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Wachowiak J, Galimard JE, Dalissier A, Rihani R, AlSaedi H, Wynn RF, Dalle JH, Peffault de Latour R, Sedlacek P, Balduzzi A, Schroeder T, Bodova I, Gonzalez Vicent M, Gruhn B, Hamladji RM, Krivan G, Patrick K, Sobkowiak-Sobierajska A, Stepensky P, Unal A, Amrolia P, Perez Martinez A, Rialland F, Aljurf M, Isgro A, Toren A, Bierings M, Corbacioglu S, Kałwak K. Outcomes of allogeneic haematopoietic cell transplantation for myelofibrosis in children and adolescents: the retrospective study of the EBMT Paediatric Diseases WP. Bone Marrow Transplant 2024; 59:1057-1069. [PMID: 38627449 PMCID: PMC11296951 DOI: 10.1038/s41409-024-02286-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 03/28/2024] [Accepted: 04/09/2024] [Indexed: 08/04/2024]
Abstract
This retrospective study evaluated 35 children (median age 5.2 years; range 0.4-18) with myelofibrosis (MF), including 33 with primary myelofibrosis and 2 with secondary myelofibrosis transplanted from matched sibling donor (MSD) (n = 17) or non-MSD (n = 18) between 2000 and 2022. Conditioning was usually chemotherapy-based (n = 33) and myeloablative (n = 32). Fifteen patients received bone marrow (BM), 14 haematopoietic cells (HC) from peripheral blood (PB), and 6 from cord blood (CB). Day +100 acute GvHD II-IV incidence was significantly lower after MSD-haematopoietic cell transplantation (MSD-HCT) than after non-MSD-HCT [18.8% (4.3-41.1) vs 58.8% (31-78.6); p = 0.01]. Six-year non-relapse mortality (NRM) was 18% (7.1-32.8), relapse incidence was 15.9% (5.6-30.9), progression-free survival (PFS) was 66.1% (47-79.7), GvHD-free relapse-free survival was 50% (30.6-66.7), and overall survival (OS) was 71.1% (51.4-84). Six-year PFS and OS were significantly higher after BM transplantation compared to HCT from other sources [85.1% (52.3-96.1) vs 50.8% (26.3-71), p = 0.03, and 90.9% (50.8-98.7) vs 54% (28.1-74.2), p = 0.01, respectively], whereas NRM was significantly lower [0% vs 32% (12.3-53.9); p = 0.02]. This first multicentre study on outcomes of allogeneic HCT in children with myelofibrosis proves feasibility and curative effect of transplantation in these children, suggests that bone marrow transplantation is associated with better outcomes, and indicates the need for further studies.
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Affiliation(s)
- Jacek Wachowiak
- Department of Pediatric Oncology, Hematology and Transplantology, University of Medical Sciences, Poznan, Poland.
| | - Jacques-Emmanuel Galimard
- EBMT Paris Study Office, Paris, France
- Department of Haematology, Saint Antoine Hospital, INSERM UMR 938, Sorbonne University, Paris, France
| | - Arnaud Dalissier
- EBMT Paris Study Office, Paris, France
- Department of Haematology, Saint Antoine Hospital, INSERM UMR 938, Sorbonne University, Paris, France
| | - Rawad Rihani
- Department of Pediatrics, Pediatric Blood and Marrow Transplantation and Cellular Therapy Program, King Hussein Cancer Center, Amman, Jordan
| | - Hawazen AlSaedi
- Department of Pediatric Hematology and Oncology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Robert F Wynn
- Department of Blood and Marrow Transplant, Royal Manchester Children's Hospital, Manchester, UK
| | | | - Régis Peffault de Latour
- Department of Hematology and Stem Cell Transplantation, Saint Louis Hospital, Paris Cité Université, Paris, France
| | - Petr Sedlacek
- Department of Pediatric Hematology and Oncology, University Hospital Motol, Prague, Czechia
| | - Adriana Balduzzi
- Hematopoietic Stem Cell Transplant Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- Department of Medicine and Surgery, Milano-Bicocca University, Milano, Italy
| | - Thomas Schroeder
- Department of Bone Marrow Transplantation, University of Essen, Essen, Germany
| | - Ivana Bodova
- University Children's Hospital, Bratislava, Slovakia
| | | | - Bernd Gruhn
- Department of Pediatrics, Jena University Hospital, Jena, Germany
| | - Rose-Marie Hamladji
- Centre Pierre et Marie Curie, Service Hématologie Greffe de Moëlle, Alger, Algeria
| | - Gergely Krivan
- Department of Paediatric Haematology and Stem Cell Transplantation, Central Hospital for Southern Pest, National Institute for Hematology and Infectology, Budapest, Hungary
| | - Katharine Patrick
- Sheffield Children's Hospital, Western Bank, Sheffield, United Kingdom
| | | | - Polina Stepensky
- BMT and Cancer Immunotherapy Department, Hadassah Hebrew University Medical Centre, Jerusalem, Israel
| | - Ali Unal
- Department Hematology and Bone Marrow Transplant Center Erciyes University Medical School, Kayseri, Turkey
| | - Persis Amrolia
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | | | - Fanny Rialland
- Hotel Dieu, CHU Nantes Dept. D'Hematologie, Nantes, France
| | - Mahmoud Aljurf
- King Faisal Specialist Hospital & Research Centre (Adult), Riyadh, Saudi Arabia
| | | | - Amos Toren
- Edmond & Lily Safra Children's Hospital, Division of Pediatric Hematology, Oncology & BMT, Sheba Medical Center, Tel_Hashomer, Israel
| | - Marc Bierings
- Princess Maxima Center, University Hospital for Children (WKZ), Stem cell transplantation, Utrecht, The Netherlands
| | - Selim Corbacioglu
- Department of Pediatrics, Division of Pediatric Oncology, Stem Cell Transplant, University Hospital of Regensburg, Regensburg, Germany
| | - Krzysztof Kałwak
- Department and Clinic of Pediatric Oncology, Hematology and Bone Marrow Transplantation, Wroclaw Medical University, Wroclaw, Poland
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2
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Kim SH, Ji YS, Yun J, Choi SH, Lim SH, Kim CK, Park SK. Is Treosulfan-Based Conditioning Attractive as a Reduced-Intensity Conditioning Regimen in Korea? J Korean Med Sci 2023; 38:e281. [PMID: 37698206 PMCID: PMC10497350 DOI: 10.3346/jkms.2023.38.e281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 05/11/2023] [Indexed: 09/13/2023] Open
Abstract
BACKGROUND Allogeneic hematopoietic stem cell transplantation (HSCT) was not actively performed in elderly acute myeloid leukemia (AML) or myelodysplastic syndrome patients who are at a high-risk based on hematopoietic cell transplantation-specific comorbidity index (HCT-CI). The advent of reduced-intensity conditioning (RIC) regimens has made HSCT applicable in this population. However, the selection of appropriate conditioning is a major concern for the attending physician. The benefits of combination of treosulfan and fludarabine (Treo/Flu) have been confirmed through many clinical studies. Korean data on treosulfan-based conditioning regimen are scarce. METHODS A retrospective study was conducted to compare the clinical outcomes of allogeneic HSCT using RIC between 13 patients receiving Treo/Flu and 39 receiving busulfan/fludarabine (Bu/Flu). RESULTS In terms of conditioning-related complications, the frequency of ≥ grade 2 nausea or vomiting was significantly lower and the duration of symptoms was shorter in the Treo/Flu group than in the Bu/Flu group. The incidence of ≥ grade 2 mucositis tended to be lower in the Treo/Flu group. In the analysis of transplant outcomes, all events of acute graft versus host disease (GVHD) and ≥ grade 2 acute GVHD occurred more frequently in the Treo/Flu group. The frequency of Epstein-Barr virus reactivation was significantly higher in the Treo/Flu group (53.8% vs. 23.1%, P = 0.037). Non-relapse mortality (NRM) at 12 months was higher in the Treo/Flu group (30.8% vs. 7.7%, P = 0.035). Significant prognostic factors included disease type, especially secondary AML, disease status and high-risk based on HCT-CI, ≥ grade 2 acute GVHD, and cases requiring ≥ 2 immunosuppressive drugs for treating acute GVHD. In the comparison of survival outcomes according to conditioning regimen, the Bu/Flu group seemed to show better results than the Treo/Flu group (60% vs. 46.2%, P = 0.092 for overall survival; 56.4% vs. 38.5%, P = 0.193 for relapse-free survival). In additional analysis for only HCT-CI high-risk groups, there was no difference in transplant outcomes except that the Treo/Flu group tended to have a higher NRM within one year after transplantation. Survival outcomes of both groups were similar. CONCLUSION This study suggests that Treo/Flu conditioning may be an alternative to Bu/Flu regimen in elderly patients with high-risk who are not suitable for standard conditioning.
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Affiliation(s)
- Se Hyung Kim
- Division of Hemato-Oncology, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Young Sok Ji
- Division of Hemato-Oncology, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Jina Yun
- Division of Hemato-Oncology, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Seong Hyeok Choi
- Division of Hemato-Oncology, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Sung Hee Lim
- Division of Hemato-Oncology, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Chan Kyu Kim
- Division of Hemato-Oncology, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Seong Kyu Park
- Division of Hemato-Oncology, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea.
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3
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Olivas-Mazón R, Bueno D, Sisinni L, Mozo Y, Casado-Abad G, Pérez-Martínez A. A retrospective study of treosulfan versus busulfan-based conditioning in pediatric patients. Eur J Haematol 2022; 109:474-482. [PMID: 35810360 DOI: 10.1111/ejh.13828] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 07/06/2022] [Accepted: 07/08/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To compare the outcomes of treosulfan-based vs. busulfan-based conditioning regimens in allogeneic hematopoietic stem cell transplantation (HSCT) in pediatric patients. METHODS Retrospective study of all consecutive patients (2012-2019) treated with allogenic HSCT and treosulfan- or busulfan-based conditioning regimens at a single center. RESULTS A total of 101 HSCT were included: 66 HSCT with busulfan and 35 with treosulfan. In malignant diseases (n=62), busulfan-based conditioning was more commonly employed than treosulfan: 82.3% vs. 17.7%. However, the use of treosulfan for malignant diseases increased over time: 6.5% of HSCT in 2012-2015 vs. 29% of HSCT in 2015-2019 (P=0.02). The cohort of treosulfan had more children under 1-year of age than the busulfan cohort (31 vs. 13%; P=0.033). The percentage of patients who received serotherapy was 73 and 89% in the non-malignant and malignant groups respectively. The engraftment, time to neutrophil, and platelet engraftment were not significantly different between the busulfan and the treosulfan cohorts. Rate of grade II-IV acute GvHD was significantly higher in the busulfan cohort than the treosulfan cohort (39% vs. 15%; P=0.016). No differences were observed in endothelial damage complications, chronic GvHD, relapse, overall survival, and transplant-related mortality. CONCLUSIONS Busulfan-based conditioning regimens are used more frequently for children undergoing allogenic HSCT, but treosulfan-based conditioning is gaining acceptance. Treosulfan-based conditioning is associated with lower rates of acute GvHD, and no significant differences on overall survival were observed compared with busulfan.
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Affiliation(s)
- Raquel Olivas-Mazón
- Pediatric Hemato-Oncology Department, La Paz University Hospital, Madrid, Spain
| | - David Bueno
- Pediatric Hemato-Oncology Department, La Paz University Hospital, Madrid, Spain
| | - Luisa Sisinni
- Pediatric Hemato-Oncology Department, La Paz University Hospital, Madrid, Spain
| | - Yasmina Mozo
- Pediatric Hemato-Oncology Department, La Paz University Hospital, Madrid, Spain
| | | | - Antonio Pérez-Martínez
- Pediatric Hemato-Oncology Department, La Paz University Hospital, Madrid, Spain.,Institute for Health Research (IdiPAZ), La Paz University Hospital, Madrid, Spain.,Faculty of Medicine, Autonomous University of Madrid, Madrid, Spain
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4
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Lüftinger R, Zubarovskaya N, Galimard JE, Cseh A, Salzer E, Locatelli F, Algeri M, Yesilipek A, de la Fuente J, Isgrò A, Alseraihy A, Angelucci E, Smiers FJ, La La Nasa G, Zecca M, Fisgin T, Unal E, Kleinschmidt K, Peters C, Lankester A, Corbacioglu S. Busulfan–fludarabine- or treosulfan–fludarabine-based myeloablative conditioning for children with thalassemia major. Ann Hematol 2022; 101:655-665. [DOI: 10.1007/s00277-021-04732-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 11/26/2021] [Indexed: 11/29/2022]
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5
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Treosulfan-induced myalgia in pediatric hematopoietic stem cell transplantation identified by an electronic health record text mining tool. Sci Rep 2021; 11:19084. [PMID: 34580398 PMCID: PMC8476488 DOI: 10.1038/s41598-021-98669-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 09/13/2021] [Indexed: 11/30/2022] Open
Abstract
Treosulfan is increasingly used as myeloablative agent in conditioning regimen prior to allogeneic hematopoietic stem cell transplantation (HSCT). In our pediatric HSCT program, myalgia was regularly observed after treosulfan-based conditioning, which is a relatively unknown side effect. Using a natural language processing and text-mining tool (CDC), we investigated whether treosulfan compared with busulfan was associated with an increased risk of myalgia. Furthermore, among treosulfan users, we studied the characteristics of given treatment of myalgia, and studied prognostic factors for developing myalgia during treosulfan use. Electronic Health Records (EHRs) until 28 days after HSCT were screened using the CDC for myalgia and 22 synonyms. Time to myalgia, location of pain, duration, severity and drug treatment were collected. Pain severity was classified according to the WHO pain relief ladder. Logistic regression was performed to assess prognostic factors. 114 patients received treosulfan and 92 busulfan. Myalgia was reported in 37 patients; 34 patients in the treosulfan group and 3 patients in the busulfan group (p = 0.01). In the treosulfan group, median time to myalgia was 7 days (0–12) and median duration of pain was 19 days (4–73). 44% of patients needed strong acting opiates and adjuvant medicines (e.g. ketamine). Hemoglobinopathy was a significant risk factor, as compared to other underlying diseases (OR 7.16 95% CI 2.09–30.03, p = 0.003). Myalgia appears to be a common adverse effect of treosulfan in pediatric HSCT, especially in hemoglobinopathy. Using the CDC, EHRs were easily screened to detect this previously unknown side effect, proving the effectiveness of the tool. Recognition of treosulfan-induced myalgia is important for adequate pain management strategies and thereby for improving the quality of hospital stay.
