)-mismatch of CB grafts. While the exact mechanism that underlies this biology remains unclear, it is hypothesized to be due to the low number of mostly immature T-cells infused as part of the graft1,2, and increased tolerance of CB-derived lymphocytes induced by the state of pregnancy. Nevertheless, acute GVHD (aGVHD) is a significant complication of CBT. In contrast, the incidence of chronic GVHD (cGVHD) following CBT is lower than what is observed following matched related or unrelated donor HSC transplantation (HSCT)3-6. This review outlines the guidelines for the prevention and management of acute and chronic GVHD following CBT.
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Affiliation(s)
- Doris M Ponce
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College; New York, New York.
| | - Ioannis Politikos
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College; New York, New York
| | - Amin Alousi
- Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Paul A Carpenter
- Fred Hutchinson Cancer Research Center, Division of Clinical Research, Department of Pediatrics, Seattle, Washington
| | - Filippo Milano
- Fred Hutchinson Cancer Research Center, Department of Oncology, Seattle, Washington
| | - Margaret L MacMillan
- Blood and Marrow Transplantation & Cellular Therapy Program, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Juliet N Barker
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College; New York, New York
| | - Mitchell E Horwitz
- Hematologic Malignancies and Cellular Therapies, Department of Medicine, Duke Cancer Institute, Durham, North Carolina
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Metheny L, Politikos I, Ballen KK, Rezvani AR, Milano F, Barker JN, Brunstein CG. Guidelines for Adult Patient Selection and Conditioning Regimens in Cord Blood Transplant Recipients with Hematologic Malignancies and Aplastic Anemia. Transplant Cell Ther 2021; 27:286-291. [PMID: 33836867 DOI: 10.1016/j.jtct.2020.11.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 11/10/2020] [Indexed: 11/16/2022]
Abstract
For cord blood transplantation (CBT), appropriate patient and conditioning regimen selection is necessary to achieve long-term disease-free survival. This review aims to provide comprehensive guidelines on these issues using evidence from the literature and experience at dedicated CBT centers. Topics include patient and disease characteristics that make CBT a good or poor choice and a review of outcomes in commonly used conditioning regimens in CBT. This is accompanied with recommendations on regimen intensity based on disease, organ function, and patient performance status and age. In addition, the use of antithymocyte globulin in CBT is discussed, as is the choice of conditioning in aplastic anemia patients who have access to acceptable CB units.
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Affiliation(s)
- Leland Metheny
- Stem Cell Transplant Program, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, Ohio.
| | - Ioannis Politikos
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Karen K Ballen
- University of Virginia Cancer Center, Charlottesville, Virginia
| | - Andrew R Rezvani
- Division of Blood & Marrow Transplantation, Stanford University, Stanford, California
| | - Filippo Milano
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Juliet N Barker
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Claudio G Brunstein
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
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Treosulfan-based conditioning is feasible and effective for cord blood recipients: a phase 2 multicenter study. Blood Adv 2021; 4:3302-3310. [PMID: 32706891 DOI: 10.1182/bloodadvances.2020002222] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 06/19/2020] [Indexed: 11/20/2022] Open
Abstract
Although the use of treosulfan (TREO) in conventional donor hematopoietic cell transplantation (HCT) has been extensively evaluated, its use in cord blood transplantation (CBT) for hematologic malignancies has not been reported. Between March 2009 and October 2019, 130 CBT recipients were enrolled in this prospective multicenter phase 2 study. The conditioning regimen consisted of TREO, fludarabine, and a single fraction of 2 Gy total-body irradiation. Cyclosporine and mycophenolate mofetil were used for graft-versus-host disease prophylaxis. The primary end point was incidence of graft failure (GF), and based on risk of GF, patients were classified as low risk (arm 1, n = 66) and high risk (arm 2, n = 64). The median age was 45 years (range, 0.6-65 years). Disease status included acute leukemias in first complete remission (CR; n = 56), in ≥2 CRs (n = 46), and myelodysplastic (n = 25) and myeloproliferative syndromes (n = 3). Thirty-five patients (27%) had received a prior HCT. One hundred twenty-three patients (95%) engrafted, with neutrophil recovery occurring at a median of 19 days for patients on arm 1 and 20 days for patients on arm 2. The 3-year overall survival, relapse-free survival (RFS), transplant-related mortality, and relapse for the combined groups were 66%, 57%, 18%, and 24%, respectively. Among patients who had a prior HCT, RFS at 3 years was 48%. No significant differences in clinical outcomes were seen between the 2 arms. Our results demonstrate that TREO-based conditioning for CBT recipients is safe and effective in promoting CB engraftment with favorable clinical outcomes. This trial was registered at www.clinicaltrials.gov as #NCT00796068.
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Politikos I, Devlin SM, Arcila ME, Barone JC, Maloy MA, Naputo KA, Ruiz JD, Mazis CM, Scaradavou A, Avecilla ST, Dahi PB, Giralt SA, Hsu KC, Jakubowski AA, Papadopoulos EB, Perales MA, Sauter CS, Tamari R, Ponce DM, O'Reilly RJ, Barker JN. Engraftment kinetics after transplantation of double unit cord blood grafts combined with haplo-identical CD34+ cells without antithymocyte globulin. Leukemia 2020; 35:850-862. [PMID: 32555371 PMCID: PMC7746597 DOI: 10.1038/s41375-020-0922-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 06/07/2020] [Accepted: 06/09/2020] [Indexed: 12/21/2022]
Abstract
Double unit cord blood (dCB) transplantation (dCBT) is associated with high engraftment rates but delayed myeloid recovery. We investigated adding haplo-identical CD34+ cells to dCB grafts to facilitate early haplo-identical donor-derived neutrophil recovery (optimal bridging) prior to CB engraftment. Seventy-eight adults underwent myeloablation with cyclosporine-A/mycophenolate mofetil immunoprophylaxis (no antithymocyte globulin, ATG). CB units (median CD34+ dose 1.1 × 105/kg/unit) had a median 5/8 unit-recipient human leukocyte antigen (HLA)-match. Haplo-identical grafts had a median CD34+ dose of 5.2 × 106/kg. Of 77 evaluable patients, 75 had sustained CB engraftment that was mediated by a dominant unit and heralded by dominant unit-derived T cells. Optimal haplo-identical donor-derived myeloid bridging was observed in 34/77 (44%) patients (median recovery 12 days). Other engrafting patients had transient bridging with second nadir preceding CB engraftment (20/77 (26%), median first recovery 12 and second 26.5 days) or no bridge (21/77 (27%), median recovery 25 days). The 2 (3%) remaining patients had graft failure. Higher haplo-CD34+ dose and better dominant unit-haplo-CD34+ HLA-match significantly improved the likelihood of optimal bridging. Optimally bridged patients were discharged earlier (median 28 versus 36 days). ATG-free haplo-dCBT can speed neutrophil recovery but successful bridging is not guaranteed due to rapid haplo-identical graft rejection.
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Affiliation(s)
- Ioannis Politikos
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA. .,Department of Medicine, Weill Cornell Medical College, New York, NY, USA.
| | - Sean M Devlin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Maria E Arcila
- Diagnostic Molecular Pathology, Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jonathan C Barone
- Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Molly A Maloy
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kristine A Naputo
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Josel D Ruiz
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Christopher M Mazis
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andromachi Scaradavou
- Stem Cell Transplantation and Cellular Therapies, MSK Kids, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Pediatrics, Weill Cornell Medical College, New York, NY, USA
| | - Scott T Avecilla
- Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Parastoo B Dahi
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Sergio A Giralt
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Katherine C Hsu
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Ann A Jakubowski
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Esperanza B Papadopoulos
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Miguel A Perales
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Craig S Sauter
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Roni Tamari
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Doris M Ponce
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Richard J O'Reilly
- Stem Cell Transplantation and Cellular Therapies, MSK Kids, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Pediatrics, Weill Cornell Medical College, New York, NY, USA
| | - Juliet N Barker
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA. .,Department of Medicine, Weill Cornell Medical College, New York, NY, USA.
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Li D, Li X, Liao L, Li N. Unrelated cord blood transplantation versus haploidentical transplantation in adult and pediatric patients with hematological malignancies-A meta-analysis and systematic review. AMERICAN JOURNAL OF BLOOD RESEARCH 2020; 10:1-10. [PMID: 32206440 PMCID: PMC7076284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Accepted: 01/03/2020] [Indexed: 06/10/2023]
Abstract
Several clinical trials have compared the safety and efficacy of umbilical cord blood transplantation (UCBT) with haploidentical transplantation (HIT) in patients with hematological malignancies. To obtain more reliable evidence, we performed a systematic review and meta-analysis. Seven studies were included and there was a combined total of 102 children and 1311 adults undergoing UCBT, along with 94 children and 915 adults undergoing HIT. Pooled comparisons of studies of UCBT and HIT in children found that the incidence of chronic graft-versus-host disease (GVHD) and disease-free survival (DFS) at 2 years (RR 0.34, 95% CI (0.03, 4.53), P=0.41; HR 0.51, 95% CI (0.23, 1.09), P=0.08) were not statistically different. For adults, although the incidence of grade II-IV acute GVHD differ (RR 1.17, 95% CI (1.02, 1.34), P=0.02), but it indicates a very small difference between the groups as the RR is barely above 1. On the other hand, although the incidence of grade III-IV acute GVHD did not differ (RR 1.51, 95% CI (0.78, 2.92), P=0.22), but there is a tendency of higher risk for the UCBT. And the incidence of chronic GVHD did not differ (RR 1.05, 95% CI (0.82, 1.34), P=0.71). There was no difference in relapse, non-relapse mortality (NRM) and DFS at 2 years (HR 0.92, 95% CI (0.74, 1.13), P=0.42; HR 0.87, 95% CI (0.49, 1.52) P=0.62 and HR 0.74 95% CI (0.39, 1.43), P=0.37). In conclusion, UCBT and HIT could be considered as equally effective option for adult patients without HLA-matched donors.
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Affiliation(s)
- Duihong Li
- Hemopoietic Stem Cell Transplantation Center, Fujian Medical University Union HospitalNo. 29 Xinquan Street, Fuzhou 350001, China
- Fujian Provincial Key Laboratory on Hematology, Fujian Institute of HematologyNo. 29 Xinquan Street, Fuzhou 350001, China
| | - Xiaofan Li
- Hemopoietic Stem Cell Transplantation Center, Fujian Medical University Union HospitalNo. 29 Xinquan Street, Fuzhou 350001, China
- Fujian Provincial Key Laboratory on Hematology, Fujian Institute of HematologyNo. 29 Xinquan Street, Fuzhou 350001, China
- Fujian Medical University Hematology Translational CenterNo. 1 Xueyuan Road, Fuzhou 350001, China
| | - Lianming Liao
- Fujian Medical University Hematology Translational CenterNo. 1 Xueyuan Road, Fuzhou 350001, China
| | - Nainong Li
- Hemopoietic Stem Cell Transplantation Center, Fujian Medical University Union HospitalNo. 29 Xinquan Street, Fuzhou 350001, China
- Fujian Provincial Key Laboratory on Hematology, Fujian Institute of HematologyNo. 29 Xinquan Street, Fuzhou 350001, China
- Fujian Medical University Hematology Translational CenterNo. 1 Xueyuan Road, Fuzhou 350001, China
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A phase II study of reduced intensity double umbilical cord blood transplantation using fludarabine, melphalan, and low dose total body irradiation. Bone Marrow Transplant 2019; 55:804-810. [DOI: 10.1038/s41409-019-0715-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 09/27/2019] [Accepted: 09/30/2019] [Indexed: 11/09/2022]
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Effect of Sirolimus on Immune Reconstitution Following Myeloablative Allogeneic Stem Cell Transplantation: An Ancillary Analysis of a Randomized Controlled Trial Comparing Tacrolimus/Sirolimus and Tacrolimus/Methotrexate (Blood and Marrow Transplant Clinical Trials Network/BMT CTN 0402). Biol Blood Marrow Transplant 2019; 25:2143-2151. [PMID: 31271885 DOI: 10.1016/j.bbmt.2019.06.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 06/26/2019] [Accepted: 06/26/2019] [Indexed: 11/21/2022]
Abstract
Although allogeneic hematopoietic cell transplantation (HCT) is a potentially curative therapy for hematologic neoplasms, one of its limiting toxicities continues to be graft-versus-host disease, both acute (aGVHD) and chronic (cGVHD). Sirolimus is a mammalian target of rapamycin inhibitor that has proven effective in GVHD prophylaxis in combination with a calcineurin inhibitor, such as tacrolimus. The impact of sirolimus on immune reconstitution has not been comprehensively investigated in vivo thus far, however. Here we present an ancillary analysis of the randomized study BMT-CTN 0402 that examined the effect of sirolimus on immune subsets post-transplantation. We further examine the association between different lymphocyte subsets and outcomes post-transplantation in each arm. BMT-CTN 0402 was a randomized trial (n = 304) comparing 2 GVHD prophylaxis regimens, tacrolimus/sirolimus (Tac/Sir) and tacrolimus/methotrexate (Tac/MTX), in patients with acute myelogenous leukemia, acute lymphoblastic leukemia, or myelodysplastic syndrome undergoing myeloablative HLA-matched HCT. There were no differences in 114-day GVHD-free survival (primary endpoint), aGVHD, cGVHD, relapse, or overall survival (OS) between the 2 arms. Of the 304 patients, 264 had available samples for the current immune reconstitution analysis. Blood samples were collected at 1, 3, 6, 12, and 24 months post-HCT. Multiparameter flow cytometry was performed at the project laboratory (Esoterix Clinical Trials Services) in a blinded fashion, and results for the 2 arms were compared. Multivariable Cox regression models, treating each phenotypic parameter as a time-dependent variable, were constructed to study the impact of reconstitution on clinical outcomes. There were no significant differences in patient and transplantation characteristics between the Tac/Sir and Tac/MTX arms in this analysis. Absolute lymphocyte count and CD3+ cell, CD4+ cell, and conventional T cell (Tcon) counts were significantly decreased in the Tac/Sir arm for up to 3 months post-HCT, whereas CD8+ cells recovered even more slowly (up to 6 months) in this arm. Interestingly, there was no clear difference in the absolute number of regulatory T cells (Tregs, defined as CD4+CD25+ cells) between the 2 arms at any point post-HCT; however, the Treg:Tcon ratio was significantly greater in the Tac/Sir arm in the first 3 months after HCT. B lymphocyte recovery was significantly compromised in the Tac/Sir arm from 1 month to 6 months after HCT, whereas natural killer cell reconstitution was not affected in the Tac/Sir arm. In the outcomes analysis, higher numbers of CD3+ cells, CD4+ cells, CD8+ cells, and Tregs were associated with better OS. Neither Treg numbers nor the Treg:Tcon ratio was correlated with GVHD. Our findings indicate that Tac/Sir has a more profound T cell suppressive effect than the combination of Tac/MTX in the early post-transplantation period, and particularly compromises the recovery of CD8+ T cells, which have been implicated in aGVHD. Sirolimus used in vivo with tacrolimus does not appear to result in increased absolute numbers of Tregs, but might have a beneficial effect on the Treg:Tcon balance in the first 3 months after transplantation. Nonetheless, no differences in aGVHD or cGVHD between the 2 arms were observed in the parent randomized trial. Calcineurin-inhibitor free, sirolimus-containing GVHD prophylaxis strategies, incorporating other novel agents, should be investigated further to maximize the potential favorable effect of sirolimus on Treg:Tcon balance in the post-transplantation immune repertoire. Sirolimus significantly compromises B cell recovery in the first 6 months post-HCT, with potential complex effects on cGVHD that merit further study.
