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National Institutes of Health Consensus Development Project on Criteria for Clinical Trials in Chronic Graft-versus-Host Disease: IV. The 2020 Highly morbid forms report. Transplant Cell Ther 2021; 27:817-835. [PMID: 34217703 DOI: 10.1016/j.jtct.2021.06.001] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 06/01/2021] [Indexed: 12/12/2022]
Abstract
Chronic graft-versus-host disease (GVHD) can be associated with significant morbidity, in part because of nonreversible fibrosis, which impacts physical functioning (eye, skin, lung manifestations) and mortality (lung, gastrointestinal manifestations). Progress in preventing severe morbidity and mortality associated with chronic GVHD is limited by a complex and incompletely understood disease biology and a lack of prognostic biomarkers. Likewise, treatment advances for highly morbid manifestations remain hindered by the absence of effective organ-specific approaches targeting "irreversible" fibrotic sequelae and difficulties in conducting clinical trials in a heterogeneous disease with small patient numbers. The purpose of this document is to identify current gaps, to outline a roadmap of research goals for highly morbid forms of chronic GVHD including advanced skin sclerosis, fasciitis, lung, ocular and gastrointestinal involvement, and to propose strategies for effective trial design. The working group made the following recommendations: (1) Phenotype chronic GVHD clinically and biologically in future cohorts, to describe the incidence, prognostic factors, mechanisms of organ damage, and clinical evolution of highly morbid conditions including long-term effects in children; (2) Conduct longitudinal multicenter studies with common definitions and research sample collections; (3) Develop new approaches for early identification and treatment of highly morbid forms of chronic GVHD, especially biologically targeted treatments, with a special focus on fibrotic changes; and (4) Establish primary endpoints for clinical trials addressing each highly morbid manifestation in relationship to the time point of intervention (early versus late). Alternative endpoints, such as lack of progression and improvement in physical functioning or quality of life, may be suitable for clinical trials in patients with highly morbid manifestations. Finally, new approaches for objective response assessment and exploration of novel trial designs for small populations are required.
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Pidala J, Kitko C, Lee SJ, Carpenter P, Cuvelier GDE, Holtan S, Flowers ME, Cutler C, Jagasia M, Gooley T, Palmer J, Randolph T, Levine JE, Ayuk F, Dignan F, Schoemans H, Tkaczyk E, Farhadfar N, Lawitschka A, Schultz KR, Martin PJ, Sarantopoulos S, Inamoto Y, Socie G, Wolff D, Blazar B, Greinix H, Paczesny S, Pavletic S, Hill G. National Institutes of Health Consensus Development Project on Criteria for Clinical Trials in Chronic Graft-versus-Host Disease: IIb. The 2020 Preemptive Therapy Working Group Report. Transplant Cell Ther 2021; 27:632-641. [PMID: 33836313 DOI: 10.1016/j.jtct.2021.03.029] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 03/30/2021] [Indexed: 11/27/2022]
Abstract
Chronic graft-versus-host disease (GVHD) commonly occurs after allogeneic hematopoietic cell transplantation (HCT) despite standard prophylactic immune suppression. Intensified universal prophylaxis approaches are effective but risk possible overtreatment and may interfere with the graft-versus-malignancy immune response. Here we summarize conceptual and practical considerations regarding preemptive therapy of chronic GVHD, namely interventions applied after HCT based on evidence that the risk of developing chronic GVHD is higher than previously appreciated. This risk may be anticipated by clinical factors or risk assignment biomarkers or may be indicated by early signs and symptoms of chronic GVHD that do not fully meet National Institutes of Health diagnostic criteria. However, truly preemptive, individualized, and targeted chronic GVHD therapies currently do not exist. In this report, we (1) review current knowledge regarding clinical risk factors for chronic GVHD, (2) review what is known about chronic GVHD risk assignment biomarkers, (3) examine how chronic GVHD pathogenesis intersects with available targeted therapeutic agents, and (4) summarize considerations for preemptive therapy for chronic GVHD, emphasizing trial development, including trial design and statistical considerations. We conclude that robust risk assignment models that accurately predict chronic GVHD after HCT and early-phase preemptive therapy trials represent the most urgent priorities for advancing this novel area of research.