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6
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Dell'Orso G, Giardino S, Pierri F, Volpi S, Mesini A, Paladini D, Faraci M. Spontaneous pregnancy after hematopoietic stem cell transplantation for chronic granulomatous disease. Pediatr Blood Cancer 2021; 68:e28783. [PMID: 33112030 DOI: 10.1002/pbc.28783] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 10/12/2020] [Accepted: 10/13/2020] [Indexed: 02/03/2023]
Affiliation(s)
- Gianluca Dell'Orso
- Hematopoietic Stem Cell Transplant Unit, Department of Hematology and Oncology, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Stefano Giardino
- Hematopoietic Stem Cell Transplant Unit, Department of Hematology and Oncology, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Filomena Pierri
- Hematopoietic Stem Cell Transplant Unit, Department of Hematology and Oncology, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Stefano Volpi
- Centro Malattie Autoinfiammatorie e Immunodeficienze, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Alessio Mesini
- Infectious Diseases Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Dario Paladini
- Fetal Medicine and Surgery Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Maura Faraci
- Hematopoietic Stem Cell Transplant Unit, Department of Hematology and Oncology, IRCCS Istituto Giannina Gaslini, Genova, Italy
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7
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Ben Hassine K, Powys M, Svec P, Pozdechova M, Versluys B, Ansari M, Shaw PJ. Total Body Irradiation Forever? Optimising Chemotherapeutic Options for Irradiation-Free Conditioning for Paediatric Acute Lymphoblastic Leukaemia. Front Pediatr 2021; 9:775485. [PMID: 34956984 PMCID: PMC8705537 DOI: 10.3389/fped.2021.775485] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 10/21/2021] [Indexed: 12/15/2022] Open
Abstract
Total-body irradiation (TBI) based conditioning prior to allogeneic hematopoietic stem cell transplantation (HSCT) is generally regarded as the gold-standard for children >4 years of age with acute lymphoblastic leukaemia (ALL). Retrospective studies in the 1990's suggested better survival with irradiation, confirmed in a small randomised, prospective study in the early 2000's. Most recently, this was reconfirmed by the early results of the large, randomised, international, phase III FORUM study published in 2020. But we know survivors will suffer a multitude of long-term sequelae after TBI, including second malignancies, neurocognitive, endocrine and cardiometabolic effects. The drive to avoid TBI directs us to continue optimising irradiation-free, myeloablative conditioning. In chemotherapy-based conditioning, the dominant myeloablative effect is provided by the alkylating agents, most commonly busulfan or treosulfan. Busulfan with cyclophosphamide is a long-established alternative to TBI-based conditioning in ALL patients. Substituting fludarabine for cyclophosphamide reduces toxicity, but may not be as effective, prompting the addition of a third agent, such as thiotepa, melphalan, and now clofarabine. For busulfan, it's wide pharmacokinetic (PK) variability and narrow therapeutic window is well-known, with widespread use of therapeutic drug monitoring (TDM) to individualise dosing and control the cumulative busulfan exposure. The development of first-dose selection algorithms has helped achieve early, accurate busulfan levels within the targeted therapeutic window. In the future, predictive genetic variants, associated with differing busulfan exposures and toxicities, could be employed to further tailor individualised busulfan-based conditioning for ALL patients. Treosulfan-based conditioning leads to comparable outcomes to busulfan-based conditioning in paediatric ALL, without the need for TDM to date. Future PK evaluation and modelling may optimise therapy and improve outcome. More recently, the addition of clofarabine to busulfan/fludarabine has shown encouraging results when compared to TBI-based regimens. The combination shows activity in ALL as well as AML and deserves further evaluation. Like busulfan, optimization of chemotherapy conditioning may be enhanced by understanding not just the PK of clofarabine, fludarabine, treosulfan and other agents, but also the pharmacodynamics and pharmacogenetics, ideally in the context of a single disease such as ALL.
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Affiliation(s)
- Khalil Ben Hassine
- Cansearch Research Platform for Pediatric Oncology and Hematology, Department of Pediatrics, Gynecology and Obstetrics, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Madeleine Powys
- Blood Transplant and Cell Therapies, Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Peter Svec
- Department of Pediatric Hematology and Oncology, Comenius University, Bratislava, Slovakia.,Bone Marrow Transplantation Unit, National Institute of Children's Diseases, Bratislava, Slovakia
| | - Miroslava Pozdechova
- Department of Pediatric Hematology and Oncology, Comenius University, Bratislava, Slovakia.,Bone Marrow Transplantation Unit, National Institute of Children's Diseases, Bratislava, Slovakia
| | | | - Marc Ansari
- Cansearch Research Platform for Pediatric Oncology and Hematology, Department of Pediatrics, Gynecology and Obstetrics, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Division of Pediatric Oncology and Hematology, Department of Women, Child and Adolescent, University Geneva Hospitals, Geneva, Switzerland
| | - Peter J Shaw
- Blood Transplant and Cell Therapies, Children's Hospital at Westmead, Sydney, NSW, Australia.,Speciality of Child and Adolescent Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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8
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Huttunen P, Taskinen M, Vettenranta K. Acute toxicity and outcome among pediatric allogeneic hematopoietic transplant patients conditioned with treosulfan-based regimens. Pediatr Hematol Oncol 2020; 37:355-364. [PMID: 32166994 DOI: 10.1080/08880018.2020.1738604] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Treosulfan-based regimens constitute a feasible and increasingly used, but still myeloablative, conditioning in pediatric allogeneic hematopoietic stem cell transplantation (HSCT). We retrospectively analyzed the acute toxicity and outcome of all consecutive (2004-2015) pediatric HSCT patients prepared for HSCT with treosulfan in a single-center setting. We included HSCTs performed for both nonmalignant (n = 23) and malignant diseases (n = 11). The controls were patients with nonmalignant diseases or hematological malignancies conditioned with cyclophosphamide (Cy)-total body irradiation (TBI)-based (39 patients) or busulfan-based regimens (11 patients). The major toxicities of the treosulfan-based regimens were limited to oral mucosa and skin. 50% of the patients needed IV morphine for severe mucositis compared to 31% in patients conditioned with Cy-TBI (P = 0.02). Other toxicities were rare. The disease-free survival (DFS) of patients transplanted for nonmalignant disorders was 88.9 ± 7.5% at 2 years. The event-free survival (EFS) at 2 years in this small cohort for those with a malignant disease and a treosulfan-based conditioning was 54.5 ± 1.5%. We conclude that a treosulfan-based conditioning regimen gives excellent DFS in pediatric HSCT performed for a nonmalignant disorder but with substantial mucosal toxicity. In a malignant disorder a treosulfan-based regimen looks promising but larger, preferably randomized, studies are needed to prove efficacy.
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Affiliation(s)
- Pasi Huttunen
- Division of Hematology-Oncology and Stem Cell Transplantation, New Children´s Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Mervi Taskinen
- Division of Hematology-Oncology and Stem Cell Transplantation, New Children´s Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Kim Vettenranta
- Division of Hematology-Oncology and Stem Cell Transplantation, New Children´s Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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9
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Chiesa R, Standing JF, Winter R, Nademi Z, Chu J, Pinner D, Kloprogge F, McLellen S, Amrolia PJ, Rao K, Lucchini G, Silva J, Ciocarlie O, Lazareva A, Gennery AR, Doncheva B, Cant AJ, Hambleton S, Flood T, Rogerson E, Devine K, Prunty H, Heales S, Veys P, Slatter M. Proposed Therapeutic Range of Treosulfan in Reduced Toxicity Pediatric Allogeneic Hematopoietic Stem Cell Transplant Conditioning: Results From a Prospective Trial. Clin Pharmacol Ther 2019; 108:264-273. [PMID: 31701524 PMCID: PMC7484914 DOI: 10.1002/cpt.1715] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 10/28/2019] [Indexed: 12/18/2022]
Abstract
Treosulfan is given off‐label in pediatric allogeneic hematopoietic stem cell transplant. This study investigated treosulfan's pharmacokinetics (PKs), efficacy, and safety in a prospective trial. Pediatric patients (n = 87) receiving treosulfan‐fludarabine conditioning were followed for at least 1 year posttransplant. PKs were described with a two‐compartment model. During follow‐up, 11 of 87 patients died and 12 of 87 patients had low engraftment (≤ 20% myeloid chimerism). For each increase in treosulfan area under the curve from zero to infinity (AUC(0‐∞)) of 1,000 mg hour/L the hazard ratio (95% confidence interval) for mortality increase was 1.46 (1.23–1.74), and the hazard ratio for low engraftment was 0.61 (0.36–1.04). A cumulative AUC(0‐∞) of 4,800 mg hour/L maximized the probability of success (> 20% engraftment and no mortality) at 82%. Probability of success with AUC(0‐∞) between 80% and 125% of this target were 78% and 79%. Measuring PK at the first dose and individualizing the third dose may be required in nonmalignant disease.
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Affiliation(s)
- Robert Chiesa
- Bone Marrow Transplantation Department, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Joseph F Standing
- Pharmacy Department, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK.,Infection, Immunity, and Inflammation, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Robert Winter
- Chemical Pathology Department, Great Ormond Street Hospital for Children,, NHS Foundation Trust, London, UK
| | - Zohreh Nademi
- Bone Marrow Transplantation Department, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK.,Bone Marrow Transplantation Department, Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Jan Chu
- Bone Marrow Transplantation Department, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Danielle Pinner
- Bone Marrow Transplantation Department, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Frank Kloprogge
- Institute for Global Health, University College London, London, UK
| | - Susan McLellen
- Clinical Biochemistry, Integrated Laboratory Medicine Directorate, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Persis J Amrolia
- Bone Marrow Transplantation Department, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK.,Infection, Immunity, and Inflammation, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Kanchan Rao
- Bone Marrow Transplantation Department, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Giovanna Lucchini
- Bone Marrow Transplantation Department, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Juliana Silva
- Bone Marrow Transplantation Department, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Oana Ciocarlie
- Bone Marrow Transplantation Department, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Arina Lazareva
- Bone Marrow Transplantation Department, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Andrew R Gennery
- Bone Marrow Transplantation Department, Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Bilyana Doncheva
- Pharmacy Department, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Andrew J Cant
- Bone Marrow Transplantation Department, Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Sophie Hambleton
- Bone Marrow Transplantation Department, Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Terence Flood
- Bone Marrow Transplantation Department, Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Elizabeth Rogerson
- Bone Marrow Transplantation Department, Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Kirsty Devine
- Bone Marrow Transplantation Department, Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Helen Prunty
- Chemical Pathology Department, Great Ormond Street Hospital for Children,, NHS Foundation Trust, London, UK
| | - Simon Heales
- Chemical Pathology Department, Great Ormond Street Hospital for Children,, NHS Foundation Trust, London, UK
| | - Paul Veys
- Bone Marrow Transplantation Department, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK.,Infection, Immunity, and Inflammation, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Mary Slatter
- Bone Marrow Transplantation Department, Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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10
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Xu Y, Thall PF, Hua W, Andersson BS. Bayesian non-parametric survival regression for optimizing precision dosing of intravenous busulfan in allogeneic stem cell transplantation. J R Stat Soc Ser C Appl Stat 2019; 68:809-828. [PMID: 31467455 PMCID: PMC6714050 DOI: 10.1111/rssc.12331] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Allogeneic stem cell transplantation (allo-SCT) is now part of standard of care for acute leukemia (AL). To reduce toxicity of the pre-transplant conditioning regimen, intravenous busulfan is usually used as a preparative regimen for AL patients undergoing allo-SCT. Systemic busulfan exposure, characterized by the area under the plasma concentration versus time curve (AUC), is strongly associated with clinical outcome. An AUC that is too high is associated with severe toxicities, while an AUC that is too low carries increased risks of disease recurrence and failure to engraft. Consequently, an optimal AUC interval needs to be determined for therapeutic use. To address the possibility that busulfan pharmacokinetics and pharmacodynamics vary significantly with patient characteristics, we propose a tailored approach to determine optimal covariate-specific AUC intervals. To estimate these personalized AUC intervals, we apply a flexible Bayesian nonparametric regression model based on a dependent Dirichlet process and Gaussian process, DDP-GP. Our analyses of a dataset of 151 patients identified optimal therapeutic intervals for AUC that varied substantively with age and whether the patient was in complete remission or had active disease at transplant. Extensive simulations to evaluate the DDP-GP model in similar settings showed that its performance compares favorably to alternative methods. We provide an R package, DDPGPSurv, that implements the DDP-GP model for a broad range of survival regression analyses.