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Karantanos T, Kim HT, Tijaro-Ovalle NM, Li L, Cutler C, Antin JH, Ballen K, Marty FM, Tan CS, Ritz J, Politikos I, Boussiotis V. Reactivation of BK virus after double umbilical cord blood transplantation in adults correlates with impaired reconstitution of CD4 + and CD8 + T effector memory cells and increase of T regulatory cells. Clin Immunol 2019; 207:18-23. [PMID: 31255803 DOI: 10.1016/j.clim.2019.06.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Revised: 06/26/2019] [Accepted: 06/26/2019] [Indexed: 12/26/2022]
Abstract
BK virus (BKV), a human polyomavirus that remains latent in renal epithelial cells, can be reactivated after hematopoietic stem cell transplantation (HSCT) leading to hemorrhagic cystitis. The incidence of BK viremia is higher after Umbilical cord blood transplantation (UCBT) than HSCT from adult donors. Data regarding the role of immune recovery after UCBT in BKV reactivation is lacking. We examined the correlation between the development of BK viremia and immune reconstitution in 27 adult recipients of UCBT. The incidence of BK viremia was 52% and developed most frequently within the first 8 weeks after the transplantation, but persisted in seven patients at 6 months, and three patients at 1-year post UCBT. Detection of BK viremia 1 year after transplant was negatively associated with the number of CD8+ cells (p = 0.03) and CD8+CD45RO+ cells (p = 0.05) at 6 months, and the number of CD4+ (p = 0.03) and CD4+CD45RO+ cells (p = 0.03) at 12 months after UCBT. Conversely, BK viremia at 6 and 12 months was positively correlated with the number of T regulatory (Treg) cells at 1 month (p = 0.005 and p = 0.016, respectively). Because UCB Treg have highly potent immunosuppressive function, our findings indicate that sustained BK viremia in UCBT recipients might be associated with the increase of Treg cells early after transplantation, which mediate impaired and delayed reconstitution of CD4+ and CD8+ T effector cells.
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Affiliation(s)
- Theodoros Karantanos
- Division of Hematology-Oncology, Beth Israel Deaconess Medical Center, Boston, MA, United States of America; Division of Medical Oncology, Johns Hopkins University, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, United States of America
| | - Haesook T Kim
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, MA, United States of America
| | - Natalia M Tijaro-Ovalle
- Division of Hematology-Oncology, Beth Israel Deaconess Medical Center, Boston, MA, United States of America
| | - Lequn Li
- Division of Hematology-Oncology, Beth Israel Deaconess Medical Center, Boston, MA, United States of America
| | - Corey Cutler
- Department of Medical Oncology, Dana-Farber Cancer Institute, United States of America
| | - Joseph H Antin
- Department of Medical Oncology, Dana-Farber Cancer Institute, United States of America
| | - Karen Ballen
- University of Virginia Health Center, Charlottesville, VA, United States of America
| | - Francisco M Marty
- Division of Infectious Diseases, Brigham and Women's Hospital, United States of America
| | - Chen Sabrina Tan
- Center for Virology and Vaccine Research, Beth Israel Deaconess Medical Center, United States of America
| | - Jerome Ritz
- Department of Medical Oncology, Dana-Farber Cancer Institute, United States of America
| | - Ioannis Politikos
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Vassiliki Boussiotis
- Division of Hematology-Oncology, Beth Israel Deaconess Medical Center, Boston, MA, United States of America.
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10
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Park H, Lee YJ, Shin SJ, Lee J, Park S, Kim I, Moon JH, Lee H, Jang JH, Yoon SS, Koh Y. Which donor is better when a matched donor is not available domestically? Comparison of outcomes of allogeneic stem cell transplantation with haploidentical and international donors in a homogenous ethnic population. Leuk Res 2018; 69:31-38. [DOI: 10.1016/j.leukres.2018.04.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 04/01/2018] [Accepted: 04/02/2018] [Indexed: 11/16/2022]
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11
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Mehta RS, Olson A, Ponce DM, Shpall EJ. Unrelated Donor Cord Blood Transplantation for Hematologic Malignancies. Hematology 2018. [DOI: 10.1016/b978-0-323-35762-3.00107-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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12
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Tsai SB, Rhodes J, Liu H, Shore T, Bishop M, Cushing MM, Gergis U, Godley L, Kline J, Larson RA, Mayer S, Odenike O, Stock W, Wickrema A, van Besien K, Artz AS. Reduced-Intensity Allogeneic Transplant for Acute Myeloid Leukemia and Myelodysplastic Syndrome Using Combined CD34-Selected Haploidentical Graft and a Single Umbilical Cord Unit Compared with Matched Unrelated Donor Stem Cells in Older Adults. Biol Blood Marrow Transplant 2017; 24:997-1004. [PMID: 29288821 DOI: 10.1016/j.bbmt.2017.12.794] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 12/20/2017] [Indexed: 11/12/2022]
Abstract
Haplo/cord transplantation combines an umbilical cord blood (UCB) graft with CD34-selected haploidentical cells and results in rapid hematopoietic recovery followed by durable UCB engraftment. We compared outcomes of transplants in older patients with acute myeloid leukemia (AML) or high-risk myelodysplastic syndromes (MDS) who received either HLA-matched unrelated donor (MUD) cells or haplo/cord grafts. Between 2007 and 2013, 109 adults ages 50 and older underwent similar reduced-intensity conditioning with fludarabine and melphalan and antibody-mediated T cell depletion for AML (n = 83) or high-risk MDS (n = 26) followed by either a MUD (n = 68) or haplo/cord (n = 41) graft. Patient characteristics were similar for each graft source except for more minority patients receiving a haplo/cord transplant (P = .01). One half of the AML patients were not in remission. Two-year progression-free survival (PFS), overall survival (OS), and graft-versus-host disease-free relapse-free survival were 38%, 48%, and 32.1% for MUD and 33%, 48%, and 33.8% for haplo/cord transplants (P = .62 for PFS; P = .97 for OS; P= .84), respectively. Acute grades II to IV and chronic graft-versus-host-disease rates did not differ at 19.5% and 4.9% in haplo/cord compared with 25% and 7.4% after MUD (P = .53 and P = .62, respectively). Multivariate analysis confirmed no significant differences in transplant outcomes by donor type. Haplo/cord reduced-intensity transplantation achieves similar outcomes relative to MUD in older AML and MDS patients, making this a promising option for those without matched donors.
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Affiliation(s)
- Stephanie B Tsai
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, Illinois; Section of Hematology-Oncology, Department of Medicine, Loyola University Medical Center, Maywood, Illinois
| | - Joanna Rhodes
- Hematopoietic Stem Cell Transplant Program, Weill-Cornell Medical College, New York, New York
| | - Hongtao Liu
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Tsiporah Shore
- Hematopoietic Stem Cell Transplant Program, Weill-Cornell Medical College, New York, New York
| | - Michael Bishop
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Melissa M Cushing
- Department of Pathology, Weill-Cornell Medical College, New York, New York
| | - Usama Gergis
- Hematopoietic Stem Cell Transplant Program, Weill-Cornell Medical College, New York, New York
| | - Lucy Godley
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Justin Kline
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Richard A Larson
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Sebastian Mayer
- Hematopoietic Stem Cell Transplant Program, Weill-Cornell Medical College, New York, New York
| | - Olatoyosi Odenike
- Section of Hematology-Oncology, Department of Medicine, Loyola University Medical Center, Maywood, Illinois
| | - Wendy Stock
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Amittha Wickrema
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Koen van Besien
- Hematopoietic Stem Cell Transplant Program, Weill-Cornell Medical College, New York, New York
| | - Andrew S Artz
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, Illinois.
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13
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Neurologic complications after allogeneic hematopoietic stem cell transplantation: risk factors and impact. Bone Marrow Transplant 2017; 53:199-206. [PMID: 29131150 DOI: 10.1038/bmt.2017.239] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 09/08/2017] [Accepted: 09/12/2017] [Indexed: 01/16/2023]
Abstract
Neurologic complications (NCs) may be a significant source of morbidity and mortality after hematopoietic cell transplantation (HCT). We performed a retrospective study of 263 consecutive patients undergoing allogeneic HCT for hematological malignancies to determine the incidence, risk factors and clinical impact of NCs in the first 5 years after HCT. We determined the incidence of central nervous system (CNS) infection, intracranial hemorrhage, ischemic stroke, metabolic encephalopathy, posterior reversal encephalopathy syndrome, seizure and peripheral neuropathy. In all, 50 patients experienced 63 NCs-37 early (⩽day +100), 21 late (day +101 to 2 years) and 5 very late (2 to 5 years). The 1- and 5-year cumulative incidences of all NCs were 15.6% and 19.2%, respectively, and of CNS complication (CNSC; all of the above complications except peripheral neuropathy) were 12.2 and 14.5%. Risk factors for CNSC were age (hazard ratio (HR)=1.06 per year, P=0.0034), development of acute GvHD grade III-IV (HR=2.78, P=0.041), transfusion-dependent thrombocytopenia (HR=3.07, P=0.025) and delayed platelet engraftment (>90th centile; HR=2.77, P=0.043). CNSCs negatively impacted progression-free survival (HR=2.29, P=0.0001), overall survival (HR=2.63, P<0.0001) and non-relapse mortality (HR=8.51, P<0.0001). NCs after HCT are associated with poor outcomes, and usually occur early after HCT.
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14
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Abstract
Allogeneic hematopoietic cell transplant is a curative procedure for many patients with leukemia, lymphoma, myelodysplasia, myeloproliferative neoplasms, and genetic disorders. Umbilical cord blood transplantation is a graft source for patients who do not have a matched donor in their family or in the unrelated registry. It is particularly difficult for Black, Hispanic, and White patients of non-Western European background to find fully matched adult volunteer donors. An estimated 700,000 umbilical cord blood units have been donated for public use, and over 40,000 umbilical cord blood transplantations have been performed. Over 25,000 patients have been cured with this approach.
