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Mohty R, Al Kadhimi Z, Kharfan-Dabaja M. Post-transplant cyclophosphamide or cell selection in haploidentical allogeneic hematopoietic cell transplantation? Hematology 2024; 29:2326384. [PMID: 38597828 DOI: 10.1080/16078454.2024.2326384] [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: 12/19/2023] [Accepted: 02/28/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND One major limitation for broader applicability of allogeneic hematopoietic cell transplantation (allo-HCT) in the past was the lack of HLA-matched histocompatible donors. Preclinical mouse studies using T-cell depleted haploidentical grafts led to an increased interest in the use of ex vivo T-cell depleted (TCD) haploidentical allo-HCT. TCD grafts through negative (T-cell depletion) or positive (CD34+ cell selection) techniques have been investigated to reduce the risk of graft-versus-host disease (GVHD) given the known implications of alloreactive T cells. A more practical approach to deplete alloreactive T cells in vivo using high doses of cyclophosphamide after allografting has proved to be feasible in overcoming the HLA barrier. Such approach has extended allo-HCT feasibility to patients for whom donors could not be found in the past. Nowadays, haploidentical donors represent a common donor source for patients in need of an allo-HCT. The broad application of haploidentical donors became possible by understanding the importance of depleting alloreactive donor T cells to facilitate engraftment and reduce incidence and severity of GVHD. These techniques involve ex vivo graft manipulation or in vivo utilization of pharmacologic agents, notably post-transplant cyclophosphamide (PTCy). DISCUSSION While acknowledging that no randomized controlled prospective studies have been yet conducted comparing TCD versus PTCy in haploidentical allo-HCT recipients, there are two advantages that would favor the PTCy, namely ease of application and lower cost. However, emerging data on adverse events associated with PTCy including, but not limited to cardiac associated toxicities or increased incidence of post-allograft infections, and others, are important to recognize.
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Affiliation(s)
- Razan Mohty
- Division of Hematology Oncology, Department of Medicine, O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA
| | - Zaid Al Kadhimi
- Division of Hematology Oncology, Department of Medicine, O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA
| | - Mohamed Kharfan-Dabaja
- Division of Hematology-Oncology, Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL, USA
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2
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Melica G, Preston E, Palazzo M, Seier K, Malard F, Cho C, Devlin SM, Maloy M, Borrill T, Maslak P, Shah GL, Perales MA. Immune reconstitution, vaccine responses, and rituximab use after ex-vivo CD34-selected myeloablative allogenic hematopoietic cell transplantation. Bone Marrow Transplant 2024; 59:625-629. [PMID: 38351281 DOI: 10.1038/s41409-024-02232-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 01/16/2024] [Accepted: 01/26/2024] [Indexed: 05/08/2024]
Abstract
Myeloablative T cell depleted (CD34-selected) hematopoietic cell transplantation (HCT) is associated with less acute and chronic graft versus host disease (GVHD). We aimed to examine vaccine responses in relation to immune reconstitution and post HCT rituximab administration in this population. This single center retrospective study included 251 patients with hematological malignancies who received a first CD34-selected HCT between 2012 and 2015. Of 251 patients, 190 were alive 1 year after HCT. Among the entire population, 77 (30.7%) patients were vaccinated. After vaccine administration, 35/44 (80%), 30/75 (40%), 27/36 (75%), 33/65 (51%), 34/51 (51%), 22/28 (79%) and 20/34 (59%) of evaluable patients had protective antibody titers for haemophilus influenzae type B (Hib), Pneumococcus, Tetanus, Diphtheria, Pertussis, hepatitis A (HAV), and hepatitis B (HBV) respectively. Responders to the pneumococcal vaccine had a higher CD45RA T cell count than non responders, with 12/18 patients (66.7%) vs 11/32 (34.4%) p = 0.04. For pneumococcal vaccine, there was also a trend to higher total lymphocyte B cell count in responders vs non responders p = 0.06. Rituximab post HCT was given to 59/251 (23.5%) patients. No difference was found in immune reconstitution patterns for rituximab use between vaccine responders and not. Recipients of CD34-selected HCT may respond to vaccination, and T and B cell subsets could be useful to predict vaccine response.
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Affiliation(s)
- Giovanna Melica
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Infectious Diseases and Clinical Immunology, Henri Mondor Hospital, APHP, Paris, France
| | - Elaina Preston
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Meighan Palazzo
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kenneth Seier
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Florent Malard
- Department of Hematology, Saint Antoine Hospital, Paris, France ; INSERM UMRs 938, Paris, France, Université Pierre et Marie Curie, Paris, France
| | - Christina Cho
- Department of Hematology, Hackensack University Medical Center, John Theurer Cancer Center, Hackensack, NJ, USA
| | - Sean M Devlin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Molly Maloy
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Taylor Borrill
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Peter Maslak
- Department of Medicine and Pathology, Roswell Park Cancer Center, Buffalo, NY, USA
| | - Gunjan L Shah
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA.
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3
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Malard F, Holler E, Sandmaier BM, Huang H, Mohty M. Acute graft-versus-host disease. Nat Rev Dis Primers 2023; 9:27. [PMID: 37291149 DOI: 10.1038/s41572-023-00438-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/02/2023] [Indexed: 06/10/2023]
Abstract
Acute graft-versus-host disease (GVHD) is a common immune complication that can occur after allogeneic haematopoietic cell transplantation (alloHCT). Acute GVHD is a major health problem in these patients, and is associated with high morbidity and mortality. Acute GVHD is caused by the recognition and the destruction of the recipient tissues and organs by the donor immune effector cells. This condition usually occurs within the first 3 months after alloHCT, but later onset is possible. Targeted organs include the skin, the lower and upper gastrointestinal tract and the liver. Diagnosis is mainly based on clinical examination, and complementary examinations are performed to exclude differential diagnoses. Preventive treatment for acute GVHD is administered to all patients who receive alloHCT, although it is not always effective. Steroids are used for first-line treatment, and the Janus kinase 2 (JAK2) inhibitor ruxolitinib is second-line treatment. No validated treatments are available for acute GVHD that is refractory to steroids and ruxolitinib, and therefore it remains an unmet medical need.