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Affiliation(s)
- Yanxun Xu
- Department of Applied Mathematics and Statistics, Johns Hopkins
University, Baltimore, USA
| | - Peter F. Thall
- Department of Biostatistics, U.T. M.D. Anderson Cancer Center,
Houston, USA
| | - William Hua
- Department of Applied Mathematics and Statistics, Johns Hopkins
University, Baltimore, USA
| | - Borje S. Andersson
- Department of Stem Cell Transplantation and Cellular Therapy, U.T.
M.D. Anderson Cancer Center, Houston, USA
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11
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El-Serafi I, Loy O, Zhao Y, Oerther S, Mattsson J. Pre-formulation investigations for establishing a protocol for treosulfan handling and activation. Pharm Dev Technol 2018; 24:639-648. [PMID: 30474459 DOI: 10.1080/10837450.2018.1551903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Treosulfan is an alkylating agent that is used for the treatment of ovarian cancer and for conditioning prior to stem cell transplantation. It is a prodrug that is activated non-enzymatically to two active epoxides. OBJECTIVES To optimize a protocol for both in vivo samples handling and in vitro drug preparation. Treosulfan stability was tested in biological fluids at different conditions as well as for its cytotoxicity on cell lines. RESULTS Plasma samples can be safely frozen for a short period up to 8 h, however; for longer periods, samples should be acidified. Urine samples and cell culture media can be safely frozen regardless their pH. For in vitro investigations, incubation of treosulfan at 37 °C for 24 h activated 100% of the drug. Whole blood acidification should be avoided for the risk of hemolysis. Finally; treosulfan cytotoxicity on HL-60 cells has increased following pre-incubation for 24 h at 37 °C compared to K562 cell line. CONCLUSION The stability profiling of treosulfan provided a valuable reference for handling of biological samples for both in vivo and in vitro studies. These results can be utilized for further investigations concerning the drug kinetics and dynamics in addition to the development of new pharmaceutical formulations.
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Affiliation(s)
- Ibrahim El-Serafi
- a Department of Laboratory Medicine , Karolinska Institutet , Stockholm , Sweden.,b Department of Clinical and Experimental Medicine , Linköping University , Linköping , Sweden.,c Department of Biochemistry, Faculty of Medicine , Port-Said University, Port-Said , Egypt
| | - Orlaith Loy
- a Department of Laboratory Medicine , Karolinska Institutet , Stockholm , Sweden
| | - Ying Zhao
- a Department of Laboratory Medicine , Karolinska Institutet , Stockholm , Sweden
| | - Sandra Oerther
- a Department of Laboratory Medicine , Karolinska Institutet , Stockholm , Sweden
| | - Jonas Mattsson
- d Department of Oncology and Pathology , Karolinska Institutet , Stockholm , Sweden.,e Department of Hematology , Oslo University Hospital , Oslo , Norway
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12
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Deeg HJ, Stevens EA, Salit RB, Ermoian RP, Fang M, Gyurkocza B, Sorror ML, Fatobene G, Baumgart J, Burroughs LM, Delaney C, Doney K, Egan DN, Flowers ME, Milano F, Radich JP, Scott BL, Sickle EJ, Wood BL, Yeung C, Storer BE. Transplant Conditioning with Treosulfan/Fludarabine with or without Total Body Irradiation: A Randomized Phase II Trial in Patients with Myelodysplastic Syndrome and Acute Myeloid Leukemia. Biol Blood Marrow Transplant 2018; 24:956-963. [DOI: 10.1016/j.bbmt.2017.12.785] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 12/14/2017] [Indexed: 01/28/2023]
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13
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Danielak D, Kasprzyk A, Wróbel T, Wachowiak J, Kałwak K, Główka F. Relationship between exposure to treosulfan and its monoepoxytransformer - An insight from population pharmacokinetic study in pediatric patients before hematopoietic stem cell transplantation. Eur J Pharm Sci 2018; 120:1-9. [PMID: 29705215 DOI: 10.1016/j.ejps.2018.04.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 04/09/2018] [Accepted: 04/23/2018] [Indexed: 11/27/2022]
Abstract
Treosulfan (TREO), a structural analog of busulfan, is currently studied as a myeloablative agent in conditioning regimens before hematopoietic stem cell transplantation in pediatric patients. High exposure to TREO (>1650 mg∗h/mL) might be related to early toxicity, especially skin toxicity and mucositis. The aim of the present study was to investigate a potential relationship between exposure to TREO and its monoepoxytransformer (S,S-EBDM), as well as variability of the pharmacokinetics of these entities by means of a population pharmacokinetic approach with a non-linear mixed-effects analysis. The study included data from 14 children with malignant and non-malignant diseases treated with TREO in daily doses 10-14 g/m2. The parent-metabolite population pharmacokinetic model was developed in NONMEM 7.3 software. Upon the constructed model, an extensive simulation was performed to assess the correlation between exposure to TREO and S,S-EBDM. It was found that TREO and S,S-EBDM pharmacokinetics was best described with 2-compartmental and 1-compartmental linear models, respectively. The vast majority (>65%) of TREO was transformed to S,S-EBDM. Overall, a considerable interpatient variability of pharmacokinetic parameters was observed, especially the clearance of S,S-EBDM. A weak correlation was found between the exposure to TREO and S,S-EBDM (r = 0.1681, p < 0.0001). Also, patients with an exposure to TREO above 1650 mg∗h/mL were most likely to have also a high exposure to S,S-EBDM (35.38 μM∗h vs. 43.14 μM∗h, p < 0.0001). In summary, a parent-metabolite population pharmacokinetic model for TREO and S,S-EBDM was developed for the first time. It was shown that there is a weak correlation between exposure to TREO and S,S-EBDM. Therefore therapeutic drug monitoring of not only prodrug but also its active epoxide might be needed.
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Affiliation(s)
- Dorota Danielak
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Święcickiego 6 St, 60-781 Poznań, Poland.
| | - Anna Kasprzyk
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Święcickiego 6 St, 60-781 Poznań, Poland
| | - Tomasz Wróbel
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Święcickiego 6 St, 60-781 Poznań, Poland
| | - Jacek Wachowiak
- Department of Pediatric Hematology, Oncology and Transplantology, Poznan University of Medical Sciences, 27/33 Szpitalna St, 60-572 Poznań, Poland.
| | - Krzysztof Kałwak
- Department of Pediatric Hematology, Oncology and Bone Marrow Transplantation, Wroclaw Medical University, 44 Bujwida St, 50-368 Wroclaw, Poland
| | - Franciszek Główka
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Święcickiego 6 St, 60-781 Poznań, Poland.
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14
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Slatter MA, Rao K, Abd Hamid IJ, Nademi Z, Chiesa R, Elfeky R, Pearce MS, Amrolia P, Worth A, Flood T, Abinun M, Hambleton S, Qasim W, Gaspar HB, Cant AJ, Gennery AR, Veys P. Treosulfan and Fludarabine Conditioning for Hematopoietic Stem Cell Transplantation in Children with Primary Immunodeficiency: UK Experience. Biol Blood Marrow Transplant 2017; 24:529-536. [PMID: 29155317 DOI: 10.1016/j.bbmt.2017.11.009] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 11/08/2017] [Indexed: 11/17/2022]
Abstract
We previously published results for 70 children who received conditioning with treosulfan and cyclophosphamide (n = 30) or fludarabine (n = 40) before undergoing hematopoietic stem cell transplantation (HSCT) for primary immunodeficiency (PID). Toxicity was lower and T cell chimerism was better in the patients receiving fludarabine, but cohort numbers were relatively small and follow-up was short. Here we report outcomes of 160 children who received homogeneous conditioning with treosulfan, fludarabine, and, in most cases, alemtuzumab (n = 124). The median age at transplantation was 1.36 years (range, .09 to 18.25 years). Donors included 73 matched unrelated, 54 1 to 3 antigen-mismatched unrelated, 12 matched sibling, 17 other matched family, and 4 haploidentical donors. Stem cell source was peripheral blood stem cells (PBSCs) in 70, bone marrow in 49, and cord blood in 41. Median duration of follow-up was 4.3 years (range, .8 to 9.4 years). Overall survival was 83%. No patients had veno-occlusive disease. Seventy-four patients (46%) had acute GVHD, but only 14 (9%) greater than grade II. Four patients underwent successful retransplantation for graft loss or poor immune reconstitution. Another patient experienced graft rejection and died. There was no association between T cell chimerism >95% and stem cell source, but a significant association was seen between myeloid chimerism >95% and use of PBSCs without an increased risk of significant GVHD compared with other sources. All 11 patients with severe combined immunodeficiency diagnosed at birth were alive at up to 8.7 years of follow-up. Long-term studies are needed to determine late gonadotoxic effects, and pharmacokinetic studies are needed to identify whether specific targeting is advantageous. The combination of treosulfan, fludarabine, and alemtuzumab is associated with excellent results in HSCT for PID.
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Affiliation(s)
- Mary A Slatter
- Department of Paediatric Immunology, Newcastle upon Tyne Hospital NHS Foundation Trust, Newcastle upon Tyne, United Kingdom.
| | - Kanchan Rao
- Great Ormond Street Hospital NHS Trust, London, United Kingdom
| | - Intan Juliana Abd Hamid
- Department of Paediatric Immunology, Newcastle upon Tyne Hospital NHS Foundation Trust, Newcastle upon Tyne, United Kingdom; Regenerative Medicine Cluster, Advanced Medical and Dental Institute, Universiti Sains Malaysia, Bertam, Malaysia
| | - Zohreh Nademi
- Department of Paediatric Immunology, Newcastle upon Tyne Hospital NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Robert Chiesa
- Great Ormond Street Hospital NHS Trust, London, United Kingdom
| | - Reem Elfeky
- Great Ormond Street Hospital NHS Trust, London, United Kingdom
| | - Mark S Pearce
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Persis Amrolia
- Great Ormond Street Hospital NHS Trust, London, United Kingdom
| | - Austen Worth
- Great Ormond Street Hospital NHS Trust, London, United Kingdom
| | - Terence Flood
- Department of Paediatric Immunology, Newcastle upon Tyne Hospital NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Mario Abinun
- Department of Paediatric Immunology, Newcastle upon Tyne Hospital NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Sophie Hambleton
- Department of Paediatric Immunology, Newcastle upon Tyne Hospital NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Waseem Qasim
- Great Ormond Street Hospital NHS Trust, London, United Kingdom
| | - Hubert B Gaspar
- Great Ormond Street Hospital NHS Trust, London, United Kingdom
| | - Andrew J Cant
- Department of Paediatric Immunology, Newcastle upon Tyne Hospital NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Andrew R Gennery
- Department of Paediatric Immunology, Newcastle upon Tyne Hospital NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Paul Veys
- Great Ormond Street Hospital NHS Trust, London, United Kingdom
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15
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van der Stoep MYEC, Bertaina A, ten Brink MH, Bredius RG, Smiers FJ, Wanders DCM, Moes DJA, Locatelli F, Guchelaar HJ, Zwaveling J, Lankester AC. High interpatient variability of treosulfan exposure is associated with early toxicity in paediatric HSCT: a prospective multicentre study. Br J Haematol 2017; 179:772-780. [DOI: 10.1111/bjh.14960] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 08/21/2017] [Indexed: 12/23/2022]
Affiliation(s)
| | - Alice Bertaina
- Department of Paediatric Haematology and Oncology; Istituto di Ricovero e Cura a Carattere Scientifico Bambino Gesù Children's Hospital, Rome; University of Pavia; Pavia Italy
| | - Marloes H. ten Brink
- Department of Clinical Pharmacy and Toxicology; Leiden University Medical Centre; Leiden the Netherlands
| | - Robbert G. Bredius
- Department of Paediatrics; Leiden University Medical Centre; Leiden the Netherlands
| | - Frans J. Smiers
- Department of Paediatrics; Leiden University Medical Centre; Leiden the Netherlands
| | | | - Dirk Jan A.R. Moes
- Department of Clinical Pharmacy and Toxicology; Leiden University Medical Centre; Leiden the Netherlands
| | - Franco Locatelli
- Department of Paediatric Haematology and Oncology; Istituto di Ricovero e Cura a Carattere Scientifico Bambino Gesù Children's Hospital, Rome; University of Pavia; Pavia Italy
| | - Henk-Jan Guchelaar
- Department of Clinical Pharmacy and Toxicology; Leiden University Medical Centre; Leiden the Netherlands
| | - Juliëtte Zwaveling
- Department of Clinical Pharmacy and Toxicology; Leiden University Medical Centre; Leiden the Netherlands
| | - Arjan C. Lankester
- Department of Paediatrics; Leiden University Medical Centre; Leiden the Netherlands
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16
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Danielak D, Twardosz J, Kasprzyk A, Wachowiak J, Kałwak K, Główka F. Population pharmacokinetics of treosulfan and development of a limited sampling strategy in children prior to hematopoietic stem cell transplantation. Eur J Clin Pharmacol 2017; 74:79-89. [PMID: 28975382 PMCID: PMC5748442 DOI: 10.1007/s00228-017-2344-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 09/26/2017] [Indexed: 12/03/2022]
Abstract
Purpose There is an increasing interest in use of treosulfan (TREO), a structural analogue of busulfan, as an agent in conditioning regimens prior to hematopoietic stem cell transplantation (HSCT), both in pediatric and adult populations. The aim of this study was to develop a population pharmacokinetic model and to establish limited sampling strategies (LSSs) enabling accurate estimation of exposure to this drug. Methods The study included 15 pediatric patients with malignant and non-malignant diseases, undergoing conditioning regimens prior to HSCT including TREO administered as a 1 h or 2 h infusion at daily doses of 10, 12, or 14 g/m2. A population pharmacokinetic model was developed by means of non-linear mixed-effect modeling approach in Monolix® software. Multivariate regression analysis and Bayesian method were used to develop 2- and 3-point strategies for estimation of exposure to TREO. Results Pharmacokinetics of TREO was best described with a two-compartmental linear model with proportional residual error. Following sampling schedules allowed accurate estimation of exposure to TREO: 1 h and 6 h or 1 h, 2 h, and 6 h for a TREO dose 12 g/m2 in a 1 h infusion, or at 2 h and 6 h or 2 h, 4 h, and 8 h for a TREO dose of 12 g/m2 and 14 g/m2 in a 2 h infusion. Conclusions A two-compartmental population pharmacokinetic model of TREO was developed and successfully used to establish 2- and 3-point LSSs for accurate and precise estimation of TREO AUC0→∞.