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Affiliation(s)
- Karen Ballen
- Stem Cell Transplant Program, University of Virginia Health System, Charlottesville, VA, USA
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15
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Anand S, Thomas S, Corbet K, Gasparetto C, Long GD, Lopez R, Morris AK, Rizzieri DA, Sullivan KM, Sung AD, Sarantopoulos S, Chao NJ, Horwitz ME. Adult Umbilical Cord Blood Transplantation Using Myeloablative Thiotepa, Total Body Irradiation, and Fludarabine Conditioning. Biol Blood Marrow Transplant 2017; 23:1949-1954. [PMID: 28729147 DOI: 10.1016/j.bbmt.2017.06.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 06/26/2017] [Indexed: 12/16/2022]
Abstract
Treatment-related mortality (TRM) remains elevated in adult patients undergoing umbilical cord blood transplantation (UCBT), including an early rise in TRM suggestive of excessive toxicity associated with the standard myeloablative total body irradiation (TBI), fludarabine, and cyclophosphamide regimen. In an attempt to reduce regimen-related toxicity, we previously studied a modified myeloablative regimen with TBI (1350 cGy) and fludarabine (160 mg/m2); TRM was decreased, but neutrophil engraftment was suboptimal. Therefore, to improve engraftment while still minimizing regimen-related toxicity, we piloted a myeloablative regimen with the addition of thiotepa (10 mg/kg) to TBI and fludarabine conditioning. Thirty-one adult patients (median age, 46 years; range, 19 to 65) with hematologic malignancies (acute leukemia/myelodysplastic syndrome, 77%; lymphoid malignancy, 23%) underwent single (n = 1) or double (n = 30) UCBT from 2010 to 2015 at our institution. The cumulative incidence of neutrophil engraftment was 90% (95% confidence interval [CI], 70% to 97%) by 60 days, with a median time to engraftment of 21 days (95% CI, 19 to 26). The cumulative incidence of platelet engraftment was 77% (95% CI, 57% to 89%) by 100 days, with a median time to engraftment of 47 days (95% CI, 37 to 73). Cumulative incidences of grades II to IV and grades III to IV acute graft-versus-host disease (GVHD) at day 100 were 45% (95% CI, 27% to 62%) and 10% (95% CI, 2% to 23%), respectively. The overall incidence of chronic GVHD at 2 years was 40% (95% CI, 22% to 57%), with 17% of patients (95% CI, 6% to 33%) experiencing moderate to severe chronic GVHD by 2 years. TRM at 180 days was 13% (95% CI, 4% to 27%), at 1 year 24% (95% CI, 10% to 41%), and at 3 years 30% (95% CI, 13% to 49%). Relapse at 1 year was 13% (95% CI, 4% to 27%) and at 3 years 19% (95% CI, 6% to 38%). With a median follow-up of 35.5 months (95% CI, 12.7 to 52.2), disease-free and overall survival at 3 years were 51% (95% CI, 29% to 69%) and 57% (95% CI, 36% to 73%), respectively. This regimen represents a reasonable alternative to myeloablative conditioning with TBI, fludarabine, and cyclophosphamide and warrants further study.
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Affiliation(s)
- Sarah Anand
- Division of Hematologic Malignancies and Cellular Therapy, Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Samantha Thomas
- Department of Biostatistics and Bioinformatics, Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Kelly Corbet
- Division of Hematologic Malignancies and Cellular Therapy, Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Cristina Gasparetto
- Division of Hematologic Malignancies and Cellular Therapy, Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Gwynn D Long
- Division of Hematologic Malignancies and Cellular Therapy, Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Richard Lopez
- Division of Hematologic Malignancies and Cellular Therapy, Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Ashley K Morris
- Division of Hematologic Malignancies and Cellular Therapy, Duke Cancer Institute, Duke University, Durham, North Carolina
| | - David A Rizzieri
- Division of Hematologic Malignancies and Cellular Therapy, Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Keith M Sullivan
- Division of Hematologic Malignancies and Cellular Therapy, Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Anthony D Sung
- Division of Hematologic Malignancies and Cellular Therapy, Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Stefanie Sarantopoulos
- Division of Hematologic Malignancies and Cellular Therapy, Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Nelson J Chao
- Division of Hematologic Malignancies and Cellular Therapy, Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Mitchell E Horwitz
- Division of Hematologic Malignancies and Cellular Therapy, Duke Cancer Institute, Duke University, Durham, North Carolina.
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16
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Wall SA, Devine S, Vasu S. The who, how and why: Allogeneic transplant for acute myeloid leukemia in patients older than 60years. Blood Rev 2017; 31:362-369. [PMID: 28802907 DOI: 10.1016/j.blre.2017.07.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 05/26/2017] [Accepted: 07/11/2017] [Indexed: 10/19/2022]
Abstract
Acute myelogenous leukemia (AML) is primarily a disease of the elderly, and as such, our approach to treatment needs to be tailored to address an aging population. Allogeneic hematopoietic stem cell transplantation (allo-HSCT) remains the only potentially curative treatment for intermediate and high risk AML, and until recently, its use had been limited to a younger population and dependent on availability of a donor. Advances in conditioning regimens, supportive care, and the use of alternative donor sources have greatly expanded access to this therapy. In this review, we summarize the challenges and unique biological aspects of treatment with allogeneic stem cell transplantation in this group of patients older than 60years. We also highlight areas of ongoing research including measurement of residual disease prior to and following transplant, post-remission maintenance therapy, and natural killer cell immunotherapy. Finally, we propose future directions for AML treatment in an elderly and aging population.
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Affiliation(s)
- Sarah A Wall
- Division of Hematology, Ohio State University, Columbus, OH, USA
| | - Steven Devine
- Division of Hematology, Ohio State University, Columbus, OH, USA
| | - Sumithira Vasu
- Division of Hematology, Ohio State University, Columbus, OH, USA.
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17
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Alonso CD, Braun DA, Patel I, Akbari M, Oh DJ, Jun T, McMasters M, Hammond SP, Glotzbecker B, Cutler C, Leffler DA, Ballen KK, Kelly CP. A multicenter, retrospective, case-cohort study of the epidemiology and risk factors for Clostridium difficile infection among cord blood transplant recipients. Transpl Infect Dis 2017; 19. [PMID: 28544102 DOI: 10.1111/tid.12728] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 03/18/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Clostridium difficile infection (CDI) is the leading cause of health-care associated infectious diarrhea. The aim of this study was to evaluate the epidemiology and risk factors for CDI in the 100 days following umbilical cord blood transplantation (UCBT) at three Boston hospitals. METHODS We performed a multicenter, retrospective, case-cohort study of 226 UCBT recipients at Beth Israel Deaconess Medical Center, Massachusetts General Hospital, and Dana Farber/Brigham and Women's Cancer Center from 2003 to 2012. CDI was defined as diarrhea (≥3 unformed bowel movements for at least 2 days) plus a positive stool test for toxinogenic C. difficile and not attributed to any other cause. RESULTS Among 226 UCBT recipients, 22 patients (9.7%) developed CDI within the first 100 days of transplant (corresponding to an infection rate of 10.8 cases per 10 000 person-days). The 100-day and 1-year rates were stable across the time period and between institutions. UCBT recipients with CDI were more likely than non-CDI patients to be older, with higher body mass indices, and to have received an antipseudomonal penicillin agent. In a time-dependent case-cohort analysis of the risk factors associated with CDI in the first 100 days after UCBT, bacterial infection after UCBT was the strongest risk factor for CDI (hazard ratio 2.8; 95% confidence interval 1.08-7.24; P=.03), after adjustment for transplant variables including antibiotic exposure. CONCLUSION This study verifies the previously reported risk factors for CDI including older age and antibiotic exposure and identifies a novel association between bacterial infections and risk for CDI.
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Affiliation(s)
- Carolyn D Alonso
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - David A Braun
- Dana-Farber/Partners CancerCare Program, Boston, MA, USA
| | - Ishan Patel
- Department of Medicine, Icahn School of Medicine, Elmhurst Program, New York, NY, USA
| | - Mona Akbari
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Daniel Jungmyung Oh
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Tomi Jun
- Stanford Health Care, Stanford, CA, USA
| | - Malgorzata McMasters
- Section of Hematological Malignancies and Bone Marrow Transplantation, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Sarah P Hammond
- Harvard Medical School, Boston, MA, USA.,Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, USA
| | - Brett Glotzbecker
- Dana Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA, USA
| | - Corey Cutler
- Dana Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA, USA
| | - Daniel A Leffler
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Karen K Ballen
- Division of Hematology/Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Ciarán P Kelly
- Harvard Medical School, Boston, MA, USA.,Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
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18
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Conditioning regimens for allogeneic hematopoietic stem cell transplants in acute myeloid leukemia. Bone Marrow Transplant 2017; 52:1504-1511. [DOI: 10.1038/bmt.2017.83] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 02/06/2017] [Accepted: 02/24/2017] [Indexed: 12/24/2022]
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19
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Optimal Practices in Unrelated Donor Cord Blood Transplantation for Hematologic Malignancies. Biol Blood Marrow Transplant 2017; 23:882-896. [PMID: 28279825 DOI: 10.1016/j.bbmt.2017.03.006] [Citation(s) in RCA: 102] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 03/02/2017] [Indexed: 12/26/2022]
Abstract
Unrelated donor cord blood transplantation (CBT) results in disease-free survival comparable to that of unrelated adult donor transplantation in patients with hematologic malignancies. Extension of allograft access to racial and ethnic minorities, rapid graft availability, flexibility of transplantation date, and low risks of disabling chronic graft-versus-host disease (GVHD) and relapse are significant advantages of CBT, and multiple series have reported a low risk of late transplantation-related mortality (TRM) post-transplantation. Nonetheless, early post-transplantation morbidity and TRM and the requirement for intensive early post-transplantation management have slowed the adoption of CBT. Targeted care strategies in CBT recipients can mitigate early transplantation complications and reduce transplantation costs. Herein we provide a practical "how to" guide to CBT for hematologic malignancies on behalf of the National Marrow Donor Program and the American Society of Blood and Marrow Transplantation's Cord Blood Special Interest Group. It shares the best practices of 6 experienced US transplantation centers with a special interest in the use of cord blood as a hematopoietic stem cell source. We address donor search and unit selection, unit thaw and infusion, conditioning regimens, immune suppression, management of GVHD, opportunistic infections, and other factors in supportive care appropriate for CBT. Meticulous attention to such details has improved CBT outcomes and will facilitate the success of CBT as a platform for future graft manipulations.
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20
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Chen YB, Wang T, Hemmer MT, Brady C, Couriel DR, Alousi A, Pidala J, Urbano-Ispizua A, Choi SW, Nishihori T, Teshima T, Inamoto Y, Wirk B, Marks DI, Abdel-Azim H, Lehmann L, Yu L, Bitan M, Cairo MS, Qayed M, Salit R, Gale RP, Martino R, Jaglowski S, Bajel A, Savani B, Frangoul H, Lewis ID, Storek J, Askar M, Kharfan-Dabaja MA, Aljurf M, Ringden O, Reshef R, Olsson RF, Hashmi S, Seo S, Spitzer TR, MacMillan ML, Lazaryan A, Spellman SR, Arora M, Cutler CS. GvHD after umbilical cord blood transplantation for acute leukemia: an analysis of risk factors and effect on outcomes. Bone Marrow Transplant 2017; 52:400-408. [PMID: 27941764 PMCID: PMC5332289 DOI: 10.1038/bmt.2016.265] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 08/12/2016] [Accepted: 08/28/2016] [Indexed: 11/15/2022]
Abstract
Using the Center for International Blood and Marrow Transplant Research (CIBMTR) registry, we analyzed 1404 umbilical cord blood transplantation (UCBT) patients (single (<18 years)=810, double (⩾18 years)=594) with acute leukemia to define the incidence of acute GvHD (aGvHD) and chronic GvHD (cGvHD), analyze clinical risk factors and investigate outcomes. After single UCBT, 100-day incidence of grade II-IV aGvHD was 39% (95% confidence interval (CI), 36-43%), grade III-IV aGvHD was 18% (95% CI, 15-20%) and 1-year cGvHD was 27% (95% CI, 24-30%). After double UCBT, 100-day incidence of grade II-IV aGvHD was 45% (95% CI, 41-49%), grade III-IV aGvHD was 22% (95% CI, 19-26%) and 1-year cGvHD was 26% (95% CI, 22-29%). For single UCBT, multivariate analysis showed that absence of antithymocyte globulin (ATG) was associated with aGvHD, whereas prior aGvHD was associated with cGvHD. For double UCBT, absence of ATG and myeloablative conditioning were associated with aGvHD, whereas prior aGvHD predicted for cGvHD. Grade III-IV aGvHD led to worse survival, whereas cGvHD had no significant effect on disease-free or overall survival. GvHD is prevalent after UCBT with severe aGvHD leading to higher mortality. Future research in UCBT should prioritize prevention of GvHD.