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Affiliation(s)
- Florent Malard
- Sorbonne Université, Centre de Recherche Saint-Antoine INSERM UMRs938, Service d'Hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint Antoine, AP-HP, Paris, France.
| | - Ernst Holler
- University Hospital of Regensburg, Department of Internal Medicine 3, Regensburg, Germany
| | - Brenda M Sandmaier
- Fred Hutchinson Cancer Center, Translational Science and Therapeutics Division, Seattle, WA, USA
- University of Washington School of Medicine, Division of Medical Oncology, Seattle, WA, USA
| | - He Huang
- Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Zhejiang Province, Hangzhou, China
- Engineering Laboratory for Stem Cell and Immunity Therapy, Institute of Hematology, Zhejiang University, Hangzhou, China
- Zhejiang Laboratory for Systems & Precision Medicine, Zhejiang University Medical Center, Hangzhou, China
| | - Mohamad Mohty
- Sorbonne Université, Centre de Recherche Saint-Antoine INSERM UMRs938, Service d'Hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint Antoine, AP-HP, Paris, France.
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4
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Nawas MT, Sanchez-Escamilla M, Devlin SM, Maloy MA, Ruiz JD, Sauter CS, Giralt SA, Perales MA, Scordo M. Dynamic EASIX scores closely predict nonrelapse mortality after allogeneic hematopoietic cell transplantation. Blood Adv 2022; 6:5898-5907. [PMID: 35977079 PMCID: PMC9661383 DOI: 10.1182/bloodadvances.2022007381] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 07/25/2022] [Indexed: 11/20/2022] Open
Abstract
Endothelial activation and stress index (EASIX) predicts nonrelapse mortality (NRM) when assessed before hematopoietic cell transplantation (HCT). We sought to determine whether changes in EASIX after HCT may be an informative marker of NRM. We evaluated 509 adults who underwent reduced intensity, unmodified (N = 149, 29%), or myeloablative ex vivo CD34+-selected allogeneic HCT (allo-HCT) (N = 306, 71%) between 2008 and 2016. Patients who underwent unmodified allo-HCT received tacrolimus-based graft-versus-host disease (GVHD) prophylaxis, whereas CD34+-selected patients received no planned immunosuppression. EASIX (lactate dehydrogenase × creatinine/platelet count) was calculated continuously until 1-year after HCT. Log transformation using base 2 (log2) was applied to all EASIX variables to reduce skew. In total, 360 patients (71%) received CD34+-selected and 149 (29%) unmodified allo-HCT. Among all patients, EASIX scores increased rapidly, peaked at day +8, then declined rapidly until day +33. Thereafter, scores declined gradually but remained above the pre-HCT baseline. In unmodified HCT, scores appeared higher over time than in CD34+-selected patients. EASIX discrimination of NRM was highest around day +180 (concordance index = 0.85) in both platforms, but the prognostic impact of EASIX across time points differed between the 2 platforms. Mean EASIX scores were higher in men (mean log2 +0.52) and in patients who developed grade 2 to 4 GVHD (+0.81) and lower in patients who received matched vs mismatched donors (-0.81, all P < .01). EASIX scores are dynamic and variably concordant with NRM when analyzed longitudinally, and patterns differ between HCT platforms. Compared to pre-HCT evaluation, post-HCT EASIX scores may better predict risk of NRM as patients acquire additional endothelial injury and toxicities.
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Affiliation(s)
- Mariam T. Nawas
- Hematopoietic Cellular Therapy Program, Department of Medicine, University of Chicago Medicine, Chicago, IL
| | - Miriam Sanchez-Escamilla
- Department of Hematological Malignancies and Stem Cell Transplantation, Research Institute of Marques de Valdecilla (IDIVAL), Santander, Spain
| | - Sean M. Devlin
- Department of Biostatistics and Epidemiology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Molly A. Maloy
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Josel D. Ruiz
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Craig S. Sauter
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Sergio A. Giralt
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Michael Scordo
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
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5
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Hamilton BK, Cutler C, Divine C, Juckett M, LeMaistre C, Stewart S, Wilder J, Horowitz M, Khera N, Burns LJ. Are We Making PROGRESS in Preventing Graft-versus-Host Disease and Improving Clinical Outcomes? Impact of BMT CTN 1301 Study Results on Clinical Practice. Transplant Cell Ther 2022; 28:419-425. [PMID: 35550441 PMCID: PMC9364468 DOI: 10.1016/j.jtct.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 04/28/2022] [Accepted: 05/01/2022] [Indexed: 11/15/2022]
Abstract
The need for prospective randomized clinical trials investigating novel graft-versus-host disease (GVHD) prevention strategies that include other clinical outcomes impacted by GVHD has been highlighted as a priority for the field of hematopoietic cell transplantation. A recently completed study through the Blood and Marrow Transplant Clinical Trials Network (BMT CTN 1301) comparing CD34+ selection and post-transplantation cyclophosphamide with tacrolimus/methotrexate (Tac/MTX) for GVHD prevention demonstrated no significant differences in the primary endpoint of chronic GVHD relapse-free survival among the 3 approaches. The trial did not demonstrate a superior approach compared with Tac/MTX; however, it did highlight several challenges in determining the best and most relevant approaches to clinical trial design, particularly in the context of current and ongoing changes in real-world practices. Here we review the results of BMT CTN 1301 and their implications for clinical practice and future clinical trial design.
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Affiliation(s)
- Betty K Hamilton
- Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Corey Cutler
- Division of Stem Cell Transplantation and Cellular Therapy, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Clint Divine
- Division of Hematologic Malignancies and Cellular Therapeutics, University of Kansas Medical Center, Kansas City, Kansas
| | - Mark Juckett
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | | | - Susan Stewart
- Blood and Marrow Transplant Information Network, Highland Park, Illinois
| | - Jennifer Wilder
- Clinical Monitoring Research Program Directorate, Frederick National Laboratory for Cancer Research sponsored by the National Cancer Institute, Frederick, Maryland
| | - Mary Horowitz
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nandita Khera
- Division of Hematology and Oncology, Mayo Clinic Arizona, Phoenix, Arizona
| | - Linda J Burns
- Center for International Blood and Marrow Transplant Research, Milwaukee, Wisconsin
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6
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Shouval R, Fein JA, Cho C, Avecilla ST, Ruiz J, Tomas AA, Sanchez-Escamilla M, Flores NC, Yáñez L, Barker JN, Dahi P, Giralt SA, Geyer AI, Gyurkocza B, Jakubowski AA, Lin RJ, O’Reilly RJ, Papadopoulos EB, Politikos I, Ponce DM, Sauter CS, Scordo M, Shaffer B, Shah GL, Sullivan JP, Tamari R, van den Brink MRM, Young JW, Nagler A, Devlin S, Shimoni A, Perales MA. The Simplified Comorbidity Index: a new tool for prediction of nonrelapse mortality in allo-HCT. Blood Adv 2022; 6:1525-1535. [PMID: 34507354 PMCID: PMC8905694 DOI: 10.1182/bloodadvances.2021004319] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 06/10/2021] [Indexed: 11/20/2022] Open
Abstract
Individual comorbidities have distinct contributions to nonrelapse mortality (NRM) following allogeneic hematopoietic cell transplantation (allo-HCT). We studied the impact of comorbidities individually and in combination in a single-center cohort of 573 adult patients who underwent CD34-selected allo-HCT following myeloablative conditioning. Pulmonary disease, moderate to severe hepatic comorbidity, cardiac disease of any type, and renal dysfunction were associated with increased NRM in multivariable Cox regression models. A Simplified Comorbidity Index (SCI) composed of the 4 comorbidities predictive of NRM, as well as age >60 years, stratified patients into 5 groups with a stepwise increase in NRM. NRM rates ranged from 11.4% to 49.9% by stratum, with adjusted hazard ratios of 1.84, 2.59, 3.57, and 5.38. The SCI was also applicable in an external cohort of 230 patients who underwent allo-HCT with unmanipulated grafts following intermediate-intensity conditioning. The area under the receiver operating characteristic curve (AUC) of the SCI for 1-year NRM was 70.3 and 72.0 over the development and external-validation cohorts, respectively; corresponding AUCs of the Hematopoietic Cell Transplantation-specific Comorbidity Index (HCT-CI) were 61.7 and 65.7. In summary, a small set of comorbidities, aggregated into the SCI, is highly predictive of NRM. The new index stratifies patients into distinct risk groups, was validated in an external cohort, and provides higher discrimination than does the HCT-CI.