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Affiliation(s)
- Dorota Danielak
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Święcickiego 6 St, 60-781, Poznań, Poland.
| | - Jadwiga Twardosz
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Święcickiego 6 St, 60-781, Poznań, Poland
| | - Anna Kasprzyk
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Święcickiego 6 St, 60-781, Poznań, Poland
| | - Jacek Wachowiak
- Department of Pediatric Hematology, Oncology and Transplantology, Poznan University of Medical Sciences, Poznań, Poland
| | - Krzysztof Kałwak
- Department of Pediatric Hematology, Oncology and Bone Marrow Transplantation, Wroclaw Medical University, Wrocław, Poland
| | - Franciszek Główka
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Święcickiego 6 St, 60-781, Poznań, Poland
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17
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Toxicological effects of fludarabine and treosulfan conditioning before allogeneic stem-cell transplantation. Int J Hematol 2017; 106:471-475. [DOI: 10.1007/s12185-017-2320-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 08/15/2017] [Accepted: 08/21/2017] [Indexed: 12/20/2022]
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18
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Nagler A, Labopin M, Beelen D, Ciceri F, Volin L, Shimoni A, Foá R, Milpied N, Peccatori J, Polge E, Mailhol A, Mohty M, Savani BN. Long-term outcome after a treosulfan-based conditioning regimen for patients with acute myeloid leukemia: A report from the Acute Leukemia Working Party of the European Society for Blood and Marrow Transplantation. Cancer 2017; 123:2671-2679. [DOI: 10.1002/cncr.30646] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Arnon Nagler
- Acute Leukemia Working Party; European Society for Blood and Marrow Transplantation Paris Study Office/European Center for Biostatistical and Epidemiological Evaluation in Hematopoietic Cell Therapy (CEREST-TC); Paris France
- Hematology Division; Chaim Sheba Medical Center; Tel Hashomer Israel
| | - Myriam Labopin
- Acute Leukemia Working Party; European Society for Blood and Marrow Transplantation Paris Study Office/European Center for Biostatistical and Epidemiological Evaluation in Hematopoietic Cell Therapy (CEREST-TC); Paris France
- Department of Hematology; St. Antoine Hospital; Paris France
- INSERM UMR 938; Paris France
- Pierre and Marie Curie University; Paris France
| | - Dietrich Beelen
- Department of Bone Marrow Transplantation; University Hospital; Essen Germany
| | - Fabio Ciceri
- Hematology and Bone Marrow Transplantation Unit; San Raffaele Scientific Institute; Milano Italy
| | - Liisa Volin
- Stem Cell Transplantation Unit, Comprehensive Cancer Center; Helsinki University Central Hospital; Helsinki Finland
| | - Avichai Shimoni
- Hematology Division; Chaim Sheba Medical Center; Tel Hashomer Israel
| | - Roberto Foá
- Department of Cellular Biotechnology and Hematology; University La Sapienza; Rome Italy
| | - Noel Milpied
- CHU Bordeaux, Hôpital Haut-Leveque; Pessac France
| | - Jacopo Peccatori
- Hematology and Bone Marrow Transplantation Unit; San Raffaele Scientific Institute; Milano Italy
| | - Emmanuelle Polge
- Acute Leukemia Working Party; European Society for Blood and Marrow Transplantation Paris Study Office/European Center for Biostatistical and Epidemiological Evaluation in Hematopoietic Cell Therapy (CEREST-TC); Paris France
| | - Audrey Mailhol
- Acute Leukemia Working Party; European Society for Blood and Marrow Transplantation Paris Study Office/European Center for Biostatistical and Epidemiological Evaluation in Hematopoietic Cell Therapy (CEREST-TC); Paris France
| | - Mohamad Mohty
- Acute Leukemia Working Party; European Society for Blood and Marrow Transplantation Paris Study Office/European Center for Biostatistical and Epidemiological Evaluation in Hematopoietic Cell Therapy (CEREST-TC); Paris France
- Department of Hematology; St. Antoine Hospital; Paris France
- INSERM UMR 938; Paris France
- Pierre and Marie Curie University; Paris France
| | - Bipin N. Savani
- Acute Leukemia Working Party; European Society for Blood and Marrow Transplantation Paris Study Office/European Center for Biostatistical and Epidemiological Evaluation in Hematopoietic Cell Therapy (CEREST-TC); Paris France
- Long-Term Transplantation Clinic; Vanderbilt University Medical Center; Nashville Tennessee
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Tomatsu S, Azario I, Sawamoto K, Pievani AS, Biondi A, Serafini M. Neonatal cellular and gene therapies for mucopolysaccharidoses: the earlier the better? J Inherit Metab Dis 2016; 39:189-202. [PMID: 26578156 PMCID: PMC4754332 DOI: 10.1007/s10545-015-9900-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 10/21/2015] [Accepted: 10/22/2015] [Indexed: 12/03/2022]
Abstract
Mucopolysaccharidoses (MPSs) are a group of lysosomal storage disorders (LSDs). The increasing interest in newborn screening procedures for LSDs underlines the need for alternative cellular and gene therapy approaches to be developed during the perinatal period, supporting the treatment of MPS patients before the onset of clinical signs and symptoms. The rationale for considering these early therapies results from the clinical experience in the treatment of MPSs and other genetic disorders. The normal or gene-corrected hematopoiesis transplanted in patients can produce the missing protein at levels sufficient to improve and/or halt the disease-related abnormalities. However, these current therapies are only partially successful, probably due to the limited efficacy of the protein provided through the hematopoiesis. An alternative explanation is that the time at which the cellular or gene therapy procedures are performed could be too late to prevent pre-existing or progressive organ damage. Considering these aspects, in the last several years, novel cellular and gene therapy approaches have been tested in different animal models at birth, a highly early stage, showing that precocious treatment is critical to prevent long-term pathological consequences. This review provides insights into the state-of-art accomplishments made with neonatal cellular and gene-based therapies and the major barriers that need to be overcome before they can be implemented in the medical community.
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Affiliation(s)
- Shunji Tomatsu
- Department of Biomedical Research, Alfred I. duPont Institute Hospital for Children, Wilmington, DE, USA.
- Skeletal Dysplasia Lab, Department of Biomedical Research, Nemours/Alfred I. duPont Hospital for Children, 1600 Rockland Rd., Wilmington, DE, 19899-0269, USA.
| | - Isabella Azario
- Dulbecco Telethon Institute at Centro Ricerca M. Tettamanti, Department of Paediatrics, University of Milano-Bicocca, San Gerardo Hospital, via Pergolesi, 33, 20900, Monza, MB, Italy
| | - Kazuki Sawamoto
- Department of Biomedical Research, Alfred I. duPont Institute Hospital for Children, Wilmington, DE, USA
| | - Alice Silvia Pievani
- Dulbecco Telethon Institute at Centro Ricerca M. Tettamanti, Department of Paediatrics, University of Milano-Bicocca, San Gerardo Hospital, via Pergolesi, 33, 20900, Monza, MB, Italy
| | - Andrea Biondi
- Centro Ricerca M. Tettamanti, Department of Paediatrics, University of Milano-Bicocca, Via Pergolesi, 33, Monza, 20900, Italy
| | - Marta Serafini
- Dulbecco Telethon Institute at Centro Ricerca M. Tettamanti, Department of Paediatrics, University of Milano-Bicocca, San Gerardo Hospital, via Pergolesi, 33, 20900, Monza, MB, Italy.
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20
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Yabe H, Tanaka A, Chinen Y, Kato S, Sawamoto K, Yasuda E, Shintaku H, Suzuki Y, Orii T, Tomatsu S. Hematopoietic stem cell transplantation for Morquio A syndrome. Mol Genet Metab 2016; 117:84-94. [PMID: 26452513 PMCID: PMC5016080 DOI: 10.1016/j.ymgme.2015.09.011] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 09/29/2015] [Accepted: 09/29/2015] [Indexed: 12/15/2022]
Abstract
Morquio A syndrome features systemic skeletal dysplasia. To date, there has been no curative therapy for this skeletal dysplasia. No systemic report on a long-term effect of hematopoietic stem cell transplantation (HSCT) for Morquio A has been described. We conducted HSCT for 4 cases with Morquio A (age at HSCT: 4-15years, mean 10.5years) and followed them at least 10years (range 11-28years; mean 19years). Current age ranged between 25 and 36years of age (mean 29.5years). All cases had a successful full engraftment of allogeneic bone marrow transplantation without serious GVHD. Transplanted bone marrow derived from HLA-identical siblings (three cases) or HLA-identical unrelated donor. The levels of the enzyme activity in the recipient's lymphocytes reached the levels of donors' enzyme activities within two years after HSCT. For the successive over 10years post-BMT, GALNS activity in lymphocytes was maintained at the same level as the donors. Except one case who had osteotomy in both legs one year later post BMT, other three cases had no orthopedic surgical intervention. All cases remained ambulatory, and three of them could walk over 400m. Activity of daily living (ADL) in patients with HSCT was better than untreated patients. The patient who underwent HSCT at four years of age showed the best ADL score. In conclusion, the long-term study of HSCT has demonstrated therapeutic effect in amelioration of progression of the disease in respiratory function, ADL, and biochemical findings, suggesting that HSCT is a therapeutic option for patients with Morquio A.
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Affiliation(s)
- Hiromasa Yabe
- Department of Cell Transplantation and Regenerative Medicine, Tokai University School of Medicine, Isehara, Japan.
| | - Akemi Tanaka
- Department of Pediatrics, Osaka City University Graduate School of Medicine, Osaka, Japan.
| | - Yasutsugu Chinen
- Department of Pediatrics, Faculty of Medicine, University of the Ryukyus, Japan.
| | - Shunichi Kato
- Department of Cell Transplantation and Regenerative Medicine, Tokai University School of Medicine, Isehara, Japan
| | - Kazuki Sawamoto
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, United States
| | - Eriko Yasuda
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, United States
| | - Haruo Shintaku
- Department of Pediatrics, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yasuyuki Suzuki
- Medical Education Development Center, Gifu University, Japan
| | - Tadao Orii
- Department of Pediatrics, Gifu University, Gifu, Japan
| | - Shunji Tomatsu
- Department of Pediatrics, Gifu University, Gifu, Japan; Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, United States.
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21
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Maschan M, Shelikhova L, Ilushina M, Kurnikova E, Boyakova E, Balashov D, Persiantseva M, Skvortsova Y, Laberko A, Muzalevskii Y, Kazachenok A, Glushkova S, Bobrynina V, Kalinina V, Olshanskaya Y, Baidildina D, Novichkova G, Maschan A. TCR-alpha/beta and CD19 depletion and treosulfan-based conditioning regimen in unrelated and haploidentical transplantation in children with acute myeloid leukemia. Bone Marrow Transplant 2016; 51:668-74. [PMID: 26808573 DOI: 10.1038/bmt.2015.343] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 09/27/2015] [Accepted: 12/02/2015] [Indexed: 01/01/2023]
Abstract
We evaluated the depletion of TCR-alpha/beta cells from the graft of children with high-risk AML, who received transplantation from unrelated (n=20) and haploidentical donors (n=13). The preparative regimen included treosulfan, melphalan, fludarabine and anti-thymocyte globulin. Grafts were PBSC engineered by TCR-alpha/beta and CD19 depletion. The graft contained a median of 9 × 10(6)/kg of CD34+ and 20 × 10(3)/kg of αβ-T cells. Post-transplant immune suppression included tacrolimus till day +30 and Mtx in 21 patients, tacrolimus in 5, Mtx in 2 and no prophylaxis in 5 patients. Sixteen patients received native or TCR-alpha/beta-depleted donor lymphocytes at a median of 47 (40-204) days. Median follow-up is 1.76 years. Primary engraftment was achieved in 33 patients (100%). Cumulative incidence of acute GvHD (aGvHD) grade 2-3 was 39 (26-60)%, half of them had skin-only aGvHD. Cumulative incidence of chronic GvHD was 30(18-50)%. Transplant-related mortality is 10(4-26)%. Event-free survival (EFS) is 60(43-76)% and overall survival (OS) is 67(50-84)% at 2 years. In a subgroup of patients, who received transplantation in CR, EFS is 66(48-84)% and OS-72(53-90)% at 2 years. Our data suggest that TCR-alpha/beta and CD19 depletion is a robust method of graft manipulation, which can be used to engineer grafts for children with AML.