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Affiliation(s)
- Yi-Bin Chen
- Massachusetts General Hospital, Boston, Massachusetts
| | - Tao Wang
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
- Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Michael T. Hemmer
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Colleen Brady
- Center for International Blood and Marrow Transplant Research, National Marrow Donor Program/Be The Match, Minneapolis, Minneapolis
| | - Daniel R. Couriel
- Utah Blood and Marrow Transplant Program, Adults, Salt Lake City, Utah
| | - Amin Alousi
- Division of Cancer Medicine, Department of Stem Cell Transplantation, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Joseph Pidala
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Alvaro Urbano-Ispizua
- Department of Hematology, Hospital Clinic, University of Barcelona, IDIBAPS and Institute of Research Josep Carreras, Barcelona, Spain
| | | | - Taiga Nishihori
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | | | - Yoshishiro Inamoto
- Division of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Baldeep Wirk
- Division of Bone Marrow Transplant, Seattle Cancer Care Alliance, Seattle, WA
| | - David I Marks
- Adult Bone Marrow Transplant, University Hospitals Bristol NHS Trust, Bristol, United Kingdom
| | - Hisham Abdel-Azim
- Division of Hematology, Oncology and Blood & Marrow Transplantation, Children’s Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Leslie Lehmann
- Dana-Farber Cancer Institute/Boston Children’s Hospital, Boston, MA
| | - Lolie Yu
- Dvision of Hematology/Oncology &HSCT, The Center for Cancer and Blood Disorders, Children’s Hospital/Louisiana State University Medical Center, New Orleans, LA
| | - Menachem Bitan
- Department of Pediatric Hematology/Oncology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Mitchell S. Cairo
- Division of Pediatric Hematology, Oncology and Stem Cell Transplantation, Department of Pediatrics, New York Medical College, Valhalla NY
| | - Muna Qayed
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Rachel Salit
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Robert Peter Gale
- Hematology Research Centre, Division of Experimental Medicine, Department of Medicine, Imperial College London, London, United Kingdom
| | - Rodrigo Martino
- Division of Clinical Hematology, Hospital de la Santa Creu I Sant Pau, Barcelona, Spain
| | - Samantha Jaglowski
- Division of Hematology, The Ohio State University Medical Center, Columbus, OH
| | - Ashish Bajel
- Royal Malbourne Hospital City Campus, Victoria, Australia
| | - Bipin Savani
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Haydar Frangoul
- Division of Hematology-Oncology, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - Ian D. Lewis
- Haematology and Bone Marrow Transplant Unit, Royal Adelaide Hospital. Adelaide, SA, Australia
| | - Jan Storek
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | | | - Mohamed A. Kharfan-Dabaja
- Department of Blood and Marrow Transplantation, H. Lee Mofitt Cancer Center and Research Institute, Tampa, FL
| | - Mahmoud Aljurf
- Department of Oncology, King Faisal Specialist Hospital Center & Research, Riyadh, Saudi Arabia
| | - Olle Ringden
- Division of Therapeutic Immunology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
- Centre for Clinical Research Sormland, Uppsala University, Uppsala, Sweden
| | - Ran Reshef
- Blood and Marrow Transplantation Program and Columbia Center for Translational Immunology, Columbia University Medical Center, New York, NY
| | - Richard F. Olsson
- Division of Therapeutic Immunology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
- Centre for Clinical Research Sormland, Uppsala University, Uppsala, Sweden
| | | | - Sachiko Seo
- National Cancer Research Center, East Hospital, Kashiwa, Chiba, Japan
| | | | | | | | - Stephen R. Spellman
- Center for International Blood and Marrow Transplant Research, National Marrow Donor Program/Be The Match, Minneapolis, Minneapolis
| | - Mukta Arora
- Division of Hematology, Oncology, Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Corey S. Cutler
- Center for Hematologic Oncology, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
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21
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Brunstein CG, Cutler CS, DeFor TE, Kim H, Bejanyan N, Garfall A, Verneris MR, Chen YB, Warlick ED, Spitzer T, Miller JS, Antin JH, Weisdorf DJ, Soiffer R, Wagner JE, Ballen KK. Matching at Human Leukocyte Antigen-C Improved the Outcomes after Double Umbilical Cord Blood Transplantation for Recipients of Two to Four of Six Human Leukocyte Antigen-Matched Grafts. Biol Blood Marrow Transplant 2017; 23:126-133. [PMID: 27989929 PMCID: PMC5510875 DOI: 10.1016/j.bbmt.2016.10.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 10/22/2016] [Indexed: 10/20/2022]
Abstract
We studied the effect of HLA-C matching in 515 patients after double umbilical cord blood (UCB) transplantation. After HLA matching HLA-A, -B, and -DRB1 at the allele level, we scored patients according to number of donor-recipient HLA-C matches at 4 possible loci: 2 from each donor unit, at the allele level. Given a direct interaction between HLA-A, -B, and -DRB1 matching and HLA-C score, we analyzed HLA-C matching in those receiving at least 1 2/6 to 4/6 HLA-matched unit (n = 389) versus those receiving only 5/6 or 6/6-matched units (n = 126). In those with at least 1 2/6 to 4/6 HLA-matched unit, a better HLA-C matching score was associated with significantly lower risk of death of any cause and nonrelapse mortality and better disease-free survival. There was no association with the risk of relapse, acute and chronic graft-versus-host disease, and hematopoietic recovery. In contrast, among patients receiving only allele-level 5/6 or 6/6 HLA-matched UCB units, HLA-C match had no demonstrable effect on any outcome. For patients receiving at least 1 allele-level 2/6 to 4/6 HLA-matched UCB unit, matching at HLA-C reduces nonrelapse mortality and improves survival.
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Affiliation(s)
- Claudio G Brunstein
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota.
| | | | - Todd E DeFor
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | - Haesook Kim
- The Dana Farber Cancer Institute, Boston, Massachusetts
| | - Nelli Bejanyan
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | | | - Michael R Verneris
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | - Yi-Bin Chen
- Massachusetts General Hospital, Boston, Massachusetts
| | - Erica D Warlick
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | | | - Jeffrey S Miller
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | | | - Daniel J Weisdorf
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | | | - John E Wagner
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
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22
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Politikos I, T Kim H, Karantanos T, Brown J, McDonough S, Li L, Cutler C, Antin JH, Ballen KK, Ritz J, Boussiotis VA. Angiogenic Factors Correlate with T Cell Immune Reconstitution and Clinical Outcomes after Double-Unit Umbilical Cord Blood Transplantation in Adults. Biol Blood Marrow Transplant 2017; 23:103-112. [PMID: 27777141 PMCID: PMC5489056 DOI: 10.1016/j.bbmt.2016.10.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 10/15/2016] [Indexed: 11/18/2022]
Abstract
Umbilical cord blood (UCB) is a valuable graft source for allogeneic hematopoietic stem cell transplantation (HSCT) in patients who lack adult donors. UCB transplantation (UCBT) in adults results in delayed immune reconstitution, leading to high infection-related morbidity and mortality. Angiogenic factors and markers of endothelial dysfunction have biologic and prognostic significance in conventional HSCT, but their role in UCBT has not been investigated. Furthermore, the interplay between angiogenesis and immune reconstitution has not been studied. Here we examined whether angiogenic cytokines, angiopoietin-1 (ANG-1) and vascular endothelial growth factor (VEGF), or markers of endothelial injury, thrombomodulin (TM) and angiopoietin-2 (ANG-2), associate with thymic regeneration as determined by T cell receptor excision circle (TREC) values and recovery of T cell subsets, as well as clinical outcomes in adult recipients of UCBT. We found that plasma levels of ANG-1 significantly correlated with the reconstitution of naive CD4+CD45RA+ and CD8+CD45RA+ T cell subsets, whereas plasma levels of VEGF displayed a positive correlation with CD4+CD45RO+ T cells and regulatory T cells and a weak correlation with TRECs. Assessment of TM and ANG-2 revealed a strong inverse correlation of both factors with naive T cells and TRECs. The angiogenic capacity of each patient's plasma, as determined by an in vitro angiogenesis assay, positively correlated with VEGF levels and with reconstitution of CD4+ T cell subsets. Higher VEGF levels were associated with worse progression-free survival and higher risk of relapse, whereas higher levels of TM were associated with chronic graft-versus-host disease and nonrelapse mortality. Thus, angiogenic factors may serve as valuable markers associated with T cell reconstitution and clinical outcomes after UCBT.
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Affiliation(s)
- Ioannis Politikos
- Hematology-Oncology and Cancer Biology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Haesook T Kim
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Theodoros Karantanos
- Hematology-Oncology and Cancer Biology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Julia Brown
- Hematology-Oncology and Cancer Biology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Sean McDonough
- Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Lequn Li
- Hematology-Oncology and Cancer Biology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Corey Cutler
- Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Joseph H Antin
- Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Karen K Ballen
- Bone Marrow Transplant Unit, Massachusetts General Hospital, Boston, Massachusetts
| | - Jerome Ritz
- Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Vassiliki A Boussiotis
- Hematology-Oncology and Cancer Biology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
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23
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Pharmacokinetics, Pharmacodynamics, and Pharmacogenomics of Immunosuppressants in Allogeneic Hematopoietic Cell Transplantation: Part II. Clin Pharmacokinet 2016; 55:551-93. [PMID: 26620047 DOI: 10.1007/s40262-015-0340-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Part I of this article included a pertinent review of allogeneic hematopoietic cell transplantation (alloHCT), the role of postgraft immunosuppression in alloHCT, and the pharmacokinetics, pharmacodynamics, and pharmacogenomics of the calcineurin inhibitors and methotrexate. In this article (Part II), we review the pharmacokinetics, pharmacodynamics, and pharmacogenomics of mycophenolic acid (MPA), sirolimus, and the antithymocyte globulins (ATG). We then discuss target concentration intervention (TCI) of these postgraft immunosuppressants in alloHCT patients, with a focus on current evidence for TCI and on how TCI may improve clinical management in these patients. Currently, TCI using trough concentrations is conducted for sirolimus in alloHCT patients. Several studies demonstrate that MPA plasma exposure is associated with clinical outcomes, with an increasing number of alloHCT patients needing TCI of MPA. Compared with MPA, there are fewer pharmacokinetic/dynamic studies of rabbit ATG and horse ATG in alloHCT patients. Future pharmacokinetic/dynamic research of postgraft immunosuppressants should include '-omics'-based tools: pharmacogenomics may be used to gain an improved understanding of the covariates influencing pharmacokinetics as well as proteomics and metabolomics as novel methods to elucidate pharmacodynamic responses.
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24
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Bejanyan N, Rogosheske J, DeFor TE, Lazaryan A, Arora M, Holtan SG, Jacobson PA, MacMillan ML, Verneris MR, Blazar BR, Weisdorf DJ, Wagner JE, Brunstein CG. Sirolimus and Mycophenolate Mofetil as Calcineurin Inhibitor-Free Graft-versus-Host Disease Prophylaxis for Reduced-Intensity Conditioning Umbilical Cord Blood Transplantation. Biol Blood Marrow Transplant 2016; 22:2025-2030. [PMID: 27519278 DOI: 10.1016/j.bbmt.2016.08.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 08/05/2016] [Indexed: 11/25/2022]
Abstract
The use of calcineurin inhibitors (CNIs) to reduce the risk of graft-versus-host disease (GVHD) after hematopoietic cell transplantation (HCT) requires intensive post-transplantation toxicity monitoring. Sirolimus-based GVHD prophylaxis is associated with a favorable toxicity profile and requires less intensive monitoring. However, the efficacy of sirolimus-based regimen compared with CNI-based regimen has not been evaluated in the setting of reduced-intensity conditioning (RIC) double umbilical cord blood (UCB) HCT. We compared outcomes of patients receiving sirolimus/mycophenolate mofetil (MMF) (n = 37) or cyclosporine (CSA)/MMF (n = 123) in an ongoing phase II study of RIC UCB transplantation. In multiple regression analysis, sirolimus/MMF did not influence the risk of grades II to IV or grades III and IV acute GVHD. In addition, there was no association between type of GVHD prophylaxis and hematopoietic engraftment. Infection density analysis found a significantly lower risk of infections with sirolimus/MMF between days +46 and +180 after HCT compared with CSA/MMF (3.4 versus 6.3 per 1000 patient-days, P = .03); however, no difference was observed before day +45. Sirolimus/MMF use resulted in no thrombotic microangiopathy, fewer instances of elevated serum creatinine >2 mg/dL (14% versus 45%; P <.01), and similar rates of sinusoidal obstruction syndrome (2.7% versus 4%; P = .68), compared with CSA/MMF. Disease-free survival at 1 year was 51% for sirolimus/MMF and 41% for CSA/MMF (P = .41), and sirolimus/MMF use did not influence the risk of nonrelapse mortality or survival. In conclusion, sirolimus/MMF GVHD prophylaxis was better tolerated and resulted in similar rates of GVHD and survival as compared to CSA/MMF after RIC double UCB transplantation.
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Affiliation(s)
- Nelli Bejanyan
- Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota.
| | - John Rogosheske
- Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, Minnesota
| | - Todd E DeFor
- Adult and Pediatric Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | - Aleksandr Lazaryan
- Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Mukta Arora
- Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Shernan G Holtan
- Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Pamala A Jacobson
- Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, Minnesota
| | - Margaret L MacMillan
- Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Michael R Verneris
- Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Bruce R Blazar
- Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Daniel J Weisdorf
- Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - John E Wagner
- Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Claudio G Brunstein
- Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
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25
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IL-10+ regulatory B cells are enriched in cord blood and may protect against cGVHD after cord blood transplantation. Blood 2016; 128:1346-61. [PMID: 27439912 DOI: 10.1182/blood-2016-01-695122] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Accepted: 07/12/2016] [Indexed: 12/19/2022] Open
Abstract
Cord blood (CB) offers a number of advantages over other sources of hematopoietic stem cells, including a lower rate of chronic graft-versus-host disease (cGVHD) in the presence of increased HLA disparity. Recent research in experimental models of autoimmunity and in patients with autoimmune or alloimmune disorders has identified a functional group of interleukin-10 (IL-10)-producing regulatory B cells (Bregs) that negatively regulate T-cell immune responses. At present, however, there is no consensus on the phenotypic signature of Bregs, and their prevalence and functional characteristics in CB remain unclear. Here, we demonstrate that CB contains an abundance of B cells with immunoregulatory function. Bregs were identified in both the naive and transitional B-cell compartments and suppressed T-cell proliferation and effector function through IL-10 production as well as cell-to-cell contact involving CTLA-4. We further show that the suppressive capacity of CB-derived Bregs can be potentiated through CD40L signaling, suggesting that inflammatory environments may induce their function. Finally, there was robust recovery of IL-10-producing Bregs in patients after CB transplantation, to higher frequencies and absolute numbers than seen in the peripheral blood of healthy donors or in patients before transplant. The reconstituting Bregs showed strong in vitro suppressive activity against allogeneic CD4(+) T cells, but were deficient in patients with cGVHD. Together, these findings identify a rich source of Bregs and suggest a protective role for CB-derived Bregs against cGVHD development in CB recipients. This advance could propel the development of Breg-based strategies to prevent or ameliorate this posttransplant complication.