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Affiliation(s)
- Joseph Pidala
- Blood and Marrow Transplantation and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida.
| | - Carrie Kitko
- Division of Pediatric Hematology/Oncology, Dpeartment of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Stephanie J Lee
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Paul Carpenter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | - Shernan Holtan
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Mary E Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Corey Cutler
- Division of Stem Cell Transplantation and Cellular Therapy, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Madan Jagasia
- Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ted Gooley
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Joycelynne Palmer
- Division of Biostatistics, Department of Computational and Quantitative Medicine, City of Hope, Duarte, California
| | - Tim Randolph
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - John E Levine
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fiona Dignan
- Department of Clinical Haematology, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Helene Schoemans
- Department of Hematology, University Hospitals Leuven and Department of Public Health, KU Leuven, Leuven, Belgium
| | - Eric Tkaczyk
- Department of Veterans Affairs and Departments of Dermatology and Biomedical Engineering, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Nosha Farhadfar
- Division of Hematology and Oncology, Department of Medicine, University of Florida, Gainesville, Florida
| | - Anita Lawitschka
- Stem Cell Transplantation Unit, St Anna Children's Hospital, Medical University of Vienna, Vienna, Austria; Children's Cancer Research Institute, Vienna, Austria
| | - Kirk R Schultz
- Pediatric Hematology/Oncology/BMT, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Paul J Martin
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Stefanie Sarantopoulos
- Division of Hematological Malignancies and Cellular Therapy, Duke Cancer Institute, Duke University Department of Medicine, Durham, North Carolina
| | - Yoshihiro Inamoto
- Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Gerard Socie
- Hematology and Bone Marrow Transplant Department, AP-HP Saint Louis Hospital and University of Paris, Paris, France
| | - Daniel Wolff
- Department of Internal Medicine III, University Hospital of Regensburg, Regensburg, Germany
| | - Bruce Blazar
- Department of Pediatrics, Division of Blood & Marrow Transplantation & Cellular Therapy, University of Minnesota, Minneapolis, Minnesota
| | - Hildegard Greinix
- Clinical Division of Hematology, Medical University of Graz, Graz, Austria
| | - Sophie Paczesny
- Department of Microbiology and Immunology and Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Steven Pavletic
- Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Geoffrey Hill
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
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Rosenthal EA, Ho PS, Joe GO, Mitchell SA, Booher S, Pavletic SZ, Baird K, Cowen EW, Comis LE. Motor ability, function, and health-related quality of life as correlates of symptom burden in patients with sclerotic chronic graft-versus-host disease receiving imatinib mesylate. Support Care Cancer 2019; 28:3679-3689. [PMID: 31811481 DOI: 10.1007/s00520-019-05207-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 11/24/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE To explore improvement in motor ability, function, health-related quality of life (HRQOL), and symptom severity in patients with sclerotic chronic graft-versus-host disease (ScGVHD) in response to treatment as well as the relationship among changes on such measures. METHODS This study was a secondary analysis of data from 13 individuals with severe ScGVHD enrolled in a clinical trial evaluating the efficacy of imatinib mesylate (clinicaltrials.gov identifier: NCT00702689). Self-reported, clinician-reported, and performance-based indicators of motor ability, function, HRQOL, and symptom severity were assessed at baseline and 6 months following the administration of imatinib mesylate. RESULTS Participants did not show statistically significant improvement on any measures over time. Approximately one-third of patients displayed clinically significant improvement on measures of motor ability (palmar pinch strength, dominant hand, 30.8%), functioning (Manual Ability Measure-36, 41.7%), HRQOL (Short Form 36 [SF-36] Mental Component Summary, 33.3%), and symptom severity (Lee Symptom Scale, 38.5%). Improvement in cGVHD symptom burden was correlated with improvement in function (Assessment of Motor and Process Skills [AMPS] and Disabilities of the Arm, Shoulder, and Hand [DASH] scores) and HRQOL (SF-36 Physical Component Summary scores). CONCLUSIONS Findings suggest the potential utility of administering patient-reported and performance-based functional measures, such as the DASH and the AMPS, to patients with cGVHD. By understanding the functional consequences of ScGVHD, interdisciplinary teams of health care providers, including rehabilitation professionals, can work to improve long-term outcomes.