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Affiliation(s)
- M Maschan
- Department of hematopoietic stem cell transplantation, Dmitriy Rogachev Federal center for pediatric hematology, oncology and immunology, Moscow, Russia
| | - L Shelikhova
- Department of hematopoietic stem cell transplantation, Dmitriy Rogachev Federal center for pediatric hematology, oncology and immunology, Moscow, Russia
| | - M Ilushina
- Department of hematopoietic stem cell transplantation, Dmitriy Rogachev Federal center for pediatric hematology, oncology and immunology, Moscow, Russia
| | - E Kurnikova
- Blood bank and hematopoietic stem cell processing laboratory, Dmitriy Rogachev Federal center for pediatric hematology, oncology and immunology, Moscow, Russia
| | - E Boyakova
- Laboratory of hematopoietic stem cell transplantation biology, Dmitriy Rogachev Federal center for pediatric hematology, oncology and immunology, Moscow, Russia
| | - D Balashov
- Department of hematopoietic stem cell transplantation, Dmitriy Rogachev Federal center for pediatric hematology, oncology and immunology, Moscow, Russia
| | - M Persiantseva
- Department of hematopoietic stem cell transplantation, Dmitriy Rogachev Federal center for pediatric hematology, oncology and immunology, Moscow, Russia
| | - Y Skvortsova
- Department of hematopoietic stem cell transplantation, Dmitriy Rogachev Federal center for pediatric hematology, oncology and immunology, Moscow, Russia
| | - A Laberko
- Department of hematopoietic stem cell transplantation, Dmitriy Rogachev Federal center for pediatric hematology, oncology and immunology, Moscow, Russia
| | - Y Muzalevskii
- Blood bank and hematopoietic stem cell processing laboratory, Dmitriy Rogachev Federal center for pediatric hematology, oncology and immunology, Moscow, Russia
| | - A Kazachenok
- Blood bank and hematopoietic stem cell processing laboratory, Dmitriy Rogachev Federal center for pediatric hematology, oncology and immunology, Moscow, Russia
| | - S Glushkova
- Laboratory of hematopoietic stem cell transplantation biology, Dmitriy Rogachev Federal center for pediatric hematology, oncology and immunology, Moscow, Russia
| | - V Bobrynina
- Laboratory of molecular biology, Dmitriy Rogachev Federal center for pediatric hematology, oncology and immunology, Moscow, Russia
| | - V Kalinina
- Laboratory of molecular biology, Dmitriy Rogachev Federal center for pediatric hematology, oncology and immunology, Moscow, Russia
| | - Y Olshanskaya
- Laboratory of cytogenetics and molecular genetics, Dmitriy Rogachev Federal center for pediatric hematology, oncology and immunology, Moscow, Russia
| | - D Baidildina
- Department of pediatric hematology and oncology, Dmitriy Rogachev Federal center for pediatric hematology, oncology and immunology, Moscow, Russia
| | - G Novichkova
- Department of pediatric hematology and oncology, Dmitriy Rogachev Federal center for pediatric hematology, oncology and immunology, Moscow, Russia
| | - A Maschan
- Department of hematopoietic stem cell transplantation, Dmitriy Rogachev Federal center for pediatric hematology, oncology and immunology, Moscow, Russia.,Department of pediatric hematology and oncology, Dmitriy Rogachev Federal center for pediatric hematology, oncology and immunology, Moscow, Russia
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22
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Boztug H, Sykora KW, Slatter M, Zecca M, Veys P, Lankester A, Cant A, Skinner R, Wachowiak J, Glogova E, Pötschger U, Peters C. European Society for Blood and Marrow Transplantation Analysis of Treosulfan Conditioning Before Hematopoietic Stem Cell Transplantation in Children and Adolescents With Hematological Malignancies. Pediatr Blood Cancer 2016; 63:139-48. [PMID: 26398915 DOI: 10.1002/pbc.25764] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Accepted: 08/08/2015] [Indexed: 01/09/2023]
Abstract
BACKGROUND Standard myeloablative conditioning regimens for children with hematological malignancies undergoing allogeneic HSCT are based mainly on total body irradiation or busulfan. Their serious short- and long-term side effects warranted the exploration of less toxic alternatives. Treosulfan is increasingly used for adults and children before HSCT due to its potent immunosuppressive and cytotoxic effects combined with low organ toxicity. PROCEDURE To further investigate the role of treosulfan conditioning in children, the EBMT Pediatric diseases working party performed a retrospective analysis of 193 children with hematological malignancies (ALL n = 71, AML n = 47, MDS/MPS n = 40, other leukemia/lymphoma n = 25) undergoing allogeneic HSCT following treosulfan between January 2005 and July 2010. RESULTS Early regimen-related toxicity was low and mainly gastrointestinal. Veno-occlusive disease and neurological toxicity were rare. There was no association of toxicity with type of disease or treosulfan dose. High-grade early toxicity was not higher in infants or patients undergoing second or later transplantation. Treatment related mortality was low at 14%. Three-year event-free survival was 45 ± 4% and not significantly influenced by number of transplants, however it appeared to be significantly better for infants (P = 0.022). When compared to treosulfan plus fludarabine, the combination of treosulfan, fludarabine and an alkylator (either thiotepa or melphalan) resulted in significantly better overall survival (OS, P = 0.048) and a trend toward better EFS. CONCLUSIONS Treosulfan based conditioning is a safe and effective approach for children with hematological malignancies, including and importantly for infants and those patients undergoing second or later transplantation.
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Affiliation(s)
- Heidrun Boztug
- St. Anna Kinderspital and Childrens Cancer Research Institute, Department of Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Karl-Walter Sykora
- Department of Pediatric Hematology/Oncology, Hannover Medical School, Hannover, Germany
| | - Mary Slatter
- Children's HSCT Unit, Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Marco Zecca
- Pediatric Hematology/Oncology, Fondazione IRCCS, Policlinico San Matteo, Pavia, Italy
| | - Paul Veys
- Great Ormond Street Hospital for Children National Health Service Trust, London, United Kingdom
| | - Arjan Lankester
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Andrew Cant
- Children's HSCT Unit, Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Roderick Skinner
- Children's HSCT Unit, Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Jacek Wachowiak
- Department of Pediatric Hematology, Oncology, and Hematopoietic Stem Cell Transplantation, University of Medical Sciences, Poznań, Poland
| | - Evgenia Glogova
- St. Anna Kinderspital and Childrens Cancer Research Institute, Department of Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Ulrike Pötschger
- St. Anna Kinderspital and Childrens Cancer Research Institute, Department of Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Christina Peters
- St. Anna Kinderspital and Childrens Cancer Research Institute, Department of Pediatrics, Medical University of Vienna, Vienna, Austria
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23
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Romański M, Urbaniak B, Kokot Z, Główka FK. Activation of Prodrug Treosulfan at pH 7.4 and 37°C Accompanied by Hydrolysis of Its Active Epoxides: Kinetic Studies with Clinical Relevance. J Pharm Sci 2015; 104:4433-4442. [DOI: 10.1002/jps.24662] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Revised: 08/31/2015] [Accepted: 09/09/2015] [Indexed: 11/09/2022]
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24
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Koyyalamudi SR, Kuzhiumparambil U, Nath CE, Byrne JA, Fraser CJ, O'Brien TA, Earl JW, Shaw PJ. Development and Validation of a High Pressure Liquid Chromatography-UV Method for the Determination of Treosulfan and Its Epoxy Metabolites in Human Plasma and Its Application in Pharmacokinetic Studies. J Chromatogr Sci 2015; 54:326-33. [PMID: 26433392 DOI: 10.1093/chromsci/bmv145] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Indexed: 11/12/2022]
Abstract
Treosulfan (l-threitol-1,4-di-methanesulfonate) is a prodrug of a bifunctional alkylating agent that is being used increasingly in pediatric bone marrow transplantation regimens. The activation pathway is a complex reaction, which consists of two consecutive reactions leading to epoxybutane derivatives which are responsible for DNA alkylation. A simple, sensitive high performance liquid chromatography method for the determination of the sum of treosulfan and its epoxy metabolites by UV detection after derivatization with sodium diethyldithiocarbamate in human plasma was developed and validated. Plasma samples containing treosulfan and epoxy metabolites were converted into thiocarbamate derivative with 10% sodium diethyldithiocarbamate. Dinitrobiphenyl was used as an internal standard. The analysis was carried out using a reversed phase C18 column with a mobile phase consisting of methanol-water (65:35, v/v) at a flow rate of 1 mL/min. The eluent was monitored at 254 nm. The standard calibration curve was established between 2.5 and 50 µg/mL, with a correlation coefficient of 0.9987. Intra- and interday precision and accuracy of the method was <8% and met the analytical criteria. Pharmacokinetic parameters were determined in six children who received intravenous treosulfan (dose range 12-24 g/m(2)) in combination with fludarabine prior to blood or marrow transplantation.
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Affiliation(s)
- Sundar R Koyyalamudi
- Department of Biochemistry, The Children's Hospital at Westmead, Sydney, NSW 2145, Australia Department of Oncology, The Children's Hospital at Westmead, Sydney, NSW 2145, Australia Discipline of Paediatrics and Child Health, The University of Sydney, The Children's Hospital at Westmead, Sydney, NSW 2145, Australia
| | | | - Christa E Nath
- Department of Biochemistry, The Children's Hospital at Westmead, Sydney, NSW 2145, Australia Department of Oncology, The Children's Hospital at Westmead, Sydney, NSW 2145, Australia
| | - Jennifer A Byrne
- Discipline of Paediatrics and Child Health, The University of Sydney, The Children's Hospital at Westmead, Sydney, NSW 2145, Australia Children's Cancer Research Unit, The Children's Hospital at Westmead, Sydney, NSW 2145, Australia
| | | | - Tracey A O'Brien
- Kids Cancer Centre, Sydney Children's Hospital, Randwick, NSW 2031, Australia Women's & Children's Health, Faculty of Medicine, University of New South Wales, Kensington, NSW 2052, Australia
| | - John W Earl
- Department of Biochemistry, The Children's Hospital at Westmead, Sydney, NSW 2145, Australia Discipline of Paediatrics and Child Health, The University of Sydney, The Children's Hospital at Westmead, Sydney, NSW 2145, Australia
| | - Peter J Shaw
- Department of Oncology, The Children's Hospital at Westmead, Sydney, NSW 2145, Australia Discipline of Paediatrics and Child Health, The University of Sydney, The Children's Hospital at Westmead, Sydney, NSW 2145, Australia
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25
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Romański M, Baumgart J, Böhm S, Główka FK. Penetration of Treosulfan and its Active Monoepoxide Transformation Product into Central Nervous System of Juvenile and Young Adult Rats. Drug Metab Dispos 2015; 43:1946-54. [PMID: 26428246 DOI: 10.1124/dmd.115.066050] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 09/30/2015] [Indexed: 11/22/2022] Open
Abstract
Treosulfan (TREO) is currently investigated as an alternative treatment of busulfan in conditioning before hematopoietic stem cell transplantation. The knowledge of the blood-brain barrier penetration of the drug is still scarce. In this paper, penetration of TREO and its active monoepoxide (S,S-EBDM) and diepoxide (S,S-DEB) into the CNS was studied in juvenile (JR) and young adult rats (YAR) for the first time. CD rats of both sexes (n = 96) received an intravenous dose of TREO 500 mg/kg b.wt. Concentrations of TREO, S,S-EBDM, and S,S-DEB in rat plasma, brain, and cerebrospinal fluid (CSF, in YAR only) were determined by validated bioanalytical methods. Pharmacokinetic calculations were performed in WinNonlin using a noncompartmental analysis and statistical evaluation was done in Statistica software. In male JR, female JR, male YAR, and female YAR, the brain/plasma area under the curve (AUC) ratio for unbound TREO was 0.14, 0.17, 0.10, and 0.07 and for unbound S,S-EBDM, it was 0.52, 0.48, 0.28, and 0.22, respectively. The CSF/plasma AUC ratio in male and female YAR was 0.12 and 0.11 for TREO and 0.66 and 0.64 for S,S-EBDM, respectively. Elimination rate constants of TREO and S,S-EBDM in all the matrices were sex-independent with a tendency to be lower in the JR. No quantifiable levels of S,S-DEB were found in the studied samples. TREO and S,S-EBDM demonstrated poor and sex-independent penetration into CNS. However, the brain exposure was greater in juvenile rats, so very young children might potentially be more susceptible to high-dose TREO-related CNS exposure than young adults.
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Affiliation(s)
- Michał Romański
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Poznan, Poland (M.R., F.K.G.); and medac GmbH, Wedel, Germany (J.B., S.B.)
| | - Joachim Baumgart
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Poznan, Poland (M.R., F.K.G.); and medac GmbH, Wedel, Germany (J.B., S.B.)
| | - Sonja Böhm
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Poznan, Poland (M.R., F.K.G.); and medac GmbH, Wedel, Germany (J.B., S.B.)
| | - Franciszek K Główka
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Poznan, Poland (M.R., F.K.G.); and medac GmbH, Wedel, Germany (J.B., S.B.)