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26
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Hexner EO, Luger SM, Reshef R, Jeschke GR, Mangan JK, Frey NV, Frank DM, Richman LP, Vonderheide RH, Aqui NA, Rosenbach M, Zhang Y, Chew A, Loren AW, Stadtmauer EA, Levine BL, June CH, Emerson SG, Porter DL. Infusion of CD3/CD28 costimulated umbilical cord blood T cells at the time of single umbilical cord blood transplantation may enhance engraftment. Am J Hematol 2016; 91:453-60. [PMID: 26858124 PMCID: PMC6145177 DOI: 10.1002/ajh.24303] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 01/09/2016] [Accepted: 01/12/2016] [Indexed: 01/04/2023]
Abstract
Limited cell numbers in umbilical cord blood (UCB) grafts present a major impediment to favorable outcomes in adult transplantation, largely related to delayed or failed engraftment. The advent of UCB transplantation (UCBT) using two grafts successfully circumvents this obstacle, despite the engraftment of only one unit. Preclinical models suggested that the addition of UCB T cells at the time of transplant can enhance engraftment. We tested whether ex vivo activation by CD3/CD28 costimulation and expansion of T cells from a single UCB graft would be safe and feasible in adults with advanced hematologic malignancies, with an overall objective of optimizing engraftment in single unit UCBT. In this phase 1 study, recipients of single UCB units were eligible if the unit was stored in two adequate fractions. Dose limiting toxicity was defined as grade 3 or grade 4 GVHD within 90 days of UCBT. Four patients underwent UCBT; all were treated at the first dose level (10(5) cells/kg). At the 10(5) cells/kg dose level two subjects experienced grade 3 intestinal GVHD, thus meeting stopping criteria. For three subjects, neutrophil engraftment was early (12, 17, and 20 days), while one subject experienced primary graft failure. We observed early donor T cell trafficking and found that expanded T cells produced supraphysiologic levels of cytokines relevant to engraftment and to lymphoid differentiation and function. Taken together, these preliminary data suggest rapid engraftment in recipients of a single UCBT combined with relatively low doses of activated T cells, though potentially complicated by severe GVHD.
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Affiliation(s)
- Elizabeth O. Hexner
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Selina M. Luger
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ran Reshef
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Grace R. Jeschke
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - James K. Mangan
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Noelle V. Frey
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Dale M. Frank
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lee P. Richman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert H. Vonderheide
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Abramson Family Cancer Research Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nicole A. Aqui
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Misha Rosenbach
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Yi Zhang
- Department of Microbiology and Immunology, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - Anne Chew
- Center for Cellular Immunotherapy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alison W. Loren
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Edward A. Stadtmauer
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Bruce L. Levine
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Center for Cellular Immunotherapy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Carl H. June
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Abramson Family Cancer Research Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Center for Cellular Immunotherapy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Stephen G. Emerson
- Columbia College of Physicians and Surgeons, Herbert Irving Comprehensive Cancer Center, New York
| | - David L. Porter
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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27
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Kekre N, Antin JH. Cord blood versus haploidentical stem cell transplantation for hematological malignancies. Semin Hematol 2016; 53:98-102. [DOI: 10.1053/j.seminhematol.2016.01.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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28
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van Besien K, Hari P, Zhang MJ, Liu HT, Stock W, Godley L, Odenike O, Larson R, Bishop M, Wickrema A, Gergis U, Mayer S, Shore T, Tsai S, Rhodes J, Cushing MM, Korman S, Artz A. Reduced intensity haplo plus single cord transplant compared to double cord transplant: improved engraftment and graft-versus-host disease-free, relapse-free survival. Haematologica 2016; 101:634-43. [PMID: 26869630 DOI: 10.3324/haematol.2015.138594] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 02/05/2016] [Indexed: 12/30/2022] Open
Abstract
Umbilical cord blood stem cell transplants are commonly used in adults lacking HLA-identical donors. Delays in hematopoietic recovery contribute to mortality and morbidity. To hasten recovery, we used co-infusion of progenitor cells from a partially matched related donor and from an umbilical cord blood graft (haplo-cord transplant). Here we compared the outcomes of haplo-cord and double-cord transplants. A total of 97 adults underwent reduced intensity conditioning followed by haplo-cord transplant and 193 patients received reduced intensity conditioning followed by double umbilical cord blood transplantation. Patients in the haplo-cord group were more often from minority groups and had more advanced malignancy. Haplo-cord recipients received fludarabine-melphalan-anti-thymocyte globulin. Double umbilical cord blood recipients received fludarabine-cyclophosphamide and low-dose total body irradiation. In a multivariate analysis, haplo-cord had faster neutrophil (HR=1.42, P=0.007) and platelet (HR=2.54, P<0.0001) recovery, lower risk of grade II-IV acute graft-versus-host disease (HR=0.26, P<0.0001) and chronic graft-versus-host disease (HR=0.06, P<0.0001). Haplo-cord was associated with decreased risk of relapse (HR 0.48, P=0.001). Graft-versus-host disease-free, relapse-free survival was superior with haplo-cord (HR 0.63, P=0.002) but not overall survival (HR=0.97, P=0.85). Haplo-cord transplantation using fludarabine-melphalan-thymoglobulin conditioning hastens hematopoietic recovery with a lower risk of relapse relative to double umbilical cord blood transplantation using the commonly used fludarabine-cyclophosphamide-low-dose total body irradiation conditioning. Graft-versus-host disease-free and relapse-free survival is significantly improved. Haplo-cord is a readily available graft source that improves outcomes and access to transplant for those lacking HLA-matched donors. Trials registered at clinicaltrials.gov identifiers 00943800 and 01810588.
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Affiliation(s)
- Koen van Besien
- Department of Hematology/Oncology and Meyer Cancer Center - Stem Cell Transplant Program, Weill Cornell Medical College, New York, NY, USA
| | - Parameswaran Hari
- Center for International Bone Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Mei-Jie Zhang
- Center for International Bone Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Hong-Tao Liu
- Section of Hematology/Oncology-Hematopoietic Cellular Therapy Program, University of Chicago, Il, USA
| | - Wendy Stock
- Section of Hematology/Oncology-Hematopoietic Cellular Therapy Program, University of Chicago, Il, USA
| | - Lucy Godley
- Section of Hematology/Oncology-Hematopoietic Cellular Therapy Program, University of Chicago, Il, USA
| | - Olatoyosi Odenike
- Section of Hematology/Oncology-Hematopoietic Cellular Therapy Program, University of Chicago, Il, USA
| | - Richard Larson
- Section of Hematology/Oncology-Hematopoietic Cellular Therapy Program, University of Chicago, Il, USA
| | - Michael Bishop
- Section of Hematology/Oncology-Hematopoietic Cellular Therapy Program, University of Chicago, Il, USA
| | - Amittha Wickrema
- Section of Hematology/Oncology-Hematopoietic Cellular Therapy Program, University of Chicago, Il, USA
| | - Usama Gergis
- Department of Hematology/Oncology and Meyer Cancer Center - Stem Cell Transplant Program, Weill Cornell Medical College, New York, NY, USA
| | - Sebastian Mayer
- Department of Hematology/Oncology and Meyer Cancer Center - Stem Cell Transplant Program, Weill Cornell Medical College, New York, NY, USA
| | - Tsiporah Shore
- Department of Hematology/Oncology and Meyer Cancer Center - Stem Cell Transplant Program, Weill Cornell Medical College, New York, NY, USA
| | - Stephanie Tsai
- Department of Hematology/Oncology and Meyer Cancer Center - Stem Cell Transplant Program, Weill Cornell Medical College, New York, NY, USA
| | - Joanna Rhodes
- Department of Hematology/Oncology and Meyer Cancer Center - Stem Cell Transplant Program, Weill Cornell Medical College, New York, NY, USA
| | - Melissa M Cushing
- Department of Pathology - Cellular Therapy Laboratory, Weill Cornell Medical College, New York, NY, USA
| | - Sandra Korman
- Center for International Bone Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Andrew Artz
- Department of Hematology/Oncology and Meyer Cancer Center - Stem Cell Transplant Program, Weill Cornell Medical College, New York, NY, USA
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29
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Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) is a curative treatment for patients with hematological diseases. The probability of finding a human leukocyte antigen (HLA)- identical donor among family members is around 25% and 30% that of having a full matched unrelated donor in the registry. Patients in need may also benefit of a HLA-mismatched HSCT either from an haploidentical donors or from umbilical cord blood (UCB). Much has been learned about UCB transplant (UCBT) since the first human UCBT was performed back in 1988. Cord blood banks have been established worldwide for the collection, cryopreservation, and distribution of UCB for HSCT. Today, a global network of cord blood banks and transplant centers has been established with a large common inventory of more than 650,000 UCB units available, allowing for more than 40,000 UCBT worldwide in children and adults with severe hematological diseases. Several studies have been published on UCBT, assessing risk factors such as cell dose and HLA mismatch. Outcomes of several retrospective comparative studies showed similar results using other stem cell sources both in pediatric and adult setting. New strategies are ongoing to facilitate engraftment and reduce transplant-related mortality. In this issue, we review the current results of UCBT in adults with hematological malignancies and the clinical studies comparing UCBT with other transplant strategies. We provide guidelines for donor algorithm selection in UCBT setting.
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Affiliation(s)
- Annalisa Ruggeri
- Service d'Hématologie et Thérapie Cellulaire, Hôpital Saint Antoine, Eurocord, Hôpital Saint Louis, Paris, France.
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30
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Ballen KK, Lazarus H. Cord blood transplant for acute myeloid leukaemia. Br J Haematol 2016; 173:25-36. [PMID: 26766286 DOI: 10.1111/bjh.13926] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 11/17/2015] [Indexed: 12/14/2022]
Abstract
Umbilical cord blood is a haematopoietic progenitor cell source for patients with acute myeloid leukaemia (AML), other haematological malignancies and metabolic diseases who can be cured by allogeneic haematopoietic cell transplantation, but who do not have a human leucocyte antigen compatible related or unrelated donor. Although the first cord blood transplants were done in children, there are currently more cord blood transplants performed in adults. In this review, we explore the history of umbilical cord blood transplantation, paediatric and adult outcome results, and novel trends to improve engraftment and reduce infection. Umbilical cord blood transplantation cures approximately 30-40% of adults and 60-70% of children with AML. Controversial issues, including the use of double versus single cord blood units for transplantation, optimal cord blood unit selection, infection prophylaxis, conditioning regimens and graft versus host disease prophylaxis, will be reviewed. Finally, comparison to other graft sources, cost, access to care, and the ideal graft source are discussed.
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Affiliation(s)
- Karen K Ballen
- Division of Hematology/Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Hillard Lazarus
- Seidman Cancer Center, Case Western Reserve University, Cleveland, OH, USA
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31
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Ponce DM, Eapen M, Sparapani R, O'Brien TA, Chan KW, Chen J, Craddock J, Schultz KR, Wagner JE, Perales MA, Barker JN. In Vivo T Cell Depletion with Myeloablative Regimens on Outcomes after Cord Blood Transplantation for Acute Lymphoblastic Leukemia in Children. Biol Blood Marrow Transplant 2015; 21:2173-2179. [PMID: 26327630 PMCID: PMC4639413 DOI: 10.1016/j.bbmt.2015.08.022] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 08/17/2015] [Indexed: 11/20/2022]
Abstract
The inclusion of antithymocyte globulin (ATG) in cord blood transplantation is controversial. We evaluated outcomes according to ATG inclusion in 297 children and adolescents with acute lymphoblastic leukemia (ALL) who received myeloablative total body irradiation-based conditioning and either single-unit (74%) or double-unit (26%) grafts. Ninety-two patients (31%) received ATG and 205 (69%) did not. ATG recipients were more likely to be cytomegalovirus seronegative. The incidences of day 100 grades II to IV acute graft-versus-host disease (GVHD; 30% versus 54%, P = .0002) and chronic GVHD (22% versus 43%, P = .0008) were lower with ATG compared with non-ATG regimens. However, day 100 grades III to IV acute GVHD was comparable (11% versus 17%, P = .15). The 3-year incidences of transplant-related mortality (16% versus 17%, P = .98), relapse (17% versus 27%, P = .12), and leukemia-free survival (66% versus 55%, P = .23) in ATG and non-ATG recipients were similar. There were no differences in viral reactivation between treatment groups (60% versus 58%, P = .83). Therefore, the data suggest that incorporation of ATG with myeloablative conditioning regimens may be useful in reducing the risk of acute and chronic GVHD without any deleterious effect on transplant-related mortality, relapse, or leukemia-free survival in children and adolescents with ALL.