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Affiliation(s)
- Emily A Rosenthal
- Rehabilitation Medicine Department, Clinical Center, National Institutes of Health, MSC 1604, 10 Center Drive, Bethesda, MD, 20892, USA
| | - Pei-Shu Ho
- Rehabilitation Medicine Department, Clinical Center, National Institutes of Health, MSC 1604, 10 Center Drive, Bethesda, MD, 20892, USA
| | - Galen O Joe
- Rehabilitation Medicine Department, Clinical Center, National Institutes of Health, MSC 1604, 10 Center Drive, Bethesda, MD, 20892, USA
| | - Sandra A Mitchell
- Outcomes Research Branch, Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Susan Booher
- Autoimmunity and Mucosal Immunology Branch, Division of Allergy, Immunology and Transplantation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA
| | - Steven Z Pavletic
- Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Kristin Baird
- Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA.,Office of Tissues and Advanced Therapies, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | - Edward W Cowen
- Dermatology Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Leora E Comis
- Rehabilitation Medicine Department, Clinical Center, National Institutes of Health, MSC 1604, 10 Center Drive, Bethesda, MD, 20892, USA.
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The concurrent administration of imatinib with extracorporeal photopheresis leads to complete and durable responses in patients with refractory sclerotic type chronic graft-versus-host disease. Curr Res Transl Med 2019; 68:71-76. [PMID: 31631014 DOI: 10.1016/j.retram.2019.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 09/23/2019] [Accepted: 10/06/2019] [Indexed: 12/11/2022]
Abstract
Therapeutic options are limited for patients developing refractory sclerotic-type chronic graft-versus-host disease (cGVHD) after allogeneic hematopoietic cell transplantation. We previously showed that imatinib mesylate (IM) could be efficacious in this situation, although complete responses were uncommon (Magro L Blood 2009). We hypothesized that the combination of extracorporeal photopheresis (ECP) and IM could have synergistic effects to treat SR steroid-refractory cGVHD. While IM and ECP are separately used for the treatment of refractory cGVHD, the combination of both has never been investigated. We describe here the efficacy of the concurrent administration of IM with ECP in seven patients with refractory sclerotic-type cGVHD who had showed insufficient response to either IM or ECP. Seven consecutive patients (3 males and 4 females) with a median age of 46 years old, who received imatinib with concurrent ECP for refractory sclerotic-type cGVHD, were included. Patients were considered refractory if they were steroid-refractory or steroid-dependent. Four patients had previously showed insufficient partial response (PR) to IM, while three patients showed insufficient PR while receiving ECP. IM was started at 200 mg/day and increased to 400 mg/day if well-tolerated. ECP was initiated twice weekly then less frequently according to the patient's individual treatment response. With a median follow-up of 56 months, the concurrent administration of IM with ECP deepened responses in all patients and induced durable complete responses (CR) in 4 (57%). Median time to best response was 4 months. Median duration of combination treatment was 42 months (range: 4-60). As of February 2018, 5 patients were still alive. Two patients died of myocardial infarction and one from relapse of a preexisting prostate cancer. The concurrent administration of IM with ECP led to complete and sustained responses in patients with refractory sclerotic-type cGVHD.