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26
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Strocchio L, Zecca M, Comoli P, Mina T, Giorgiani G, Giraldi E, Vinti L, Merli P, Regazzi M, Locatelli F. Treosulfan-based conditioning regimen for allogeneic haematopoietic stem cell transplantation in children with sickle cell disease. Br J Haematol 2015; 169:726-36. [PMID: 25818248 DOI: 10.1111/bjh.13352] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 01/20/2015] [Indexed: 12/01/2022]
Abstract
Although allogeneic haematopoietic stem cell transplantation (HSCT) still represents the only consolidated possibility of cure for sickle cell disease (SCD) patients, its use has been limited by the risk of morbidity and mortality associated with conventional myeloablative therapy. The introduction of treosulfan to replace busulfan in conditioning regimens has recently been explored by virtue of its lower toxicity profile. We report our experience with a treosulfan/thiotepa/fludarabine conditioning for human leucocyte antigen (HLA)-matched sibling or unrelated donor-HSCT in 15 children with SCD, and compare patient outcomes with those of a historical cohort (15 patients) given a busulfan-based regimen. Engraftment was achieved in 28 out of 30 patients (93%), with one case of graft failure in either group. The conditioning regimen was well tolerated in both groups, with no cases of grade III-IV regimen-related toxicity. The 7-year overall survival (OS) and disease-free survival (DFS) for the whole cohort were 100% and 93%, respectively, with a 93% DFS in both busulfan and treosulfan groups. No SCD-related adverse events occurred after engraftment in patients with complete or mixed donor chimerism. This retrospective analysis suggests that a treosulfan-based conditioning regimen is able to ensure engraftment with excellent OS/DFS and low regimen-related toxicity in patients with SCD.
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Affiliation(s)
- Luisa Strocchio
- Oncoematologia Pediatrica, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Marco Zecca
- Oncoematologia Pediatrica, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Patrizia Comoli
- Oncoematologia Pediatrica, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Tommaso Mina
- Oncoematologia Pediatrica, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Giovanna Giorgiani
- Oncoematologia Pediatrica, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Eugenia Giraldi
- Unità Pediatria, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - Luciana Vinti
- Dipartimento di Oncoematologia Pediatrica, IRCCS Ospedale Pediatrico Bambino Gesù, Roma, Italy
| | - Pietro Merli
- Dipartimento di Oncoematologia Pediatrica, IRCCS Ospedale Pediatrico Bambino Gesù, Roma, Italy
| | - Mario Regazzi
- Farmacocinetica Clinica dei Trapianti e delle Malattie Autoimmuni, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Franco Locatelli
- Dipartimento di Oncoematologia Pediatrica, IRCCS Ospedale Pediatrico Bambino Gesù, Roma, Italy.,Università degli Studi di Pavia, Pavia, Italy
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27
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Pharmacokinetics of treosulfan in pediatric patients undergoing hematopoietic stem cell transplantation. Ther Drug Monit 2015; 36:465-72. [PMID: 24487253 DOI: 10.1097/ftd.0000000000000047] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND High-dose treosulfan is used in conditioning regimens before hematopoietic stem cell transplantation in children. Pharmacokinetic data to optimize treosulfan dosing are scarce in this patient population. The aims of this study were the development and validation of an analytical method for treosulfan in human serum and the development of a pharmacokinetic model for treosulfan in pediatric patients. Furthermore, we aimed to develop a limited sampling strategy to estimate treosulfan systemic exposure with a minimum of inconvenience and risk for the patient. METHODS A reversed phase high-performance liquid chromatography method using ultraviolet detection to determine treosulfan in human serum samples was developed and validated according to food and drug administration guidelines. Serum pharmacokinetics after the first treosulfan administration was investigated in 20 children using nonlinear mixed-effect modeling, and a limited sampling strategy was developed and validated. RESULTS The assay was validated in a 10-500 mg/L concentration range with a lower limit of quantification of 10 mg/L. Accuracies were within the 90%-110% limit. The coefficients of variation of the within-day imprecision and between-days imprecision were less than 5%. Pharmacokinetics was adequately described with a 1-compartment model. The population estimates for clearance (CL) and volume of distribution were 6.85 L/h and 13.2 L for a typical patient of 20 kg, respectively. Treosulfan exposure could be adequately quantified with 2 samples, at 4 and 7 hours after the start of a 3-hour treosulfan infusion, with a mean deviation of 3% of individual CL and area under the curve based on limited sampling in comparison with the full data set in a total cohort. CONCLUSIONS In this study, a bioanalytical method, PK model, and limited sampling model were developed and validated. Furthermore, PK parameters of 20 pediatric patients were analyzed, demonstrating an interpatient variability in area under the curve of 14.5%. This study demonstrates the essential developments in the optimization of treosulfan therapy based on PK data.
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28
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Pharmacokinetics of treosulfan and its active monoepoxide in pediatric patients after intravenous infusion of high-dose treosulfan prior to HSCT. Eur J Pharm Sci 2015; 68:87-93. [DOI: 10.1016/j.ejps.2014.12.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Revised: 11/18/2014] [Accepted: 12/09/2014] [Indexed: 11/24/2022]
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29
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Giardino S, Lanino E, Morreale G, Madeo A, Di Rocco M, Gattorno M, Faraci M. Long-term outcome of a successful cord blood stem cell transplant in mevalonate kinase deficiency. Pediatrics 2015; 135:e211-5. [PMID: 25535259 DOI: 10.1542/peds.2014-2553] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Mevalonate kinase deficiency (MKD) is a rare autosomal recessive inborn error of metabolism with an autoinflammatory phenotype that may be expressed as a spectrum of disease phenotypes, from those with prevailing autoinflammatory syndrome and variable response to anti-inflammatory therapies, to mevalonic aciduria, which is associated with dysmorphic features, severe neurologic involvement, and the worst prognosis. We describe a boy, aged 2 years, 10 months, with severe phenotype of mevalonate kinase deficiency who underwent allogeneic hematopoietic stem cell transplantation (HSCT) from HLA-identical unrelated cord blood because his condition had failed to improve with antiinflammatory treatment as first-line therapy and an anticytokine drug as second-line therapy. The child had a sustained remission of febrile attacks and inflammation after transplant, and during a 5-year follow-up period, psychomotor and neurologic development were normal, without signs of underlying disease or late transplant-related effects. This case confirms that allogeneic HSCT is a safe and effective cure for patients affected by MKD in whom anticytokine drugs alone are insufficient for the management of autoinflammatory syndrome and for the unfavorable outcome of the disease.
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Affiliation(s)
- Stefano Giardino
- Stem Cell Transplantation Unit, Department of Pediatric Hematology and Oncology,
| | - Edoardo Lanino
- Stem Cell Transplantation Unit, Department of Pediatric Hematology and Oncology
| | - Giuseppe Morreale
- Stem Cell Transplantation Unit, Department of Pediatric Hematology and Oncology
| | | | - Maja Di Rocco
- Rare Diseases Unit, Department of Paediatrics, Istituto G. Gaslini, Genoa, Italy
| | | | - Maura Faraci
- Stem Cell Transplantation Unit, Department of Pediatric Hematology and Oncology
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30
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Personalized busulfan and treosulfan conditioning for pediatric stem cell transplantation: the role of pharmacogenetics and pharmacokinetics. Drug Discov Today 2014; 19:1572-86. [DOI: 10.1016/j.drudis.2014.04.005] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 03/01/2014] [Accepted: 04/08/2014] [Indexed: 01/22/2023]
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31
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Treosulfan-based conditioning regimens for allogeneic HSCT in children with acute lymphoblastic leukaemia. Ann Hematol 2014; 94:297-306. [DOI: 10.1007/s00277-014-2196-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2014] [Accepted: 08/19/2014] [Indexed: 12/19/2022]
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32
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Burroughs LM, Nemecek ER, Torgerson TR, Storer BE, Talano JA, Domm J, Giller RH, Shimamura A, Delaney C, Skoda-Smith S, Thakar MS, Baker KS, Rawlings DJ, Englund JA, Flowers MED, Deeg HJ, Storb R, Woolfrey AE. Treosulfan-based conditioning and hematopoietic cell transplantation for nonmalignant diseases: a prospective multicenter trial. Biol Blood Marrow Transplant 2014; 20:1996-2003. [PMID: 25196857 DOI: 10.1016/j.bbmt.2014.08.020] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 08/25/2014] [Indexed: 01/09/2023]
Abstract
Hematopoietic cell transplantation is an effective treatment for patients with nonmalignant diseases and for many is the only known cure. Conventional myeloablative regimens have been associated with unacceptably high early transplant-related mortality (TRM), particularly in patients with comorbid conditions. This prospective multicenter trial was designed to determine the safety and engraftment efficacy of treosulfan-based conditioning in patients with nonmalignant diseases. Thirty-one patients received HLA-matched related (n = 4) or unrelated (n = 27) grafts after conditioning with treosulfan (total dose, 42 g/m(2)), fludarabine (total dose, 150 mg/m(2)), ± thymoglobulin (6 mg/kg; n = 22). Graft-versus-host disease (GVHD) prophylaxis consisted of tacrolimus and methotrexate. All patients engrafted. Day-100 TRM was 0%. With a median follow-up of 2 years, the 2-year survival was 90%. Three patients died of GVHD, recurrent hemophagocytic lymphohistiocytosis, and a surgical complication, respectively. The cumulative incidences of grades II to IV and III to IV acute GVHD at day 100 and chronic GVHD at 2 years were 62%, 10%, and 21%, respectively. Patients who received thymoglobulin had a significantly lower incidence of grades III to IV acute GVHD (0% versus 33%; P = .005). These results indicate that the combination of treosulfan, fludarabine, and thymoglobulin is effective at establishing donor engraftment with low toxicity and improved survival in patients with nonmalignant diseases and support the need for future disease-specific clinical trials.
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Affiliation(s)
- Lauri M Burroughs
- Fred Hutchinson Cancer Research Center, Seattle, Washington; University of Washington School of Medicine, Seattle, Washington; Seattle Children's Hospital, Seattle, Washington.
| | | | - Troy R Torgerson
- University of Washington School of Medicine, Seattle, Washington; Seattle Children's Hospital, Seattle, Washington
| | - Barry E Storer
- Fred Hutchinson Cancer Research Center, Seattle, Washington; University of Washington School of Medicine, Seattle, Washington
| | | | | | | | - Akiko Shimamura
- Fred Hutchinson Cancer Research Center, Seattle, Washington; University of Washington School of Medicine, Seattle, Washington; Seattle Children's Hospital, Seattle, Washington
| | - Colleen Delaney
- Fred Hutchinson Cancer Research Center, Seattle, Washington; University of Washington School of Medicine, Seattle, Washington; Seattle Children's Hospital, Seattle, Washington
| | - Suzanne Skoda-Smith
- University of Washington School of Medicine, Seattle, Washington; Seattle Children's Hospital, Seattle, Washington
| | | | - K Scott Baker
- Fred Hutchinson Cancer Research Center, Seattle, Washington; University of Washington School of Medicine, Seattle, Washington; Seattle Children's Hospital, Seattle, Washington
| | - David J Rawlings
- University of Washington School of Medicine, Seattle, Washington; Seattle Children's Hospital, Seattle, Washington
| | - Janet A Englund
- University of Washington School of Medicine, Seattle, Washington; Seattle Children's Hospital, Seattle, Washington
| | - Mary E D Flowers
- Fred Hutchinson Cancer Research Center, Seattle, Washington; University of Washington School of Medicine, Seattle, Washington
| | - H Joachim Deeg
- Fred Hutchinson Cancer Research Center, Seattle, Washington; University of Washington School of Medicine, Seattle, Washington
| | - Rainer Storb
- Fred Hutchinson Cancer Research Center, Seattle, Washington; University of Washington School of Medicine, Seattle, Washington
| | - Ann E Woolfrey
- Fred Hutchinson Cancer Research Center, Seattle, Washington; University of Washington School of Medicine, Seattle, Washington; Seattle Children's Hospital, Seattle, Washington
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Slatter MA, Gennery AR. Advances in hematopoietic stem cell transplantation for primary immunodeficiency. Expert Rev Clin Immunol 2014; 9:991-9. [PMID: 24128161 DOI: 10.1586/1744666x.2013.836061] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The transplantation of hematopoietic stem cells in patients with primary immunodeficiencies has improved significantly over the last 40 years. In favorable circumstances when there is minimal or no infection present, no end-organ damage and the availability of a well HLA-matched donor, survival and cure reaches 90%. Barriers to further success include late identification of disease, with accumulation of infection- and inflammation-related organ damage, stem cell manipulation when there is no HLA-matched donor, toxicity of conditioning regimens and prediction and treatment of graft-versus-host disease. This review will outline recent developments in conditioning regimens, stem cell source manipulation and early detection and treatment of graft-versus-host disease, with a particular emphasis on patients with primary immunodeficiency.