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Affiliation(s)
- Roni Shouval
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel Aviv University, Israel
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Joshua A. Fein
- Department of Medicine, University of Connecticut Medical Center, Farmington, CT
| | - Christina Cho
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | | | - Josel Ruiz
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Ana Alarcon Tomas
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Miriam Sanchez-Escamilla
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Nerea Castillo Flores
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Lucrecia Yáñez
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Juliet N. Barker
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Parastoo Dahi
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Sergio A. Giralt
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Alexander I. Geyer
- Department of Medicine, Weill Cornell Medical College, New York, NY
- Pulmonary Service, Department of Medicine
| | - Boglarka Gyurkocza
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Ann A. Jakubowski
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Richard J. Lin
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Richard J. O’Reilly
- Department of Medicine, Weill Cornell Medical College, New York, NY
- Bone Marrow Transplant Service, Department of Pediatrics, and
| | - Esperanza B. Papadopoulos
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Ioannis Politikos
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Doris M. Ponce
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Craig S. Sauter
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Michael Scordo
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Brian Shaffer
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Gunjan L. Shah
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | | | - Roni Tamari
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Marcel R. M. van den Brink
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - James W. Young
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Arnon Nagler
- Department of Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel Aviv University, Israel
| | - Sean Devlin
- Department of Biostatistics and Epidemiology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Avichai Shimoni
- Department of Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel Aviv University, Israel
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
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7
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Alarcon Tomas A, Whiting K, Maloy M, Ruiz JD, Devlin S, Sanchez-Escamilla M, Yañez L, Castillo N, Pennisi M, Cho C, Shaffer B, Castro-Malaspina H, Klimek V, Giralt SA, Tamari R, Perales MA. The post-transplant scoring system (PTSS) is associated with outcomes in patients with MDS after CD34+selected allogeneic stem cell transplant. Bone Marrow Transplant 2021; 56:2749-2754. [PMID: 34253878 PMCID: PMC8273566 DOI: 10.1038/s41409-021-01392-w] [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: 09/24/2020] [Revised: 06/10/2021] [Accepted: 06/23/2021] [Indexed: 11/23/2022]
Abstract
The post-transplant scoring system (PTSS), developed by the Francophone Society of Bone Marrow Transplantation and Cellular Therapy, is based on three independent post-transplant risk factors: grade of acute graft-versus-host disease, lack of platelet recovery before day 100, and relapse before day 100; discriminating low- (0), intermediate- (1–3), and high-risk (4–8) patients. We investigated the prognostic value of the PTSS in a cohort of patients with MDS who underwent myeloablative CD34-selected TCD transplants. From 2008 to 2018, 109 patients underwent a first TCD-HCT for MDS at our center. We used Cox proportional hazards models and different landmark analyses to evaluate the association of categorized PTSS score risk groups with overall survival (OS). Patients with an intermediate/ high risk PTSS score had decreased OS at day 180 (univariate HR 3.25 [95% CI 1.60, 6.60], p = 0.001) and at day 365 (univariate HR 5.42 [95% CI 2.21, 13.3], p < 0.001) compared to low risk PTSS scores. This association remained significant after adjusting for HCT-CI. PTSS score calculated at day 100 was not associated with OS, even after adjusting for HCT-CI subgroups. In summary, the PTSS predicted survival at day 180 and day 365 in recipients of T-cell-depleted allografts for myelodysplastic syndrome.
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Affiliation(s)
- Ana Alarcon Tomas
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Karissa Whiting
- Department of Biostatistics and Epidemiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Molly Maloy
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Josel D Ruiz
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sean Devlin
- Department of Biostatistics and Epidemiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Miriam Sanchez-Escamilla
- Department of Hematology, University Hospital Marqués de Valdecilla, Santander, Spain.,Department of Hematological Malignancies and Stem Cell Transplantation, Research Institute of Marques de Valdecilla (IDIVAL), Santander, Spain
| | - Lucrecia Yañez
- Department of Hematology, University Hospital Marqués de Valdecilla, Santander, Spain.,Department of Hematological Malignancies and Stem Cell Transplantation, Research Institute of Marques de Valdecilla (IDIVAL), Santander, Spain
| | - Nerea Castillo
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Martina Pennisi
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Christina Cho
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Brian Shaffer
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Hugo Castro-Malaspina
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Virginia Klimek
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA.,Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sergio A Giralt
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Roni Tamari
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA. .,Department of Medicine, Weill Cornell Medical College, New York, NY, USA.