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Affiliation(s)
- Doris M Ponce
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Mary Eapen
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Rodney Sparapani
- Divison of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Tracey A O'Brien
- Blood & Marrow Transplant Program, Kids Cancer Centre, Sydney Children's Hospital, Sydney, Australia
| | - Ka Wah Chan
- Department of Pediatrics, Texas Transplant Institute, San Antonio, Texas
| | - Junfang Chen
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - John Craddock
- Center for Cancer and Blood Disorders, Children's Hospital Colorado, Aurora, Colorado
| | - Kirk R Schultz
- Department of Pediatric Hematology, Oncology and Bone Marrow Transplant, British Columbia's Children's Hospital, The University of British Columbia, Vancouver, British Columbia, Canada
| | - John E Wagner
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Juliet N Barker
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
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Politikos I, Kim HT, Nikiforow S, Li L, Brown J, Antin JH, Cutler C, Ballen K, Ritz J, Boussiotis VA. IL-7 and SCF Levels Inversely Correlate with T Cell Reconstitution and Clinical Outcomes after Cord Blood Transplantation in Adults. PLoS One 2015; 10:e0132564. [PMID: 26177551 PMCID: PMC4503696 DOI: 10.1371/journal.pone.0132564] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 06/11/2015] [Indexed: 11/19/2022] Open
Abstract
Recovery of thymopoiesis is critical for immune reconstitution after HSCT. IL-7 and SCF are two major thymotropic cytokines. We investigated whether the kinetics of circulating levels of these cytokines might provide insight into the prolonged immunodeficiency after double umbilical cord blood transplantation (dUCBT) in adults. We examined plasma levels of IL-7 and SCF, T-cell receptor rearrangement excision circle (TREC) levels and T cell subsets in 60 adult patients undergoing dUCBT. Median levels of IL-7 increased by more than 3-fold at 4 weeks and remained elevated through 100 days after dUCBT. SCF showed a less than 2-fold increase and more protracted elevation than IL-7. IL-7 levels inversely correlated with the reconstitution of various T cell subsets but not with TRECs. SCF levels inversely correlated with reconstitution of CD4+T cells, especially the naïve CD4+CD45RA+ subset, and with TRECs suggesting that SCF but not IL-7 had an effect on thymic regeneration. In Cox models, elevated levels of IL-7 and SCF were associated with higher non-relapse mortality (p = 0.03 and p = 0.01) and worse overall survival (p = 0.002 and p = 0.001). Elevated IL-7 but not SCF was also associated with development of GvHD (p = 0.03). Thus, IL-7 and SCF are elevated for a prolonged period after dUCBT and persistently high levels of these cytokines may correlate with worse clinical outcomes.
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Affiliation(s)
- Ioannis Politikos
- Department of Medicine and Division of Hematology Oncology, Beth Israel Deaconess Medical Center, Boston, MA, United States of America
| | - Haesook T. Kim
- Department of Computational Biology, Dana-Farber Cancer Institute, Boston, MA, United States of America
| | - Sarah Nikiforow
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States of America
| | - Lequn Li
- Department of Medicine and Division of Hematology Oncology, Beth Israel Deaconess Medical Center, Boston, MA, United States of America
| | - Julia Brown
- Department of Medicine and Division of Hematology Oncology, Beth Israel Deaconess Medical Center, Boston, MA, United States of America
| | - Joseph H. Antin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States of America
| | - Corey Cutler
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States of America
| | - Karen Ballen
- Bone Marrow Transplantation Unit, Massachusetts General Hospital, Boston, MA, United States of America
| | - Jerome Ritz
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States of America
| | - Vassiliki A. Boussiotis
- Department of Medicine and Division of Hematology Oncology, Beth Israel Deaconess Medical Center, Boston, MA, United States of America
- * E-mail:
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Bejanyan N, Haddad H, Brunstein C. Alternative Donor Transplantation for Acute Myeloid Leukemia. J Clin Med 2015; 4:1240-68. [PMID: 26239557 PMCID: PMC4484998 DOI: 10.3390/jcm4061240] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 05/18/2015] [Accepted: 05/21/2015] [Indexed: 02/07/2023] Open
Abstract
Allogeneic hematopoietic cell transplantation (allo-HCT) is a potentially curative therapy for adult patients with acute myeloid leukemia (AML), but its use for consolidation therapy after first remission with induction chemotherapy used to be limited to younger patients and those with suitable donors. The median age of AML diagnosis is in the late 60s. With the introduction of reduced-intensity conditioning (RIC), many older adults are now eligible to receive allo-HCT, including those who are medically less fit to receive myeloablative conditioning. Furthermore, AML patients commonly have no human leukocyte antigen (HLA)-identical or medically suitable sibling donor available to proceed with allo-HCT. Technical advances in donor matching, suppression of alloreactivity, and supportive care have made it possible to use alternative donors, such as unrelated umbilical cord blood (UCB) and partially HLA-matched related (haploidentical) donors. Outcomes after alternative donor allo-HCT are now approaching the outcomes observed for conventional allo-HCT with matched related and unrelated donors. Thus, with both UCB and haploidentical donors available, lack of donor should rarely be a limiting factor in offering an allo-HCT to adults with AML.
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Affiliation(s)
- Nelli Bejanyan
- Division of Hematology, Oncology and Transplantation, University of Minnesota, 420 Delaware Street SE, Mayo Mail Code 480, Minneapolis, MN 55455, USA.
| | - Housam Haddad
- Hematology and Oncology Department, Staten Island University Hospital, 475 Seaview Ave, Staten Island, NY 10305, USA.
| | - Claudio Brunstein
- Division of Hematology, Oncology and Transplantation, University of Minnesota, 420 Delaware Street SE, Mayo Mail Code 480, Minneapolis, MN 55455, USA.
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Ballen KK. Is there a best graft source of transplantation in acute myeloid leukemia? Best Pract Res Clin Haematol 2015; 28:147-54. [DOI: 10.1016/j.beha.2015.10.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Umbilical cord blood donation: public or private? Bone Marrow Transplant 2015; 50:1271-8. [PMID: 26030051 DOI: 10.1038/bmt.2015.124] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 04/15/2015] [Indexed: 02/01/2023]
Abstract
Umbilical cord blood (UCB) is a graft source for patients with malignant or genetic diseases who can be cured by allogeneic hematopoietic cell transplantation (HCT), but who do not have an appropriately HLA-matched family or volunteer unrelated adult donor. Starting in the 1990s, unrelated UCB banks were established, accepting donations from term deliveries and storing UCB units for public use. An estimated 730 000 UCB units have been donated and stored to date and ~35 000 UCB transplants have been performed worldwide. Over the past 20 years, private and family banks have grown rapidly, storing ~4 million UCB units for a particular patient or family, usually charging an up-front and yearly storage fee; therefore, these banks are able to be financially sustainable without releasing UCB units. Private banks are not obligated to fulfill the same regulatory requirements of the public banks. The public banks have released ~30 times more UCB units for therapy. Some countries have transitioned to an integrated banking model, a hybrid of public and family banking. Today, pregnant women, their families, obstetrical providers and pediatricians are faced with multiple choices about the disposition of their newborn's cord blood. In this commentary, we review the progress of UCB banking technology; we also analyze the current data on pediatric and adult unrelated UCB, including the recent expansion of interest in transplantation for hemoglobinopathies, and discuss emerging studies on the use of autologous UCB for neurologic diseases and regenerative medicine. We will review worldwide approaches to UCB banking, ethical considerations, criteria for public and family banking, integrated banking ideas and future strategies for UCB banking.
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Murata M. Prophylactic and therapeutic treatment of graft-versus-host disease in Japan. Int J Hematol 2015; 101:467-86. [DOI: 10.1007/s12185-015-1784-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 03/17/2015] [Indexed: 11/29/2022]
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Sureda A, Bader P, Cesaro S, Dreger P, Duarte RF, Dufour C, Falkenburg JHF, Farge-Bancel D, Gennery A, Kröger N, Lanza F, Marsh JC, Nagler A, Peters C, Velardi A, Mohty M, Madrigal A. Indications for allo- and auto-SCT for haematological diseases, solid tumours and immune disorders: current practice in Europe, 2015. Bone Marrow Transplant 2015; 50:1037-56. [PMID: 25798672 DOI: 10.1038/bmt.2015.6] [Citation(s) in RCA: 216] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 01/09/2015] [Indexed: 12/17/2022]
Abstract
This is the sixth special report that the European Society for Blood and Marrow Transplantation regularly publishes on the current practice and indications for haematopoietic SCT for haematological diseases, solid tumours and immune disorders in Europe. Major changes have occurred in the field of haematopoietic SCT over the last years. Cord blood units as well as haploidentical donors have been increasingly used as stem cell sources for allo-SCT, thus, augmenting the possibility of finding a suitable donor for a patient. Continuous refinement of conditioning strategies has also expanded not only the number of potential indications but also has permitted consideration of older patients or those with co-morbidity for a transplant. There is accumulating evidence of the role of haematopoietic SCT in non-haematological disorders such as autoimmune diseases. On the other hand, the advent of new drugs and very effective targeted therapy has challenged the role of SCT in some instances or at least, modified its position in the treatment armamentarium of a given patient. An updated report with revised tables and operating definitions is presented.
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Affiliation(s)
- A Sureda
- Department of Haematology, Institut Catala d'Oncologia, Hospital Duran I Reynals, Barcelona, Spain
| | - P Bader
- Universitätsklinikum Frankfurt, Goethe-Universität, Klinik für Kinder- und Jugendmedizin, Frankfurt, Germany
| | - S Cesaro
- Paediatric Haematology Oncology, Policlinico G.B. Rossi, Verona, Italy
| | - P Dreger
- Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
| | - R F Duarte
- Department of Haematology, Institut Catala d'Oncologia, Hospital Duran I Reynals, Barcelona, Spain
| | - C Dufour
- Clinical And Experimental Hematology Unit. Institute G. Gaslini, Genoa, Italy
| | - J H F Falkenburg
- Department of Haematology, Leiden University Medical Center, Leiden, The Netherlands
| | - D Farge-Bancel
- Department of Haematology-BMT, Hopital St Louis, Paris, France
| | - A Gennery
- Children's BMT Unit, Great North Children's Hospital, Newcastle-Upon-Tyne, UK
| | - N Kröger
- Department of Stem Cell Transplantation, University hospital Eppendorf, Hamburg, Germany
| | - F Lanza
- Haematology and BMT Unit, Cremona, Italy
| | - J C Marsh
- Department of Haematological Medicine, King's College Hospital/King's College London, London, UK
| | - A Nagler
- Chaim Sheva Medical Center, Tel-Hashomer, Israel
| | - C Peters
- Stem Cell Transplantation Unit, St Anna Kinderspital, Vienna, Austria
| | - A Velardi
- Sezione di Ematologia, Dipartimento di Medicina Clinica e Sperimentale, Università di Perugia, Perugia, Italy
| | - M Mohty
- Department of Haematology, H. Saint Antoine, Paris, France
| | - A Madrigal
- Anthony Nolan Research Institute, Royal Free and University College, London, UK
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Saliba RM, Rezvani K, Leen A, Jorgensen J, Shah N, Hosing C, Parmar S, Oran B, Olson A, Rondon G, Chen J, Martinez C, Hamdi A, Mehta RS, Chemaly RF, Saunders IM, Bollard CM, Shpall EJ. General and Virus-Specific Immune Cell Reconstitution after Double Cord Blood Transplantation. Biol Blood Marrow Transplant 2015; 21:1284-90. [PMID: 25708219 DOI: 10.1016/j.bbmt.2015.02.017] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2014] [Accepted: 02/16/2015] [Indexed: 01/09/2023]
Abstract
Cord blood transplantation (CBT) is curative for many patients with hematologic malignancies but is associated with delayed immune recovery and an increased risk of viral infections compared with HLA-matched bone marrow or peripheral blood progenitor cell transplantation. In this study we evaluated the significance of lymphocyte recovery in 125 consecutive patients with hematologic malignancies who underwent double-unit CBT (DUCBT) with an antithymocyte globulin-containing regimen at our institution. A subset of 65 patients was prospectively evaluated for recovery of T, natural killer (NK), and B cells, and in 46 patients we also examined viral-specific T cell recovery against adenovirus, Epstein-Barr virus, cytomegalovirus, BK virus, respiratory syncytial virus, and influenza antigen. Our results indicate that in recipients of DUCBT, the day 30 absolute lymphocyte count is highly predictive of nonrelapse mortality and overall survival. Immune recovery post-DUCBT was characterized by prolonged CD8+ and CD4+ T lymphopenia associated with preferential expansion of B and NK cells. We also observed profound delays in quantitative and functional recovery of viral-specific CD4+ and CD8+ T cell responses for the first year post-CBT. Taken together, our data support efforts aimed at optimizing viral-specific T cell recovery to improve outcomes post-CBT.