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Affiliation(s)
- Mary A Slatter
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, NE1 7RU, UK and Department of Paediatric Immunology and HSCT, Great North Children's Hospital, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK
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Balduzzi A, Di Maio L, Silvestri D, Songia S, Bonanomi S, Rovelli A, Conter V, Biondi A, Cazzaniga G, Valsecchi MG. Minimal residual disease before and after transplantation for childhood acute lymphoblastic leukaemia: is there any room for intervention? Br J Haematol 2014; 164:396-408. [PMID: 24422724 DOI: 10.1111/bjh.12639] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Accepted: 09/18/2013] [Indexed: 11/26/2022]
Abstract
Eighty-two children and adolescents who underwent allogeneic transplantation for acute lymphoblastic leukaemia in remission (period 2001-2011, median follow-up 4·9 years) had been assessed for minimal residual disease (MRD) by real-time quantitative polymerase chain reaction before and at 1, 3, 6, 9 and 12 months after transplantation. Five-year event-free survival (EFS) and cumulative incidence of relapse were 77·7% [standard error (SE) 5·7] and 11·4% (SE 4·4), respectively, for patients with pre-transplant MRD <1 × 10(-4) (68%), versus 30·8% (SE 9·1; P < 0·001) and 61·5% (SE 9·5; P < 0·001), respectively, for those with MRD ≥1 × 10(-4) (32%). Pre-transplant MRD ≥1 × 10(-4) was associated with a 9·2-fold risk of relapse [95% confidence interval (CI) 3·54-23·88; P < 0·001] compared with patients with MRD <1 × 10(-4). Patients who received additional chemotherapy pre-transplant to reduce MRD had a fivefold reduction of risk of failure (hazard ratio 0·19, CI 0·05-0·70, P = 0·01). Patients who experienced MRD positivity post-transplant did not necessarily relapse (5-year EFS 40·3%, SE 9·3), but had a 2·5-fold risk of failure (CI 1·05-5·75; P = 0·04) if any MRD was detected in the first 100 d, which increased to 7·8-fold (CI 2·2-27·78; P = 0·002) if detected after 6 months. Anticipated immunosuppression-tapering according to MRD may have improved outcome, nevertheless all patients with post-transplant MRD ≥1 × 10(-3) ultimately relapsed, regardless of immunosuppression discontinuation or donor-lymphocyte-infusion. In conclusion, MRD before transplantation had the strongest impact on relapse and MRD positivity after transplantation, mostly if detected early and at low levels, did not necessarily imply relapse. Additional intensified chemotherapy and modulation of immunosuppression may reduce relapse risk and improve ultimate outcome.
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Affiliation(s)
- Adriana Balduzzi
- Clinica Pediatrica, Università degli Studi di Milano-Bicocca, Ospedale San Gerardo, Monza, Italy
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Long-term outcome and prognostic factors of unrelated cord blood transplantation in children with haematological malignancies: a retrospective study using the Spanish Working Party for BMT in Children (GETMON) database. Bone Marrow Transplant 2014; 49:767-72. [PMID: 24614843 DOI: 10.1038/bmt.2014.30] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Revised: 01/16/2014] [Accepted: 01/16/2014] [Indexed: 11/09/2022]
Abstract
Outcomes of unrelated cord blood transplants (UCBT) were assessed in 172 consecutive children, median age 5 years (range: 0.5-18), with haematological malignancies treated at nine Spanish hospitals between February 1996 and April 2009. Data were collected from the Spanish Working Party for Blood and Marrow Transplantation in Children (GETMON) database. ALL was diagnosed in 125 patients, AML in 43 and myelodysplastic syndrome in 4. Myeloid engraftment (ANC⩾0.5 × 10(9)/L) occurred in 87.2% at a median of 22 days and was associated with the total nucleated cell (TNC) dose infused and use of a TT-containing conditioning regimen. Cumulative incidence of relapse was 20% at 1 year post transplant and 29% at 3 years, being higher in patients with a diagnosis of ALL, very high risk disease and GVHD grades 0-1. Cumulative incidence of non-relapse mortality (NRM) was 19% at 100 days post transplant and 39% at 1 year. BU-FLU-TT-ATG-conditioned patients had lower NRM. Disease-free survival (DFS) was 40% at 2 years post transplant (for patients transplanted since 2006). On multivariate analysis, TNC dose infused, AML and BU-FLU-TT-ATG-conditioning regimen increased the probability of DFS. It is of paramount importance to select cord blood units with the highest cell dose. As the BU-FLU-TT-ATG-conditioning regimen was associated with better DFS owing to lower NRM, further prospective studies testing this regimen are warranted.
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Gyurkocza B, Gutman J, Nemecek ER, Bar M, Milano F, Ramakrishnan A, Scott B, Fang M, Wood B, Pagel JM, Baumgart J, Delaney C, Maziarz RT, Sandmaier BM, Estey EH, Appelbaum FR, Storer BE, Deeg HJ. Treosulfan, fludarabine, and 2-Gy total body irradiation followed by allogeneic hematopoietic cell transplantation in patients with myelodysplastic syndrome and acute myeloid leukemia. Biol Blood Marrow Transplant 2014; 20:549-55. [PMID: 24440648 DOI: 10.1016/j.bbmt.2014.01.009] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Accepted: 01/10/2014] [Indexed: 10/25/2022]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) offers curative therapy for many patients with myelodysplastic syndrome (MDS) or acute myeloid leukemia (AML). However, post-HCT relapse remains a major problem, particularly in patients with high-risk cytogenetics. In this prospective phase II trial, we assessed the efficacy and toxicity of treosulfan, fludarabine, and 2 Gy total body irradiation (TBI) as conditioning for allogeneic HCT in patients with MDS or AML. Ninety-six patients with MDS (n = 36: 15 refractory cytopenia with multilineage dysplasia, 10 refractory anemia with excess blasts type 1, 10 refractory anemia with excess blasts type 2, 1 chronic myelomonocytic leukemia type 1) or AML (n = 60: 35 first complete remission [CR], 18 second CR, 3 advanced CR, 4 refractory relapse) were enrolled; median age was 51 (range, 1 to 60) years. Twelve patients had undergone a prior HCT with high-intensity conditioning. Patients received 14 g/m(2)/day treosulfan i.v. on days -6 to -4, 30 mg/m(2)/day fludarabine i.v. on days -6 to -2, and 2 Gy TBI on day 0, followed by infusion of hematopoietic cells from related (n = 27) or unrelated (n = 69) donors. Graft-versus-host disease prophylaxis consisted of tacrolimus and methotrexate. With a median follow-up of 30 months, the 2-year overall survival (OS), relapse incidence, and nonrelapse mortality were 73%, 27%, and 8%, respectively. The incidences of grades II to IV (III to IV) acute and chronic graft-versus-host disease were 59% (10%) and 47%, respectively. Two-year OS was not significantly different between MDS patients with poor-risk and good/intermediate-risk cytogenetics (69% and 85%, respectively) or between AML patients with unfavorable and favorable/intermediate-risk cytogenetics (64% and 76%, respectively). In AML patients, minimal residual disease (MRD; n = 10) at the time of HCT predicted higher relapse incidence (70% versus 18%) and lower OS (41% versus 79%) at 2 years, when compared with patients without MRD. In conclusion, treosulfan, fludarabine, and low-dose TBI provided effective conditioning for allogeneic HCT in patients with MDS or AML and resulted in low relapse incidence, regardless of cytogenetic risk. In patients with AML, MRD at the time of HCT remained a risk factor for post-HCT relapse.
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Affiliation(s)
- Boglarka Gyurkocza
- Clinical Research Division, Fred Hutchinson Cancer Research Center and Department of Medicine, University of Washington School of Medicine, Seattle, Washington.
| | - Jonathan Gutman
- Department of Medicine, University of Colorado, Denver, Colorado
| | - Eneida R Nemecek
- Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Merav Bar
- Clinical Research Division, Fred Hutchinson Cancer Research Center and Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Filippo Milano
- Clinical Research Division, Fred Hutchinson Cancer Research Center and Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Aravind Ramakrishnan
- Clinical Research Division, Fred Hutchinson Cancer Research Center and Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Bart Scott
- Clinical Research Division, Fred Hutchinson Cancer Research Center and Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Min Fang
- Clinical Research Division, Fred Hutchinson Cancer Research Center and Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | | | - John M Pagel
- Clinical Research Division, Fred Hutchinson Cancer Research Center and Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Joachim Baumgart
- Department of Laboratory Medicine, University of Washing School of Medicine, Seattle, WA
| | - Colleen Delaney
- Clinical Research Division, Fred Hutchinson Cancer Research Center and Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Richard T Maziarz
- Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Brenda M Sandmaier
- Clinical Research Division, Fred Hutchinson Cancer Research Center and Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Elihu H Estey
- Clinical Research Division, Fred Hutchinson Cancer Research Center and Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Frederick R Appelbaum
- Clinical Research Division, Fred Hutchinson Cancer Research Center and Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Barry E Storer
- Clinical Research Division, Fred Hutchinson Cancer Research Center and Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Hans Joachim Deeg
- Clinical Research Division, Fred Hutchinson Cancer Research Center and Department of Medicine, University of Washington School of Medicine, Seattle, Washington
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Hematopoietic stem cell transplantation in children and young adults with secondary myelodysplastic syndrome and acute myelogenous leukemia after aplastic anemia. Biol Blood Marrow Transplant 2013; 20:425-9. [PMID: 24316460 DOI: 10.1016/j.bbmt.2013.11.031] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Accepted: 11/30/2013] [Indexed: 11/23/2022]
Abstract
Secondary myelodysplastic syndrome and acute myelogenous leukemia (sMDS/sAML) are the most serious secondary events occurring after immunosuppressive therapy in patients with aplastic anemia. Here we evaluate the outcome of hematopoietic stem cell transplantation (HSCT) in 17 children and young adults with sMDS/sAML after childhood aplastic anemia. The median interval between the diagnosis of aplastic anemia and the development of sMDS/sAML was 2.9 years (range, 1.2 to 13.0 years). At a median age of 13.1 years (range, 4.4 to 26.7 years), patients underwent HSCT with bone marrow (n = 6) or peripheral blood stem cell (n = 11) grafts from HLA-matched sibling donors (n = 2), mismatched family donors (n = 2), or unrelated donors (n = 13). Monosomy 7 was detected in 13 patients. The preparative regimen consisted of busulfan, cyclophosphamide, and melphalan in 11 patients and other agents in 6 patients. All patients achieved neutrophil engraftment. The cumulative incidence of grade II-IV acute graft-versus-host disease (GVHD) was 47%, and that of chronic GVHD was 70%. Relapse occurred in 1 patient. The major cause of death was transplant-related complication (n = 9). Overall survival and event-free survival at 5 years after HSCT were both 41%. In summary, this study indicates that HSCT is a curative therapy for some patients with sMDS/sAML after aplastic anemia. Future efforts should focus on reducing transplantation-related mortality.
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Lehmberg K, Albert MH, Beier R, Beutel K, Gruhn B, Kröger N, Meisel R, Schulz A, Stachel D, Woessmann W, Janka G, Müller I. Treosulfan-based conditioning regimen for children and adolescents with hemophagocytic lymphohistiocytosis. Haematologica 2013; 99:180-4. [PMID: 24162790 DOI: 10.3324/haematol.2013.094730] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
In hematopoietic stem cell transplantation for hemophagocytic lymphohistiocytosis, high transplant-related mortality after busulfan-based myeloablative regimens has been observed. Conditioning regimens with reduced toxicity based on melphalan or treosulfan are promising alternatives. We retrospectively analyzed hematopoietic stem cell transplantations in 19 hemophagocytic lymphohistiocytosis patients after conditioning with fludarabine, treosulfan, alemtuzumab, with or without thiotepa. Overall and disease-free survivals were 100% (follow up 7-31 months). Two patients required second transplant (1 after haploidentical transplantation). In 6 patients, overall donor chimerism dropped below 75% and prompted donor lymphocyte infusions. Administration of donor lymphocytes or second transplantation were significantly more frequent after transplantation from a human leukocyte antigen mismatched (9/10) versus matched (10/10) donor (P=0.018). The toxicity profile was favorable, with one veno-occlusive disease, one grade 3 graft-versus-host disease after donor lymphocyte infusion, and 2 severe viral infections (1 influenza, 1 Epstein Barr virus). In conclusion, the treosulfan-based regimen in hemophagocytic lymphohistiocytosis is effective with low toxicity and gives excellent overall and disease-free survival rates. In the future, the incidence of mixed chimerism, particularly after human leukocyte antigen mismatched donor transplants, needs to be addressed.
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Bauer F, Filipiak-Pittroff B, Wawer A, von Luettichau I, Burdach S. Escalating topotecan in combination with treosulfan has acceptable toxicity in advanced pediatric sarcomas. Pediatr Hematol Oncol 2013; 30:263-72. [PMID: 23509879 DOI: 10.3109/08880018.2013.777948] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Patients with advanced pediatric sarcomas have a poor prognosis and novel combination therapies are needed to improve the response rates. Hematological and organ related toxicities have been observed when administering topotecan in combination with, e.g., high dose thiotepa. This study evaluates the toxicity of escalating doses of topotecan alone or in combination with thiotepa or treosulfan. We compared the toxicity including death of complication (DOC) of topotecan alone or in combination with thiotepa or treosulfan in advanced pediatric sarcomas (n = 12). Ten of 12 patients (0.83) suffered from advanced tumors of the Ewing family (i.e., bone or marrow metastases or relapse <24 month after diagnosis, including one neuroepithelial tumor of the kidney) and two from alveolar rhabdomyosarcoma stage IV (0.17). Median age was 15 years (range 5-28). Ratio of female to male was 1:1. Two patients received topotecan alone (1.25 mg/m(2) q 5d and 1.5 mg/m(2) q 5d), three patients received four courses of topotecan (2 mg/m(2) q d 1-5) in combination with thiotepa (100 mg/m(2) q d 1-5), and seven patients received topotecan (2 mg/m(2) q d 1-5) in combination with treosulfan (10g/m(2) q d 3-5). Overall toxicity was not different between all three groups; mean scores were 1.6, 1.8, and 1.7 according to WHO grading (Scale 0-4). Organ related toxicity ranged between 0 and 4 and was not different as well. DOC was 0/2, 1/3, and 0/7 patients respectively. Escalating therapy with topotecan in combination with treosulfan has acceptable toxicity and warrants further investigation in advanced pediatric sarcomas.