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8
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Cho C, Hilden P, Avecilla ST, Barker JN, Castro-Malaspina H, Giralt SA, Gyurkocza B, Jakubowski AA, Maloy MA, O’Reilly RJ, Papadopoulos EB, Peled JU, Ponce DM, Shaffer B, Tamari R, van den Brink MRM, Young JW, Barba P, Perales MA. Combining the Disease Risk Index and Hematopoietic Cell Transplant Co-Morbidity Index provides a comprehensive prognostic model for CD34 +-selected allogeneic transplantation. ADVANCES IN CELL AND GENE THERAPY 2021; 4:e103. [PMID: 36339371 PMCID: PMC9634849 DOI: 10.1002/acg2.103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 07/21/2020] [Indexed: 06/16/2023]
Abstract
UNLABELLED T cell depletion by CD34+ cell selection of hematopoietic stem cell allografts ex vivo reduces the incidence and severity of GvHD, without increased risk of relapse in patients with acute leukemia in remission or MDS. The optimal candidate for CD34+-selected HCT remains unknown, however. OBJECTIVE To determine outcomes based on both disease- and patient-specific factors, we evaluated a prognostic model combining the Disease Risk Index (DRI) and Hematopoietic Cell Transplantation Comorbidity Index (HCT-CI), an approach recently shown to predicted overall survival in a broad population of allograft recipients (1). METHODS This was a retrospective analysis of 506 adult recipients of first allogeneic HCT with CD34+ selected PBSCs from 7/8- or 8/8-matched donors for AML (n = 290), ALL (n = 72), or MDS (n = 144). The Kaplan-Meier method estimated OS and RFS. The cumulative incidence method for competing risks estimated relapse and non-relapse mortality (NRM). We evaluated the univariate association between variables of interest and OS and RFS using the log-rank test. Cox regression models assessed the adjusted effect of covariates on OS/RFS. RESULTS Stratification of patients based on a composite of DRI (low/intermediate vs. high/very high) and HCT-CI (0-2 vs. ≥ 3) revealed differences in OS and RFS between the 4 groups. Compared with reference groups of patients with low/intermediate DRI and low or high HCT-CI, those with high DRI had a greater risk of death (HR 2.30; 95% CI 1.39, 3.81) and relapse or death (HR 2.50; 95% CI 1.55, 4.05) than patients with any HCT-CI but low/intermediate DRI (HR death 1.80; 95% CI 1.34, 2.43; HR relapse/death 1.68; 95% CI 1.26, 2.24). CONCLUSIONS AND CLINICAL IMPLICATIONS A model combining DRI and HCT-CI predicted survival after CD34+ cell-selected HCT. Application of this combined model to other cohorts, both in retrospective analyses and prospective trials, will enhance clinical decision making and patient selection for different transplant approaches. DATA AVAILABILITY STATEMENT The data that support the findings of this study are available on request from the corresponding author, C Cho. In order to protect the privacy of research participants, the data are not publicly available.
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Affiliation(s)
- Christina Cho
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Patrick Hilden
- Department of Biostatistics and Epidemiology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Scott T. Avecilla
- Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Juliet N. Barker
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Hugo Castro-Malaspina
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Sergio A. Giralt
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Boglarka Gyurkocza
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Ann A. Jakubowski
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Molly A. Maloy
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Richard J. O’Reilly
- Department of Medicine, Weill Cornell Medical College, New York, NY
- Bone Marrow Transplant Service, Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Esperanza B. Papadopoulos
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Jonathan U. Peled
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Doris M. Ponce
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Brian Shaffer
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Roni Tamari
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Marcel R. M. van den Brink
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - James W. Young
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
- The Rockefeller University, New York, NY
| | - Pere Barba
- Department of Hematology, Hospital Vall d’Hebrón, Universitate Autònoma de Barcelona
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
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9
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Martinez-Cibrian N, Zeiser R, Perez-Simon JA. Graft-versus-host disease prophylaxis: Pathophysiology-based review on current approaches and future directions. Blood Rev 2020; 48:100792. [PMID: 33386151 DOI: 10.1016/j.blre.2020.100792] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 11/11/2020] [Accepted: 12/10/2020] [Indexed: 12/13/2022]
Abstract
Graft-versus-host disease (GvHD) was first described in 1959, since then major efforts have been made in order to understand its physiopathology and animal models have played a key role. Three steps, involving different pathways, have been recognised in either acute and chronic GvHD, identifying them as two distinct entities. In order to reduce GvHD incidence and severity, prophylactic measures were added to transplant protocols. The combination of a calcineurin inhibitor (CNI) plus an antimetabolite remains the standard of care. Better knowledge of GvHD pathophysiology has moved this field forward and nowadays different drugs are being used on a daily basis. Improving GvHD prophylaxis is a major goal as it would translate into less non-relapse mortality and better overall survival. As compared to CNI plus methotrexate the combination of CNI plus mycophenolate mophetil (MMF) allows us to obtain similar results in terms of GvHD incidence but a lower toxicity rate in terms of neutropenia or mucositis. The use of ATG has been related to a lower risk of acute and chronic GvHD in prospective randomized trials as well as the use of posttransplant Cyclophosphamide, with no or marginal impact on overall survival but with an improvement in GvHD-relapse free survival (GRFS). The use of sirolimus has been related to a lower risk of acute GvHD and significantly influenced overall survival in one prospective randomized trial. Other prospective trials have evaluated the use of receptors such as CCR5 or α4β7 to avoid T-cells trafficking into GvHD target organs, cytokine blockers or immune check point agonists. Also, epigenetic modifiers have shown promising results in phase II trials. Attention should be paid to graft-versus-leukemia, infections and immune recovery before bringing new prophylactic strategies to clinical practice. Although the list of novel agents for GvHD prophylaxis is growing, randomized trials are still lacking for many of them.
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Affiliation(s)
- Nuria Martinez-Cibrian
- Department of Hematology, University Hospital Virgen del Rocio, Instituto de Biomedicina de Sevilla (IBIS/CSIC/CIBERONC), Universidad de Sevilla, Spain
| | - Robert Zeiser
- Department of Hematology, Oncology, and Stem Cell Transplantation, Faculty of Medicine, Freiburg University Medical Center, Freiburg, Germany
| | - Jose A Perez-Simon
- Department of Hematology, University Hospital Virgen del Rocio, Instituto de Biomedicina de Sevilla (IBIS/CSIC/CIBERONC), Universidad de Sevilla, Spain.