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Affiliation(s)
- Rima M Saliba
- Department of Stem Cell Transplantation and Cellular Therapy, MD Anderson Cancer Center, Houston, Texas
| | - Katayoun Rezvani
- Department of Stem Cell Transplantation and Cellular Therapy, MD Anderson Cancer Center, Houston, Texas
| | - Ann Leen
- Department of Pediatrics, Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, Texas
| | - Jeffrey Jorgensen
- Department of Laboratory Medicine, MD Anderson Cancer Center, Houston, Texas
| | - Nina Shah
- Department of Stem Cell Transplantation and Cellular Therapy, MD Anderson Cancer Center, Houston, Texas
| | - Chitra Hosing
- Department of Stem Cell Transplantation and Cellular Therapy, MD Anderson Cancer Center, Houston, Texas
| | - Simrit Parmar
- Department of Stem Cell Transplantation and Cellular Therapy, MD Anderson Cancer Center, Houston, Texas
| | - Betul Oran
- Department of Stem Cell Transplantation and Cellular Therapy, MD Anderson Cancer Center, Houston, Texas
| | - Amanda Olson
- Department of Stem Cell Transplantation and Cellular Therapy, MD Anderson Cancer Center, Houston, Texas
| | - Gabriela Rondon
- Department of Stem Cell Transplantation and Cellular Therapy, MD Anderson Cancer Center, Houston, Texas
| | - Julianne Chen
- Department of Stem Cell Transplantation and Cellular Therapy, MD Anderson Cancer Center, Houston, Texas
| | - Charles Martinez
- Department of Stem Cell Transplantation and Cellular Therapy, MD Anderson Cancer Center, Houston, Texas
| | - Amir Hamdi
- Department of Stem Cell Transplantation and Cellular Therapy, MD Anderson Cancer Center, Houston, Texas
| | - Rohtesh S Mehta
- Department of Stem Cell Transplantation and Cellular Therapy, MD Anderson Cancer Center, Houston, Texas
| | - Roy F Chemaly
- Department of Infectious Diseases, MD Anderson Cancer Center, Houston, Texas
| | - Ila M Saunders
- Hematology/Oncology and Bone Marrow Transplant, Skaggs School of Pharmacy & Pharmaceutical Sciences, University of California San Diego, La Jolla, California
| | - Catherine M Bollard
- Division of Blood and Marrow Transplantation, Children's National Hospital System and George Washington University, Washington, DC
| | - Elizabeth J Shpall
- Department of Stem Cell Transplantation and Cellular Therapy, MD Anderson Cancer Center, Houston, Texas.
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Satyanarayana G, Hammond SP, Broge TA, Mackenzie MR, Viscidi R, Politikos I, Koralnik IJ, Cutler CS, Ballen K, Boussiotis V, Marty FM, Tan CS. BK polyomavirus reactivation after reduced-intensity double umbilical cord blood cell transplantation. Transpl Immunol 2014; 32:116-20. [PMID: 25536223 DOI: 10.1016/j.trim.2014.12.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Revised: 12/11/2014] [Accepted: 12/11/2014] [Indexed: 12/28/2022]
Abstract
Serial serum samples from 27 patients who underwent double umbilical cord blood transplantation (dUCBT) were analyzed for BK polyomavirus (BKPyV) DNA by real-time PCR and BKPyV-specific immune globulin by ELISA. Clinical data were collected on all patients. All pre-transplant sera had detectable anti-BKPyV IgG. Fifteen patients (56%) had detectable serum BKPyV DNA (median 8.9 × 10(4) copies/ml; range 4.1 × 10(3)-7.9 × 10(6) copies/ml) a median of 40 days (range, 27-733 days) after dUCBT, with highest viral loads on Day 100 assessment. The cumulative probability of developing BKPyV viremia by Day 100 was 0.52 (95% CI, 0.33-0.71). Six of 15 patients with BKPyV viremia experienced hemorrhagic cystitis by Day 100. By Day 100, there was a trend towards higher BKPyV viral loads in sera of patients with hemorrhagic cystitis than in those BKPyV viremic patients without hemorrhagic cystitis (p = 0.06). BKPyV viremia was associated with significantly higher anti-BKPyV IgM values at 6 months post-dUCBT (P = 0.003). BKPyV viremia occurs early after dUBCT and is associated with a detectable humoral immune response by 6 months post-dUBCT.
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Affiliation(s)
- Gowri Satyanarayana
- Division of Infectious Disease, Beth Israel Deaconess Medical Center, Boston, MA, USA; Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, USA; Division of Hematology/Oncology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Sarah P Hammond
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, USA; Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Thomas A Broge
- Center for Virology and Vaccine Research, Beth Israel Deaconess Medical Center, Boston, MA, USA; Division of Neurovirology, Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Matthew R Mackenzie
- Center for Virology and Vaccine Research, Beth Israel Deaconess Medical Center, Boston, MA, USA; Division of Neurovirology, Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Raphael Viscidi
- Division of Developmental Neurovirology, Johns Hopkins University Medical Center, Baltimore, MD, USA
| | - Ioannis Politikos
- Division of Neurovirology, Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Igor J Koralnik
- Center for Virology and Vaccine Research, Beth Israel Deaconess Medical Center, Boston, MA, USA; Division of Neurovirology, Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Corey S Cutler
- Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Karen Ballen
- Division of Hematology/Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Vassiliki Boussiotis
- Division of Neurovirology, Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Francisco M Marty
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, USA; Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Chen Sabrina Tan
- Division of Infectious Disease, Beth Israel Deaconess Medical Center, Boston, MA, USA; Center for Virology and Vaccine Research, Beth Israel Deaconess Medical Center, Boston, MA, USA; Division of Neurovirology, Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA.
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40
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Bachanova V, Burns LJ, Wang T, Carreras J, Gale RP, Wiernik PH, Ballen KK, Wirk B, Munker R, Rizzieri DA, Chen YB, Gibson J, Akpek G, Costa LJ, Kamble RT, Aljurf MD, Hsu JW, Cairo MS, Schouten HC, Bacher U, Savani BN, Wingard JR, Lazarus HM, Laport GG, Montoto S, Maloney DG, Smith SM, Brunstein C, Saber W. Alternative donors extend transplantation for patients with lymphoma who lack an HLA matched donor. Bone Marrow Transplant 2014; 50:197-203. [PMID: 25402415 PMCID: PMC4336786 DOI: 10.1038/bmt.2014.259] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Revised: 10/01/2014] [Accepted: 10/02/2014] [Indexed: 01/26/2023]
Abstract
Alternative donor transplantation is increasingly used for high risk lymphoma patients. We analyzed 1593 transplant recipients (2000 to 2010) and compared transplant outcomes in recipients of 8/8 allele human leukocyte antigen (HLA)-A, -B, -C, and DRB1 matched unrelated donors (MUD; n=1176), 7/8 allele HLA-matched unrelated donors (MMUD; n=275) and umbilical cord blood donors (1 or 2 units UCB; n=142). Adjusted 3-year non-relapse mortality of MMUD (44%) was higher as compared to MUD (35%; p=0.004), but similar to UCB recipients (37%; p=0.19), although UCB had lower rates of neutrophil and platelet recovery compared to unrelated donor groups. With a median follow-up of 55 months, 3-year adjusted cumulative incidence of relapse was lower after MMUD compared with MUD (25% vs 33%, p=0.003) but similar between UCB and MUD (30% vs 33%; p=0.48). In multivariate analysis UCB recipients had lower risks of acute and chronic graft versus host disease compared with adult donor groups (UCB vs MUD: HR=0.68, p=0.05; HR=0.35; p<0.001). Adjusted 3-year overall survival was comparable (43% MUD, 37% MMUD and 41% UCB). Data highlight that patients with lymphoma have acceptable survival after alternative donor transplantation. MMUD and UCB can expand the curative potential of allotransplant to patients who lack suitable HLA-matched sibling or MUD.
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Affiliation(s)
- V Bachanova
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, MN, USA
| | - L J Burns
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, MN, USA
| | - T Wang
- 1] Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA [2] Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, WI, USA
| | - J Carreras
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - R P Gale
- Division of Experimental Medicine, Department of Medicine, Hematology Research Center, Imperial College London, London, UK
| | - P H Wiernik
- Our Lady of Mercy Medical Center, Bronx, NY, USA
| | - K K Ballen
- Department of Hematology/Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - B Wirk
- BMT Program, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - R Munker
- Department of Hematology/Oncology, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - D A Rizzieri
- Division of Hematologic Malignancies and Cellular Therapy, Duke University, Durham, NC, USA
| | - Y-B Chen
- Department of Hematology/Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - J Gibson
- Department of Hematology, Royal Prince Alfred Hospital, Camperdown, Australia
| | - G Akpek
- Banner MD Anderson Cancer Center, Gilbert, AZ, USA
| | - L J Costa
- Medical University of South Carolina, Charleston, SC, USA
| | - R T Kamble
- Department of Hematology/Oncology, Baylor College of Medicine, Houston, TX, USA
| | - M D Aljurf
- Department of Oncology, King Faisal Specialist Hospital, Riyadh, Saudi Arabia
| | - J W Hsu
- Shands HealthCare & University of Florida, Gainesville, FL, USA
| | - M S Cairo
- Department of Pediatrics, New York Medical College, Valhalla, NY, USA
| | - H C Schouten
- Academische Ziekenhuis Maastricht, Maastricht, Netherlands
| | - U Bacher
- 1] Department of Stem Cell Transplantation, University of Hamburg, Hamburg, Germany [2] MLL Munich Leukemia Laboratory, Munich, Germany
| | - B N Savani
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - J R Wingard
- 1] Shands HealthCare & University of Florida, Gainesville, FL, USA [2] LifeSouth Community Blood Centers, Gainesville, FL, USA
| | - H M Lazarus
- Seidman Cancer Center, University Hospitals Case Medical Center, Cleveland, OH, USA
| | - G G Laport
- Division of BMT, Stanford Hospitals & Clinics, Stanford, CA, USA
| | - S Montoto
- Department of Haemato-oncology, St. Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - D G Maloney
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - S M Smith
- Section of Hematology/Oncology, The University of Chicago, Chicago, IL, USA
| | - C Brunstein
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, MN, USA
| | - W Saber
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
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41
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The role of the thymus in T-cell immune reconstitution after umbilical cord blood transplantation. Blood 2014; 124:3201-11. [PMID: 25287708 DOI: 10.1182/blood-2014-07-589176] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Umbilical cord blood (UCB) is an alternative source of hematopoietic stem cells for patients without HLA-matched adult donors. UCB contains a low number of nucleated cells and mostly naive T cells, resulting in prolonged time to engraftment and lack of transferred T-cell memory. Although the first phase of T-cell reconstitution after UCB transplantation (UCBT) depends on peripheral expansion of transferred T cells, permanent T-cell reconstitution is mediated via a central mechanism, which depends on de novo production of naive T lymphocytes by the recipient's thymus from donor-derived lymphoid-myeloid progenitors (LMPs). Thymopoiesis can be assessed by quantification of recent thymic emigrants, T-cell receptor excision circle levels, and T-cell receptor repertoire diversity. These assays are valuable tools for monitoring posttransplantation thymic recovery, but more importantly they have shown the significant prognostic value of thymic reconstitution for clinical outcomes after UCBT, including opportunistic infections, disease relapse, and overall survival. Strategies to improve thymic entry and differentiation of LMPs and to accelerate recovery of the thymic stromal microenvironment may improve thymic lymphopoiesis. Here, we discuss the mechanisms and clinical implications of thymic recovery and new approaches to improve reconstitution of the T-cell repertoire after UCBT.
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42
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Somers JAE, Braakman E, van der Holt B, Petersen EJ, Marijt EWA, Huisman C, Sintnicolaas K, Oudshoorn M, Groenendijk-Sijnke ME, Brand A, Cornelissen JJ. Rapid induction of single donor chimerism after double umbilical cord blood transplantation preceded by reduced intensity conditioning: results of the HOVON 106 phase II study. Haematologica 2014; 99:1753-61. [PMID: 25107890 DOI: 10.3324/haematol.2014.106690] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Double umbilical cord blood transplantation is increasingly applied in the treatment of adult patients with high-risk hematological malignancies and has been associated with improved engraftment as compared to that provided by single unit cord blood transplantation. The mechanism of improved engraftment is, however, still incompletely understood as only one unit survives. In this multicenter phase II study we evaluated engraftment, early chimerism, recovery of different cell lineages and transplant outcome in 53 patients who underwent double cord blood transplantation preceded by a reduced intensity conditioning regimen. Primary graft failure occurred in one patient. Engraftment was observed in 92% of patients with a median time to neutrophil recovery of 36 days (range, 15-102). Ultimate single donor chimerism was established in 94% of patients. Unit predominance occurred by day 11 after transplantation and early CD4(+) T-cell chimerism predicted for unit survival. Total nucleated cell viability was also associated with unit survival. With a median follow up of 35 months (range, 10-51), the cumulative incidence of relapse and non-relapse mortality rate at 2 years were 39% and 19%, respectively. Progressionfree survival and overall survival rates at 2 years were 42% (95% confidence interval, 28-56) and 57% (95% confidence interval, 43-70), respectively. Double umbilical cord blood transplantation preceded by a reduced intensity conditioning regimen using cyclophosphamide/fludarabine/4 Gy total body irradiation results in a high engraftment rate with low non-relapse mortality. Moreover, prediction of unit survival by early CD4(+) lymphocyte chimerism might suggest a role for CD4(+) lymphocyte mediated unit-versus-unit alloreactivity. www.trialregister.nl NTR1573.