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Csanadi M, Agh T, Tordai A, Webb T, Jeyakumaran D, Sengupta N, Schain F, Mattsson J. A systematic literature review of incidence, mortality, and relapse of patients diagnosed with chronic graft versus host disease. Expert Rev Hematol 2019; 12:311-323. [DOI: 10.1080/17474086.2019.1605288] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
| | - Tamas Agh
- Syreon Research Institute, Budapest, Hungary
| | - Attila Tordai
- Department of Pathophysiology, Semmelweis University, Budapest, Hungary
| | - Thomas Webb
- Janssen Research & Development, High Wycombe, UK
| | | | | | | | - Jonas Mattsson
- Division of Medical Oncology and Hematology, Department of Medicine, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden
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Fatobene G, Storer BE, Salit RB, Lee SJ, Martin PJ, Cheng GS, Carpenter PA, Balgansuren G, Petersdorf EW, Delaney C, Sandmaier BM, Milano F, Flowers ME. Disability related to chronic graft - versus-host disease after alternative donor hematopoietic cell transplantation. Haematologica 2018; 104:835-843. [PMID: 30442722 PMCID: PMC6442956 DOI: 10.3324/haematol.2018.202754] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 11/08/2018] [Indexed: 12/21/2022] Open
Abstract
We determined the incidence of disability related to chronic graft-versus-host disease (bronchiolitis obliterans, grade ≥2 keratoconjunctivitis sicca, sclerotic features or esophageal stricture) for three categories of alternative donor: cord blood, haplorelated marrow or peripheral blood with post-transplant cyclophosphamide, and unrelated single HLA-allele mismatched peripheral blood. Among 396 consecutive hematopoietic cell transplant recipients, 129 developed chronic graft-versus-host disease with 3-year cumulative incidences of 8% for cord blood, 24% for haplorelated grafts, and 55% for unrelated single HLA-allele mismatched peripheral blood. Disability rates were significantly lower for cord blood [hazard ratio (HR) 0.13; 95% confidence interval (CI): 0.1-0.4] and for the haplorelated group (HR 0.31; 95% CI: 0.1-0.7) compared to the rate in the group transplanted with unrelated single HLA-allele mismatched peripheral blood. Cord blood recipients were also >2-fold more likely to return to work/school within 3 years from the onset of chronic graft-versus-host disease (HR 2.54; 95% CI: 1.1-5.7, P=0.02), and the haplorelated group trended similarly (HR 2.38; 95% CI: 1.0-5.9, P=0.06). Cord blood recipients were more likely to discontinue immunosuppression than were recipients of unrelated single HLA-allele mismatched peripheral blood (HR 3.96; 95% CI: 1.9-8.4, P=0.0003), similarly to the haplorelated group (HR 4.93; 95% CI: 2.2-11.1, P=0.0001). Progression-free survival and non-relapse mortality did not differ between groups grafted from different types of donors. Our observations that, compared to recipients of unrelated single HLA-allele mismatched peripheral blood, recipients of cord blood and haplorelated grafts less often developed disability related to chronic graft-versus-host disease, and were more likely to resume work/school, should help better counseling of pre-hematopoietic cell transplant candidates.
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Affiliation(s)
- Giancarlo Fatobene
- Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA, USA.,Universidade de Sao Paulo, Hospital das Clinicas, SP, Brazil
| | - Barry E Storer
- Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA, USA
| | - Rachel B Salit
- Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA, USA.,University of Washington, Division of Medical Oncology, Seattle, WA, USA
| | - Stephanie J Lee
- Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA, USA.,University of Washington, Division of Medical Oncology, Seattle, WA, USA
| | - Paul J Martin
- Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA, USA.,University of Washington, Division of Medical Oncology, Seattle, WA, USA
| | - Guang-Shing Cheng
- Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA, USA.,University of Washington, Division of Medical Oncology, Seattle, WA, USA
| | - Paul A Carpenter
- Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA, USA.,University of Washington, Division of Medical Oncology, Seattle, WA, USA
| | - Gansuvd Balgansuren
- University of Washington, Division of Medical Oncology, Seattle, WA, USA.,Seattle Cancer Care Alliance, Seattle, WA, USA
| | - Effie W Petersdorf
- Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA, USA.,University of Washington, Division of Medical Oncology, Seattle, WA, USA
| | - Colleen Delaney
- Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA, USA.,University of Washington, Division of Medical Oncology, Seattle, WA, USA
| | - Brenda M Sandmaier
- Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA, USA.,University of Washington, Division of Medical Oncology, Seattle, WA, USA
| | - Filippo Milano
- Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA, USA.,University of Washington, Division of Medical Oncology, Seattle, WA, USA
| | - Mary E Flowers
- Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA, USA .,University of Washington, Division of Medical Oncology, Seattle, WA, USA
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