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10
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Fabrizio VA, Kernan NA, Boulad F, Cancio M, Allen J, Higman M, Margossian SP, Mauguen A, Prockop S, Scaradavou A, Shah N, Spitzer B, Stieglitz E, Yeager N, O'Reilly RJ, Brentjens RJ, Jan Boelens J, Curran KJ. Low toxicity and favorable overall survival in relapsed/refractory B-ALL following CAR T cells and CD34-selected T-cell depleted allogeneic hematopoietic cell transplant. Bone Marrow Transplant 2020; 55:2160-2169. [PMID: 32390002 PMCID: PMC7606268 DOI: 10.1038/s41409-020-0926-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 04/20/2020] [Accepted: 04/24/2020] [Indexed: 01/12/2023]
Abstract
To define the tolerability and outcome of allogeneic hematopoietic stem cell transplant (allo-HSCT) following CAR T-cell therapy, we retrospectively reviewed pediatric/young adult patients with relapsed/refractory B-ALL who underwent this treatment. Fifteen patients (median age 13 years; range 1-20 years) with a median potential follow-up of 39 months demonstrated 24-month cumulative incidence of relapse, cumulative incidence of TRM, and OS of 16% (95% CI: 0-37%), 20% (95% CI: 0-40%), and 80% (95% CI: 60-100%), respectively. Severe toxicity following CAR T cells did not impact OS (p = 0.27), while greater time from CAR T cells to allo-HSCT (>80 days) was associated with a decrease in OS. In comparing CD34-selected T-cell depleted (TCD; n = 9) vs unmodified (n = 6) allo-HSCT, the cumulative incidence of relapse, TRM, and OS at 24 months was 22% (95% CI: 0-49%) vs 0% (p = 0.14), 0% vs 50% [95% CI: 10-90%] (p = 0.02) and 100% vs 50% [95% CI: 10-90%] (p = 0.02). In this small cohort of patients, CAR T cells followed by a CD34-selected TCD allo-HSCT appears to result in less TRM and favorable OS when compared with unmodified allo-HSCT. There was no evidence that disease control was impacted by the type of consolidative allo-HSCT, which demonstrates the feasibility of this approach.
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Affiliation(s)
- Vanessa A Fabrizio
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Pediatrics, Weill Cornell Medical College, New York, NY, USA
| | - Nancy A Kernan
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Pediatrics, Weill Cornell Medical College, New York, NY, USA
- Center for Cell Engineering, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Farid Boulad
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Pediatrics, Weill Cornell Medical College, New York, NY, USA
- Center for Cell Engineering, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Maria Cancio
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Pediatrics, Weill Cornell Medical College, New York, NY, USA
| | - Jennifer Allen
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Meghan Higman
- Department of Pediatrics, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Steven P Margossian
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Division of Hematology/Oncology, Boston Children's Hospital, Boston, MA, USA
| | - Audrey Mauguen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Susan Prockop
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Pediatrics, Weill Cornell Medical College, New York, NY, USA
| | - Andromachi Scaradavou
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Pediatrics, Weill Cornell Medical College, New York, NY, USA
| | - Niketa Shah
- Department of Pediatric Hematology/Oncology, Yale Cancer Center, New Haven, CT, USA
| | - Barbara Spitzer
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Pediatrics, Weill Cornell Medical College, New York, NY, USA
| | - Elliot Stieglitz
- Department of Pediatric Hematology/Oncology, UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
| | - Nicholas Yeager
- Department of Pediatric Hematology/Oncology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Richard J O'Reilly
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Pediatrics, Weill Cornell Medical College, New York, NY, USA
- Center for Cell Engineering, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Renier J Brentjens
- Center for Cell Engineering, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jaap Jan Boelens
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kevin J Curran
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Department of Pediatrics, Weill Cornell Medical College, New York, NY, USA.
- Center for Cell Engineering, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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11
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Montoro J, Roldán E, Piñana JL, Barba P, Chorão P, Quintero A, Hernani R, Ortí G, Lorenzo JI, Balaguer-Roselló A, Salamero O, Fox L, Solves P, Gómez I, Guerreiro M, Hernández Boluda JC, Sanz G, Solano C, Sanz MÁ, Valcárcel D, Sanz J. Ex vivo T-cell depletion vs post-transplant cyclophosphamide, sirolimus, and mycophenolate mofetil as graft-vs-host disease prophylaxis for allogeneic hematopoietic stem cell transplantation. Eur J Haematol 2020; 106:114-125. [PMID: 33025625 DOI: 10.1111/ejh.13529] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 09/29/2020] [Accepted: 09/30/2020] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To compare the efficacy and safety of CD34+ selected ex vivo T-cell depletion (TCD) vs post-transplant cyclophosphamide, sirolimus, and mycophenolate mofetil (PTCy-Sir-MMF) as graft-vs-host disease (GVHD) prophylaxis. METHODS We retrospectively included patients who underwent allogeneic hematopoietic stem cell transplantation (allo-HSCT) with either TCD (n = 38) or PTCy-Sir-MMF (n = 91). RESULTS Cumulative incidence of neutrophil and platelet recovery was 92% vs 99% (P = .06) and 89% vs 97% (P = .3) in TCD and PTCy-Sir-MMF, respectively. Cumulative incidences of aGHVD grade II-IV, III-IV, and moderate to severe cGVHD were 11% vs 19% (P = .2), 3% vs 2% (P = .9), and 3% vs 36% (P < .001) in TCD and PTCy-Sir-MMF, respectively. The 2-year non-relapse mortality, relapse, disease-free and overall survival were 25% vs 8% (P = .01), 20% vs 16% (P = .2), 55% vs 76% (P = .004), 57% vs 83% (P = .004) for TCD and PTCy-Sir-MMF, respectively. Cumulative incidence of cytomegalovirus and Epstein-Barr infection requiring therapy was 76% vs 40% (P < .001) and 32% vs 0% (P < .001) in TCD and PTCy-Sir-MMF, respectively. PTCy-Sir-MMF platform showed faster T-cell reconstitution. CONCLUSIONS PTCy-Sir-MMF provides better survival outcomes but is associated with higher risk of cGVHD compared to TCD.