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Affiliation(s)
- Judith A E Somers
- Erasmus MC-Daniel Den Hoed Cancer Center, Dept. of Hematology, Rotterdam Sanquin Blood Supply, Dept. of Transfusion Medicine, Rotterdam/Leiden
| | - Eric Braakman
- Erasmus MC-Daniel Den Hoed Cancer Center, Dept. of Hematology, Rotterdam
| | - Bronno van der Holt
- Erasmus MC-Daniel Den Hoed Cancer Center, Clinical Trial Center, HOVON Data Center, Rotterdam
| | | | | | | | - Kees Sintnicolaas
- Sanquin Blood Supply, Dept. of Transfusion Medicine, Rotterdam/Leiden
| | - Machteld Oudshoorn
- Europdonor Foundation, Leiden Leiden University Medical Center, Dept. of Immunohematology and Blood Transfusion, the Netherlands
| | | | - Anneke Brand
- Sanquin Blood Supply, Dept. of Transfusion Medicine, Rotterdam/Leiden Europdonor Foundation, Leiden Leiden University Medical Center, Dept. of Immunohematology and Blood Transfusion, the Netherlands
| | - Jan J Cornelissen
- Erasmus MC-Daniel Den Hoed Cancer Center, Dept. of Hematology, Rotterdam
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Broxmeyer HE, Farag S. Background and future considerations for human cord blood hematopoietic cell transplantation, including economic concerns. Stem Cells Dev 2014; 22 Suppl 1:103-10. [PMID: 24304086 DOI: 10.1089/scd.2013.0382] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Cord blood (CB) has been used since 1988 as a source of hematopoietic stem cells (HSCs) and progenitor cells for hematopoietic cell transplantation (HCT) to treat patients with malignant and nonmalignant disorders. CB has both advantages and disadvantages when compared with other tissue sources of HSCs such as bone marrow and mobilized peripheral blood, which are also being used in the setting of HCT. This short review focuses on some historical information, as well as current efforts that are being assessed to enhance the efficacy of CB HCT. Also of importance are the costs of CB, and the feasibility and economics of using such to be identified, and newly confirmed improvements worldwide for the greatest number of patients. In this context, simple methods that would not necessarily entail the need for selected cell-processing facilities to ex vivo expand or improve the CB graft's functional activity may be of interest, with one such possibility being the use of an orally active inhibitor of the enzyme dipeptidylpeptidase 4, alone or in combination with other new and innovative approaches for improving HSC engraftment and in vivo repopulating capability of CB.
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Affiliation(s)
- Hal E Broxmeyer
- 1 Department of Microbiology & Immunology, Indiana University School of Medicine , Indianapolis, Indiana
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Hematopoietic stem cell transplantation donor sources in the 21st century: choosing the ideal donor when a perfect match does not exist. Blood 2014; 124:334-43. [DOI: 10.1182/blood-2014-02-514760] [Citation(s) in RCA: 109] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Abstract
Most patients who require allogeneic stem cell transplantation do not have a matched sibling donor, and many patients do not have a matched unrelated donor. In an effort to increase the applicability of transplantation, alternative donors such as mismatched adult unrelated donors, haploidentical related donors, and umbilical cord blood stem cell products are frequently used when a well matched donor is unavailable. We do not yet have the benefit of randomized trials comparing alternative donor stem cell sources to inform the choice of donor; however, the existing data allow some inferences to be made on the basis of existing observational and phase 2 studies. All 3 alternative donor sources can provide effective lymphohematopoietic reconstitution, but time to engraftment, graft failure rate, graft-versus-host disease, transplant-related mortality, and relapse risk vary by donor source. These factors all contribute to survival outcomes and an understanding of them should help guide clinicians when choosing among alternative donor sources when a matched related or matched unrelated donor is not available.
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Tacrolimus/sirolimus vs tacrolimus/methotrexate as GVHD prophylaxis after matched, related donor allogeneic HCT. Blood 2014; 124:1372-7. [PMID: 24982504 DOI: 10.1182/blood-2014-04-567164] [Citation(s) in RCA: 141] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Grades 2-4 acute graft-versus-host disease (GVHD) occurs in approximately 35% of matched, related donor (MRD) allogeneic hematopoietic cell transplantation (HCT) recipients. We sought to determine if the combination of tacrolimus and sirolimus (Tac/Sir) was more effective than tacrolimus and methotrexate (Tac/Mtx) in preventing acute GVHD and early mortality after allogeneic MRD HCT in a phase 3, multicenter trial. The primary end point of the trial was to compare 114-day grades 2-4 acute GVHD-free survival using an intention-to-treat analysis of 304 randomized subjects. There was no difference in the probability of day 114 grades 2-4 acute GVHD-free survival (67% vs 62%, P = .38). Grades 2-4 GVHD was similar in the Tac/Sir and Tac/Mtx arms (26% vs 34%, P = .48). Neutrophil and platelet engraftment were more rapid in the Tac/Sir arm (14 vs 16 days, P < .001; 16 vs 19 days, P = .03). Oropharyngeal mucositis was less severe in the Tac/Sir arm (peak Oral Mucositis Assessment Scale score 0.70 vs 0.96, P < .001), but otherwise toxicity was similar. Chronic GVHD, relapse-free survival, and overall survival at 2 years were no different between study arms (53% vs 45%, P = .06; 53% vs 54%, P = .77; and 59% vs 63%, P = .36). Based on similar long-term outcomes, more rapid engraftment, and less oropharyngeal mucositis, the combination of Tac/Sir is an acceptable alternative to Tac/Mtx after MRD HCT. This study was funded by the National Heart, Lung, and Blood Institute and the National Cancer Institute; and the trial was registered at www.clinicaltrials.gov as #NCT00406393.
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Yang W, Jia X, Su Y, Li Q. Immunophenotypic characterization of CD45RO+ and CD45RA+ T cell subsets in peripheral blood of peripheral T cell lymphoma patients. Cell Biochem Biophys 2014; 70:993-7. [PMID: 24840225 DOI: 10.1007/s12013-014-0008-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
To study the distribution profile of CD45RO(+) and CD45RA(+) T cells in the peripheral blood of peripheral T cell lymphoma (PTCL) patients and its clinical significance. 27 patients with PTCL were enrolled in this study, together with 30 healthy individuals as the control group. Flow cytometry analysis was employed to examinate the differences in the distribution of CD45RO(+) and CD45RA(+) T cells in peripheral blood between two groups. In PTCL patient's lymphnode tissues, the T cell population displayed diverse antigenic expression, with CD4(+) T cells as the major subset. No B cell-related antigen was expressed. The percentage of CD4(+)/CD8(+) and CD4(+)CD45RO(+) T cells in patients' peripheral blood were significantly lower than that in the control samples, while the percentage of CD4(+)CD45RA(+), CD8(+)CD45RA(+), and CD8(+)CD45RO(+) T cells in patients' peripheral blood were significantly higher than that in the control samples. The percentage of CD4(+)/CD8(+), CD4(+)CD45RO(+) cells in stage I/II PTCL patients' peripheral blood were significantly higher than that in the samples from patients with stage III/IV PTCL. The percentage of CD4(+)CD45RA(+), CD8(+)CD45RA(+), and CD8(+)CD45RO(+) T cells were notably lower than that in the samples from III/IV period PTCL patients. Both CD45RO(+) and CD45RA(+) T cells play important roles in the process of PTCL. The immunophenotypic profile from this study will help to develop the differential diagnosis and treatment of PTCL patients in the future, and improve the accuracy rate of diagnosis and to ameliorate the prognosis.
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Affiliation(s)
- Wenzhong Yang
- Department of Hematology Medicine East Hospital, Tongji University School of Medicine, Shanghai, 200120, China,
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Abstract
PURPOSE OF REVIEW A review of articles published since January 2012 on the topic of cord blood banking and cord blood stem cell transplantation was conducted for this the 25th anniversary year of the first cord blood transplant performed in a human. RECENT FINDINGS Cord blood banking is performed throughout the world. Umbilical cord blood (UCB) transplantation is recognized as an acceptable alternative stem cell source for paediatric and adults requiring a haematopoietic transplant, particularly for patients of racial and ethnic minorities. To further advance the use of UCB, methods to enhance UCB stem cell expansion, engraftment and maintenance may be required. Controversy on the most effective and economically sustainable model for banking and storing an optimal UCB product continues to persist. SUMMARY Cord blood banking and transplantation of cord blood stem cells has advanced rapidly over the initial 25 years, as more than 30 ,000 patients have benefited from the therapy. New concepts on the use of methods to expand UCB stem cells for transplantation and use for nonhaematopoietic indications may increase demand for UCB over the next few decades.
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BK virus disease after allogeneic stem cell transplantation: a cohort analysis. Biol Blood Marrow Transplant 2014; 20:564-70. [PMID: 24462984 DOI: 10.1016/j.bbmt.2014.01.014] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Accepted: 01/15/2014] [Indexed: 11/21/2022]
Abstract
The clinical epidemiology of BK virus (BKV) disease after allogeneic hematopoietic stem cell transplantation (HSCT) is not well defined. We evaluated 491 patients transplanted from January 2010 to December 2011 at a single transplant center to assess incidence, severity, and risk factors for BKV disease after HSCT. BKV disease was defined as BKV detection in urine by PCR testing in association with genitourinary symptoms without other concurrent genitourinary conditions. BKV disease occurred in 78 patients (15.9%), for an incidence rate of .47/1000 patient-days (95% confidence interval [CI], .37 to .59); BKV disease was considered severe in 27 patients (5.5%). In multivariate Cox modeling, time-dependent acute graft-versus-host disease (aGVHD) grades II to IV (adjusted hazard ratio [aHR] 4.25; 95% CI, 2.51 to 7.21), cord blood HSCT (aHR 2.28; 95% CI, 1.01 to 5.15), post-transplant mycophenolate use (aHR 3.31; 95% CI, 1.83 to 5.99), and high-dose cyclophosphamide conditioning (aHR 2.34, 95% CI 1.45 to 3.77) were significant predictors of BKV disease. Time-dependent aGVHD grades III to IV (aHR 10.5; 95% CI, 4.44 to 25.0) and cord blood HSCT (aHR 5.40; 95% CI, 1.94 to 15.0) were independent risk factors for severe BKV disease. BKV disease is common and is associated with significant and prolonged morbidity after HSCT. Prospective studies are needed to better define the morbidity of post-HSCT BKV disease and inform the design of prophylaxis and treatment trials.
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Prostaglandin-modulated umbilical cord blood hematopoietic stem cell transplantation. Blood 2013; 122:3074-81. [PMID: 23996087 DOI: 10.1182/blood-2013-05-503177] [Citation(s) in RCA: 234] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Umbilical cord blood (UCB) is a valuable source of hematopoietic stem cells (HSCs) for use in allogeneic transplantation. Key advantages of UCB are rapid availability and less stringent requirements for HLA matching. However, UCB contains an inherently limited HSC count, which is associated with delayed time to engraftment, high graft failure rates, and early mortality. 16,16-Dimethyl prostaglandin E2 (dmPGE2) was previously identified to be a critical regulator of HSC homeostasis, and we hypothesized that brief ex vivo modulation with dmPGE2 could improve patient outcomes by increasing the "effective dose" of HSCs. Molecular profiling approaches were used to determine the optimal ex vivo modulation conditions (temperature, time, concentration, and media) for use in the clinical setting. A phase 1 trial was performed to evaluate the safety and therapeutic potential of ex vivo modulation of a single UCB unit using dmPGE2 before reduced-intensity, double UCB transplantation. Results from this study demonstrated clear safety with durable, multilineage engraftment of dmPGE2-treated UCB units. We observed encouraging trends in efficacy, with accelerated neutrophil recovery (17.5 vs 21 days, P = .045), coupled with preferential, long-term engraftment of the dmPGE2-treated UCB unit in 10 of 12 treated participants.
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Abstract
Umbilical cord blood is an alternative hematopoietic stem cell source for patients with hematologic diseases who can be cured by allogeneic hematopoietic cell transplantation. Initially, umbilical cord blood transplantation was limited to children, given the low cell dose infused. Both related and unrelated cord blood transplants have been performed with high rates of success for a variety of hematologic disorders and metabolic storage diseases in the pediatric setting. The results for adult umbilical cord blood transplantation have improved, with greater emphasis on cord blood units of sufficient cell dose and human leukocyte antigen match and with the use of double umbilical cord blood units and improved supportive care techniques. Cord blood expansion trials have recently shown improvement in time to engraftment. Umbilical cord blood is being compared with other graft sources in both retrospective and prospective trials. The growth of the field over the last 25 years and the plans for future exploration are discussed.
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