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Affiliation(s)
- F Bauer
- Department of Pediatrics, Pediatric Oncology Center and Roman-Herzog-Comprehensive Cancer Center (RHCCC), Kinderklinik München Schwabing, Klinik und Poliklinik für Kinder- und Jugendmedizin, Klinikum Schwabing, StKM GmbH und Klinikum Rechts der Isar der Technischen Universität München, Munich, Germany.
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Determination of partition coefficients n-octanol/water for treosulfan and its epoxy-transformers: an example of a negative correlation between lipophilicity of unionized compounds and their retention in reversed-phase chromatography. J Chromatogr B Analyt Technol Biomed Life Sci 2013; 923-924:92-7. [PMID: 23500352 DOI: 10.1016/j.jchromb.2013.02.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Revised: 02/07/2013] [Accepted: 02/11/2013] [Indexed: 11/21/2022]
Abstract
For the last decade an alkylating agent treosulfan (TREO) has been successfully applied in clinical trials in conditioning prior to hematopoietic stem cell transplantation. Pharmacological activity of the pro-drug depends on its epoxy-transformers, monoepoxide (S,S-EBDM) and diepoxide (S,S-DEB), which are formed in a non-enzymatic consecutive reaction accompanied by a release of methanesulfonic acid. In the present study partition coefficient n-octanol/water (POW) of TREO as well as its biologically active epoxy-transformers was determined empirically (applying a classical shake-flask method) and in silico for the first time. In vitro the partition was investigated at 37°C in the system composed of the pre-saturated n-octanol and 0.05 M acetate buffer pH 4.4 adjusted with sodium and potassium chloride to ionic strength of 0.16 M. Concentration of the analytes was quantified by reversed-phase high performance liquid chromatography (RP-HPLC) method in which retention time increased from S,S-DEB to TREO. It was shown that neither association nor dissociation of the tested compounds in the applied phases occurred. Calculated logPOW (TREO: -1.58±0.04, S,S-EBDM: -1.18±0.02, S,S-DEB: -0.40±0.03) indicate the hydrophilic character of the all three entities, corresponding to its pharmacokinetic parameters described in the literature. Experimentally determined logPOW of the compounds were best comparable to the values predicted by algorithm ALOGPs. Interestingly, the POW values determined in vitro as well as in silico were inversely correlated with the retention times observed in the endcapped RP-HPLC column. It might be explained by the fact that a cleavage of methansulfonic acid from a small molecule of TREO generates significant changes in the molecular structure. Consequently, despite the common chemical origin, TREO, S,S-EBDM and S,S-DEB do not constitute a 'congeneric' series of compounds. We concluded that this might occur in other low-weight species, therefore measurement of their POW by RP-HPLC had to be applied with a special care.
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Direct high-performance liquid chromatography method with refractometric detection designed for stability studies of treosulfan and its biologically active epoxy-transformers. J Pharm Biomed Anal 2013; 72:145-9. [DOI: 10.1016/j.jpba.2012.10.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Revised: 10/05/2012] [Accepted: 10/07/2012] [Indexed: 11/18/2022]
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Galaup A, Paci A. Pharmacology of dimethanesulfonate alkylating agents: busulfan and treosulfan. Expert Opin Drug Metab Toxicol 2012; 9:333-47. [PMID: 23157726 DOI: 10.1517/17425255.2013.737319] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Among the dimethanesulfonates, busulfan, in combination with other alkylating agents or nucleoside analogues, is the cornerstone of high-dose chemotherapy. It is used, and followed hematopoietic stem cell transplantation, for the treatment of various hematologic malignancies and immunodeficiencies. Treosulfan, which is a hydrophilic analogue of busulfan, was the first dimethanesufonate registered for the treatment of ovarian cancer. Recently, treosulfan has been investigated for the treatment of hematologic malignancies in combination with the same second agents before hematopoietic stem cell transplantation. AREAS COVERED This work reviews the pharmacological data of these two dimethanesulfonates alkylating agents. Specifically, the article looks at their chemistry, metabolism, anticancer activity, and their pharmacokinetics and pharmacodynamics. EXPERT OPINION Busulfan has been investigated widely for more than three decades leading to a large and precise handling of this agent with numerous studies on activity and pharmacokinetics and pharmacodynamics. In contrast, the behavior of treosulfan is still under investigation and not fully described. The complexity of treosulfan's metabolism and mechanism of action gives rise to the need of a deeper understanding of its pharmacological activity in a context of high-dose chemotherapy. Specifically, there is a great need to better understand its pharmacokinetics/pharmacodynamics relationship.
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Affiliation(s)
- Ariane Galaup
- Collège de France, Center for Interdisciplinary Research in Biology, CNRS UMR 7241, INSERM U 1050, MEMOLIFE Laboratory of Excellence & Paris Science et Lettres Research University, Paris, France
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Long-term follow-up of children conditioned with Treosulfan: German and Austrian experience. Bone Marrow Transplant 2012; 48:491-501. [PMID: 23085832 DOI: 10.1038/bmt.2012.188] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
We report the long-term follow-up of children transplanted with Treosulfan (TREO)-based conditioning in Germany and Austria. Nine centres reported a total of 109 transplantations. Patients were stratified according to the paediatric TRM risk score derived from the paediatric BMT registry (PRST) and compared with the historical transplant population of this registry. Underlying diseases were malignancies, immunodeficiencies, and haematologic and metabolic disorders. TREO total dose ranged from 21-42 g/m(2). Additional conditioning drugs included fludarabine, thiotepa, melphalan, CY and/or TBI. EFS at 3 years for non-malignant and malignant diseases was 88% and 49%, respectively. Leukaemia patients in remission had a survival of 51% at 3 years; nonremission patients relapsed and died within 18 months. TRM and OS in the low-risk groups 0 and 1 were similar to PRST controls. TRM in the high-risk groups 2 and 3 was markedly lower (9% vs 28% and 13% vs 53%, respectively) than in the PRST group, but OS was similar. In conclusion, TREO-based conditioning regimens in children resulted in excellent engraftment and long-term survival in nonmalignant disease. In high-risk malignancy, low acute toxicity was followed by low TRM but it did not translate into increased survival.
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Corker E, Astwood E, Williams J, Vora A. Treosulphan-based radiation-free myeloablative conditioning for allogeneic transplant in infant acute lymphoblastic leukaemia. Br J Haematol 2012; 159:104-6. [DOI: 10.1111/j.1365-2141.2012.09228.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Emma Corker
- Department of Paediatric Haematology; Sheffield Children's Hospital; Sheffield; UK
| | - Emma Astwood
- Department of Paediatric Haematology; Sheffield Children's Hospital; Sheffield; UK
| | - Janet Williams
- Department of Paediatric Haematology; Sheffield Children's Hospital; Sheffield; UK
| | - Ajay Vora
- Department of Paediatric Haematology; Sheffield Children's Hospital; Sheffield; UK
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Allogeneic hematopoietic stem cell transplantation in thalassemia major: results of a reduced-toxicity conditioning regimen based on the use of treosulfan. Blood 2012; 120:473-6. [DOI: 10.1182/blood-2012-04-423822] [Citation(s) in RCA: 148] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Abstract
Sixty thalassemia patients (median age, 7 years; range, 1-37) underwent allogeneic hematopoietic stem cell transplantation (HSCT) after a preparation combining thiotepa, treosulfan, and fludarabine. Before HSCT, 27 children were assigned to risk class 1 of the Pesaro classification, 17 to class 2, and 4 to class 3; 12 patients were adults. Twenty patients were transplanted from an HLA-identical sibling and 40 from an unrelated donor. The cumulative incidence of graft failure and transplantation-related mortality was 9% and 7%, respectively. Eight patients experienced grade II-IV acute GVHD, the cumulative incidence being 14%. Among 56 patients at risk, 1 developed limited chronic GVHD. With a median follow-up of 36 months (range, 4-72), the 5-year probability of survival and thalassemia-free survival are 93% and 84%, respectively. Neither the class of risk nor the donor used influenced outcome. This treosulfan-based preparation proved to be safe and effective for thalassemia patients given allogeneic HSCT.
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Casper J, Holowiecki J, Trenschel R, Wandt H, Schaefer-Eckart K, Ruutu T, Volin L, Einsele H, Stuhler G, Uharek L, Blau I, Bornhaeuser M, Zander AR, Larsson K, Markiewicz M, Giebel S, Kruzel T, Mylius HA, Baumgart J, Pichlmeier U, Freund M, Beelen DW. Allogeneic hematopoietic SCT in patients with AML following treosulfan/fludarabine conditioning. Bone Marrow Transplant 2011; 47:1171-7. [PMID: 22158386 DOI: 10.1038/bmt.2011.242] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
An alternative reduced-toxicity conditioning regimen for allogeneic transplantation, based on treosulfan and fludarabine, has recently been identified. The safety and efficacy of this new conditioning regimen has been investigated prospectively in patients with AML. A total number of 75 patients with AML in CR were treated with 3 × 14 g/m(2) treosulfan and 5 × 30 mg/m(2) fludarabine, followed by matched sibling or unrelated SCT. Patients were evaluated for engraftment, adverse events, GVHD, and for non-relapse mortality, relapse incidence, overall and disease-free survival (DFS). All patients showed primary engraftment of neutrophils after a median of 20 days. Non-hematological adverse events grade III-IV in severity included mainly infections (59%) and gastrointestinal symptoms (7%). Acute GVHD grade II-IV occurred in 21% and extensive chronic GVHD occurred in 16% of the patients. After a median follow-up of 715 days, the 2-year overall and DFS estimates were 61% and 55%, respectively. The 2-year incidences of relapse and non-relapse mortality reached 34% and 11%, respectively. In summary, our data confirm promising safety and efficacy of the treosulfan-based conditioning therapy in AML patients, ClinicalTrials.gov Identifier: NCT01063660.
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Affiliation(s)
- J Casper
- Division of Hematology and Oncology, University of Rostock, Rostock, Germany.
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Ruutu T, Volin L, Beelen DW, Trenschel R, Finke J, Schnitzler M, Holowiecki J, Giebel S, Markiewicz M, Uharek L, Blau IW, Kienast J, Stelljes M, Larsson K, Zander AR, Gramatzki M, Repp R, Einsele H, Stuhler G, Baumgart J, Mylius HA, Pichlmeier U, Freund M, Casper J. Reduced-toxicity conditioning with treosulfan and fludarabine in allogeneic hematopoietic stem cell transplantation for myelodysplastic syndromes: final results of an international prospective phase II trial. Haematologica 2011; 96:1344-50. [PMID: 21659356 DOI: 10.3324/haematol.2011.043810] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND An alternative reduced-toxicity conditioning regimen for allogeneic transplantation, based on treosulfan and fludarabine, has recently been identified. The rationale for this study was to investigate the efficacy and safety of this regimen prospectively in patients with a primary myelodysplastic syndrome. DESIGN AND METHODS A total of 45 patients with primary myelodysplastic syndromes were conditioned with 3×14 g/m(2) treosulfan and 5×30 mg/m(2) fludarabine followed by allogeneic hematopoietic stem cell transplantation. Subtypes of myelodysplastic syndromes were refractory anemia with excess blasts-2 (44%), refractory cytopenia with multilineage dysplasia (27%), refractory anemia (9%), refractory anemia with ringed sideroblasts (4%), refractory cytopenia with multilineage dysplasia and ringed sideroblasts (4%), refractory anemia with excess blasts-1 (2%), and myelodysplastic syndrome with isolated del (5q) (2%). The myelodysplastic syndrome was unclassified in 7% of the patients. Forty-seven percent of the patients had a favorable karyotype, 29% an unfavorable one, and 18% an intermediate karyotype. Patients were evaluated for engraftment, adverse events, graft-versus-host disease, non-relapse mortality, relapse incidence, overall survival and disease-free survival. RESULTS All but one patient showed primary engraftment of neutrophils after a median of 17 days. Non-hematologic adverse events of grade III-IV in severity included mainly infections and gastrointestinal symptoms (80% and 22% of the patients, respectively). Acute graft-versus-host disease grade II-IV developed in 24%, and extensive chronic graft-versus-host disease in 28% of the patients. After a median follow-up of 780 days, the 2-year overall and disease-free survival estimates were 71% and 67%, respectively. The 2-year cumulative incidences of non-relapse mortality and relapse were 17% and 16%, respectively. CONCLUSIONS Our safety and efficacy data suggest that treosulfan-based conditioning therapy is a promising treatment option for patients with myelodysplastic syndromes. clinicaltrials.gov identifier: NCT01062490.
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Affiliation(s)
- Tapani Ruutu
- Department of Medicine, Helsinki University Central Hospital, Helsinki, Finland.
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