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Affiliation(s)
- Juan Montoro
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain.,CIBERONC, Instituto Carlos III, Madrid, Spain
| | - Elisa Roldán
- Department of Hematology, Vall d'Hebrón Institue of Oncology (VHIO), Hospital Universitario Vall d'Hebrón, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - José Luis Piñana
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain.,CIBERONC, Instituto Carlos III, Madrid, Spain
| | - Pere Barba
- Department of Hematology, Vall d'Hebrón Institue of Oncology (VHIO), Hospital Universitario Vall d'Hebrón, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Pedro Chorão
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Abdiel Quintero
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Rafael Hernani
- Department of Hematology, Hospital Clínico Universitario, Valencia, Spain
| | - Guillermo Ortí
- Department of Hematology, Vall d'Hebrón Institue of Oncology (VHIO), Hospital Universitario Vall d'Hebrón, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - José Ignacio Lorenzo
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | | | - Olga Salamero
- Department of Hematology, Vall d'Hebrón Institue of Oncology (VHIO), Hospital Universitario Vall d'Hebrón, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Laura Fox
- Department of Hematology, Vall d'Hebrón Institue of Oncology (VHIO), Hospital Universitario Vall d'Hebrón, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Pilar Solves
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Inés Gómez
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Manuel Guerreiro
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Juan Carlos Hernández Boluda
- Department of Hematology, Hospital Clínico Universitario, Valencia, Spain.,Department of Medicine, University of Valencia, Valencia, Spain
| | - Guillermo Sanz
- Department of Hematology, Hospital Clínico Universitario, Valencia, Spain.,Department of Medicine, University of Valencia, Valencia, Spain
| | - Carlos Solano
- Department of Hematology, Hospital Clínico Universitario, Valencia, Spain.,Department of Medicine, University of Valencia, Valencia, Spain
| | - Miguel Ángel Sanz
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain.,Department of Medicine, University of Valencia, Valencia, Spain
| | - David Valcárcel
- Department of Hematology, Vall d'Hebrón Institue of Oncology (VHIO), Hospital Universitario Vall d'Hebrón, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Jaime Sanz
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain.,CIBERONC, Instituto Carlos III, Madrid, Spain
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12
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Montoro J, Ceberio I, Hilden P, Maloy MA, Barker J, Castro-Malaspina H, Dahi P, Koehne G, Perales MA, Ponce D, Sauter C, Shaffer B, Tamari R, Young JW, Giralt SA, O'Reilly RJ, Jakubowski AA, Papadopoulos EB. Ex Vivo T Cell-Depleted Hematopoietic Stem Cell Transplantation for Adult Patients with Acute Myelogenous Leukemia in First and Second Remission: Long-Term Disease-Free Survival with a Significantly Reduced Risk of Graft-versus-Host Disease. Biol Blood Marrow Transplant 2019; 26:323-332. [PMID: 31618690 DOI: 10.1016/j.bbmt.2019.10.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 09/26/2019] [Accepted: 10/05/2019] [Indexed: 01/21/2023]
Abstract
Large series of patients with acute myelogenous leukemia (AML) after ex vivo T cell-depleted (TCD) allogeneic hematopoietic stem cell transplantation (allo-HSCT) have not been reported previously. We retrospectively analyzed the outcomes of 266 patients (median age, 54 years) with AML who received CD34-selected TCD allo-HSCTs while in first (75%) or second (25%) complete remission (CR1/CR2) at a single institution. The conditioning regimens were all myeloablative, and no additional graft-versus-host disease (GVHD) prophylaxis was given. The cumulative incidences of grade II-IV and grade III-IV acute GVHD at 180 days were 14% (95% confidence interval [CI], 10% to 18%) and 3% (95% CI, 1% to 5%), respectively. The cumulative incidence of chronic GVHD at 3 years was 3% (95% CI, 1% to 6%). The 3-year cumulative incidence of nonrelapse mortality was 21% (95% CI, 16% to 26%) and that of relapse was 21% (95% CI, 17% to 27%). Overall survival (OS) and disease-free survival (DFS) at 1, 3, and 5 years were 75%, 61%, and 56% and 68%, 57%, and 53%, respectively. There were no significant differences in OS, DFS, and relapse rates for patients who underwent transplantation in CR1 and those who did so in CR2. However, patients with high-risk cytogenetics at diagnosis had significantly poorer outcomes. The OS and DFS rates compare favorably with those for unmodified allo-HSCT, but with considerably lower rates of GVHD.
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Affiliation(s)
- Juan Montoro
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Izaskun Ceberio
- Department of Hematology, Hospital Universtario Donostia, San Sebastian, Spain
| | - Patrick Hilden
- Department of Biostatistics and Epidemiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Molly A Maloy
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Juliet Barker
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Hugo Castro-Malaspina
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Parastoo Dahi
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Guenther Koehne
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Doris Ponce
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Craig Sauter
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Brian Shaffer
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Roni Tamari
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - James W Young
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Sergio A Giralt
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Richard J O'Reilly
- Pediatric Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Pediatrics, Weill Cornell Medical College, New York, New York
| | - Ann A Jakubowski
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Esperanza B Papadopoulos
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York.
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13
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Roldan E, Perales MA, Barba P. Allogeneic Stem Cell Transplantation with CD34+ Cell Selection. Clin Hematol Int 2019; 1:154-160. [PMID: 34595425 PMCID: PMC8432362 DOI: 10.2991/chi.d.190613.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 06/04/2019] [Indexed: 11/07/2022] Open
Abstract
The success of allogeneic stem cell transplant is hampered by the development of acute and chronic graft-versus-host disease (GvHD) which has direct impact on treatment-related mortality and morbidity. As a result, T cell depletion through positive selection of CD34+ cells has emerged as a promising strategy to reduce acute and chronic GvHD in these patients. In this review, we summarize the main characteristics of allogeneic stem cell transplant with CD34+ cell selection including risks of graft failure, GvHD, infection, organ toxicity, and long-term survival. Moreover, we highlight future strategies to improve the results of this platform and to consolidate its use in clinical practice.
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Affiliation(s)
- Elisa Roldan
- Hematology Department, Vall d'Hebron University Hospital-Universitat Autónoma de Barcelona, Pg. Vall Hebron 119, Barcelona, Spain
| | - Miguel Angel Perales
- Adult BMT Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Pere Barba
- Hematology Department, Vall d'Hebron University Hospital-Universitat Autónoma de Barcelona, Pg. Vall Hebron 119, Barcelona, Spain
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14
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DeFilipp Z, Advani AS, Bachanova V, Cassaday RD, Deangelo DJ, Kebriaei P, Rowe JM, Seftel MD, Stock W, Tallman MS, Fanning S, Inamoto Y, Kansagra A, Johnston L, Nagler A, Sauter CS, Savani BN, Perales MA, Carpenter PA, Larson RA, Weisdorf D. Hematopoietic Cell Transplantation in the Treatment of Adult Acute Lymphoblastic Leukemia: Updated 2019 Evidence-Based Review from the American Society for Transplantation and Cellular Therapy. Biol Blood Marrow Transplant 2019; 25:2113-2123. [PMID: 31446198 DOI: 10.1016/j.bbmt.2019.08.014] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 08/16/2019] [Indexed: 01/05/2023]
Abstract
The role of hematopoietic cell transplantation (HCT) in adults with acute lymphoblastic leukemia (ALL) is reviewed and critically evaluated in this systematic evidence-based review. Specific criteria were used for searching the published literature and for grading the quality and strength of the evidence and the strength of the recommendations. A panel of ALL experts developed consensus on the treatment recommendations based on the evidence. Allogeneic HCT offers a survival benefit in selected patients with ALL, and this review summarizes the standard indications as well as the areas of controversy. There is now greater experience with pediatric-inspired chemotherapy regimens that has transformed upfront therapy for adult ALL, resulting in higher remission rates and overall survival. This in turn has increased the equipoise around decision making for ALL in first complete remission (CR1) when there is no measurable residual disease (MRD) at the end of induction and/or consolidation. Randomized studies are needed for adults with ALL to compare allogeneic HCT in CR1 with pediatric-inspired chemotherapy alone. Indications for transplantation in the evolving landscape of MRD assessments and novel targeted and immune therapeutics remain important areas of investigation.
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Affiliation(s)
- Zachariah DeFilipp
- Blood and Marrow Transplant Program, Massachusetts General Hospital, Boston, MA.
| | - Anjali S Advani
- Department of Medical Oncology & Hematology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH
| | - Veronika Bachanova
- Division of Hematology/Oncology/Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, MN
| | - Ryan D Cassaday
- Division of Clinical Research, Fred Hutchinson Cancer Research Center and Department of Medicine, University of Washington, Seattle, WA, USA
| | - Daniel J Deangelo
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Partow Kebriaei
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jacob M Rowe
- Department of Hematology, Shaare Zedek Medical Center, Jerusalem, Israel
| | | | - Wendy Stock
- Department of Hematology and Oncology, Comprehensive Cancer Center, University of Chicago, Chicago, IL
| | - Martin S Tallman
- Leukemia Service, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY
| | - Suzanne Fanning
- Hematology and Medical Oncology, Greenville Health System Cancer Institute, Greenville, SC
| | - Yoshihiro Inamoto
- Division of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Ankit Kansagra
- Department of Hematology and Oncology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Laura Johnston
- Department of Medicine, Stanford University Medical Center, Stanford, CA
| | - Arnon Nagler
- Hematology and Bone Marrow Transplantation Division, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Craig S Sauter
- Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY
| | - Bipin N Savani
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY
| | - Paul A Carpenter
- Division of Clinical Research, Fred Hutchinson Cancer Research Center and Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Richard A Larson
- Department of Hematology and Oncology, Comprehensive Cancer Center, University of Chicago, Chicago, IL
| | - Daniel Weisdorf
- Division of Hematology/Oncology/Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, MN
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15
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Dierov D, Webb N, Fatmi S, Nwanne C, Ciolino C, Mosesso K, Nieves J, Perales MA, Prockop SE, Ponce DM. Establishing a standardized system for review and adjudication of chronic graft-vs-host disease data in accordance with the National Institutes Consensus criteria. ACTA ACUST UNITED AC 2019; 2. [PMID: 31886456 DOI: 10.1002/acg2.62] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
GVHD is a frequent complication following allo-HCT. The NIH consensus group established new guidelines for the evaluation of chronic GVHD. However, GVHD assessment remains challenging due its complexity and requirement for laborious evaluation. We, therefore, established a standardized approach for the assessment of chronic GVHD in accordance with the NCC guidelines. At a single institution, all allograft recipients were evaluated for GVHD within the first-year post allo-HCT following a 3-step workflow (real-time assessment, consensus review, and documentation). A GVHD adjudication committee was created and a dynamic electronic GVHD data capture form was developed guiding the clinician through a comprehensive review of systems following the NCC guidelines. We found that the assessment and reporting of GVHD reached 100% compliance. The establishment of an institutional GVHD adjudication committee enabled standardized assessment of GVHD. Our workflow can be adopted by other centers to create a similar framework for dedicated GVHD evaluation.
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Affiliation(s)
- Djamilia Dierov
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Nicholas Webb
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Samira Fatmi
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Chamberlain Nwanne
- Health Informatics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Cristi Ciolino
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kara Mosesso
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jimmy Nieves
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Miguel-Angel Perales
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY.,Weill Cornell Medical College, New York, NY
| | - Susan E Prockop
- Department of Pediatrics, Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Doris M Ponce
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY.,Weill Cornell Medical College, New York, NY
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16
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Cho C, Perales MA. Expanding Therapeutic Opportunities for Hematopoietic Stem Cell Transplantation: T Cell Depletion as a Model for the Targeted Allograft. Annu Rev Med 2019; 70:381-393. [DOI: 10.1146/annurev-med-120617-041210] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Allogeneic hematopoietic cell transplantation is a fundamental part of the treatment of hematologic malignancies and marrow failure syndromes, but complications including graft-versus-host disease, prolonged immune deficiency and infection, and organ toxicities, as well as relapse, remain obstacles to improved overall survival. As the cellular characteristics of the allograft can exert significant impact on outcomes, the development of more strategically designed grafts represents a rich area for therapeutic intervention. We describe the use of ex vivo T cell–depleted grafts as a model for the targeted graft and review evolving knowledge and approaches for further refinement of allografts to improve patient outcomes.
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Affiliation(s)
- Christina Cho
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center and Department of Medicine, Weill Cornell Medical College, New York, NY 10065, USA;,
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center and Department of Medicine, Weill Cornell Medical College, New York, NY 10065, USA;,
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17
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Abstract
Graft-versus-host (GVHD) is an important cause of morbidity and mortality after allogeneic hematopoietic cell transplantation (HCT). As donor T cells are recognized as key drivers of GVHD, some approaches to prevent GVHD have focused on T cell depletion of the allograft. In this review we summarize methods and outcomes of ex vivo T cell depleted (TCD) HCT with a focus on CD34+ selection. This platform is efficacious in preventing acute and chronic GVHD across a wide range of hematologic malignancies, and with the exception of chronic myeloid leukemia, is not associated with adverse relapse or survival outcomes compared to conventional GVHD prophylaxis platforms. In retrospective comparisons recipients of CD34+ selected HCT have higher rates of GVHD-free relapse-free survival (GRFS) than conventional HCT counterparts. Although CD34+ selected allografts require myeloablative and antithymocyte-globulin based conditioning to support engraftment, abrogation of calcineurin inhibitors and methotrexate in this approach reduces its toxicity such that it can be considered in select older and more comorbid patients who could benefit from ablative HCT. A trial comparing GVHD prophylaxis regimens (BMT CTN 1301, NCT02345850) has completed accrual and will be the first to compare CD34+ selected HCT with conventional HCT in a randomized prospective setting. Its findings have potential to establish CD34+ selected HCT as a new standard-of-care platform for GVHD prevention.
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Affiliation(s)
- Adam R Bryant
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA.,Department of Medicine, Weill Cornell Medical College, New York, NY, 10021, USA
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18
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Huang YT, Su Y, Kim SJ, Nichols P, Burack D, Maloy M, Giralt S, Perales MA, Jakubowski AA, Papanicolaou GA. Cytomegalovirus Infection in Allogeneic Hematopoietic Cell Transplantation Managed by the Preemptive Approach: Estimating the Impact on Healthcare Resource Utilization and Outcomes. Biol Blood Marrow Transplant 2018; 25:791-799. [PMID: 30476551 DOI: 10.1016/j.bbmt.2018.11.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 11/12/2018] [Indexed: 12/16/2022]
Abstract
We quantified cytomegalovirus (CMV) antiviral use and hospital length of stay (LOS) associated with CMV infection in a contemporary cohort of conventional (CONV) and CD34-selected (T cell-depleted) hematopoietic cell transplantation (HCT) recipients managed by preemptive therapy (PET) in a single US center. Adults who received first allogeneic HCT at Memorial Sloan Kettering Cancer Center from June 2010 through December 2014 were analyzed. Days on PET, number of readmissions, and readmission LOS by day 180 post-HCT were summarized. Estimated unit value (EUV) was defined as the expected number of PET days for a cohort of 100 HCT with characteristics as the analyzed cohort. Standardized incidence ratio was calculated as the ratio of observed outcomes of patients with CMV viremia over the outcomes of patients without CMV viremia. Of 318 patients, 88 received CONV and 230 CD34-selected HCT. Rates of CMV viremia were 26.3% for CONV and 41.9% for CD34-selected (P = .003). Among patients with viremia 68.2% CONV and 97.9% CD34-selected received PET. EUV for PET was 852 days and 2821 days for CONV and CD34-selected, respectively. The standardized incidence ratios for number of readmission and readmission LOS were 1.7 (95% confidence interval [CI], 1.4 to 2.1) and 1.2 (95% CI, 1.1 to 1.3), respectively, for CONV HCT and 1.7 (95% CI, 1.3 to 2.1) and 1.6 (95% CI, 1.5 to 1.7), respectively, for CD34-selected HCT. Overall survival was similar between patients with and without CMV viremia by HCT type. CMV end-organ disease was associated with lower overall survival only in CD34-selected HCT (P = .0007). CMV infection managed by PET requires substantial antiviral use and is associated with longer readmission LOS more, particularly among CD34-selected HCT.
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Affiliation(s)
- Yao-Ting Huang
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Yiqi Su
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Seong Jin Kim
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Paige Nichols
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daniel Burack
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Molly Maloy
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sergio Giralt
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Ann A Jakubowski
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Genovefa A Papanicolaou
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York.
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19
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Melve GK, Ersvaer E, Eide GE, Kristoffersen EK, Bruserud Ø. Peripheral Blood Stem Cell Mobilization in Healthy Donors by Granulocyte Colony-Stimulating Factor Causes Preferential Mobilization of Lymphocyte Subsets. Front Immunol 2018; 9:845. [PMID: 29770133 PMCID: PMC5941969 DOI: 10.3389/fimmu.2018.00845] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 04/05/2018] [Indexed: 01/23/2023] Open
Abstract
Background Allogeneic hematopoietic stem cell transplantation is associated with a high risk of immune-mediated post-transplant complications. Graft depletion of immunocompetent cell subsets is regarded as a possible strategy to reduce this risk without reducing antileukemic immune reactivity. Study design and methods We investigated the effect of hematopoietic stem cell mobilization with granulocyte colony-stimulating factor (G-CSF) on peripheral blood and stem cell graft levels of various T, B, and NK cell subsets in healthy donors. The results from flow cytometric cell quantification were examined by bioinformatics analyses. Results The G-CSF-induced mobilization of lymphocytes was a non-random process with preferential mobilization of naïve CD4+ and CD8+ T cells together with T cell receptor αβ+ T cells, naïve T regulatory cells, type 1 T regulatory cells, mature and memory B cells, and cytokine-producing NK cells. Analysis of circulating lymphoid cell capacity to release various cytokines (IFNγ, IL10, TGFβ, IL4, IL9, IL17, and IL22) showed preferential mobilization of IL10 releasing CD4+ T cells and CD3-19- cells. During G-CSF treatment, the healthy donors formed two subsets with generally strong and weaker mobilization of immunocompetent cells, respectively; hence the donors differed in their G-CSF responsiveness with regard to mobilization of immunocompetent cells. The different responsiveness was not reflected in the graft levels of various immunocompetent cell subsets. Furthermore, differences in donor G-CSF responsiveness were associated with time until platelet engraftment. Finally, strong G-CSF-induced mobilization of various T cell subsets seemed to increase the risk of recipient acute graft versus host disease, and this was independent of the graft T cell levels. Conclusion Healthy donors differ in their G-CSF responsiveness and preferential mobilization of immunocompetent cells. This difference seems to influence post-transplant recipient outcomes.
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Affiliation(s)
- Guro Kristin Melve
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Elisabeth Ersvaer
- Department of Biomedical Laboratory Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Geir Egil Eide
- Centre for Clinical Research, Haukeland University Hospital, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Einar K Kristoffersen
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Øystein Bruserud
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Division for Hematology, Department of Medicine, Haukeland University Hospital, Bergen, Norway
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20
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Barba P, Martino R, Zhou Q, Cho C, Castro-Malaspina H, Devlin S, Esquirol A, Giralt S, Jakubowski AA, Caballero D, Maloy M, Papadopoulos EB, Piñana JL, Fox ML, Márquez-Malaver FJ, Valcárcel D, Solano C, López-Corral L, Sierra J, Perales MA. CD34 + Cell Selection versus Reduced-Intensity Conditioning and Unmodified Grafts for Allogeneic Hematopoietic Cell Transplantation in Patients Age >50 Years with Acute Myelogenous Leukemia and Myelodysplastic Syndrome . Biol Blood Marrow Transplant 2018; 24:964-972. [PMID: 29305194 PMCID: PMC6800017 DOI: 10.1016/j.bbmt.2017.12.804] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 12/26/2017] [Indexed: 11/22/2022]
Abstract
Reduced-intensity conditioning (RIC) and T cell depletion (TCD) through CD34+ cell selection without the use of post-transplantation immunosuppression are 2 strategies used to reduce nonrelapse mortality (NRM) in older patients after allogeneic hematopoietic cell transplantation (allo-HCT). To compare the efficacy of the RIC and TCD approaches, we evaluated the outcomes of patients age >50 years with acute myelogenous leukemia (AML) and myelodysplastic syndrome (MDS) who underwent allo-HCT from an HLA-matched donor with one of these strategies. Baseline characteristics were comparable in the patients receiving TCD (n = 204) and those receiving RIC (n = 151), except for a higher proportion of unrelated donors (68% versus 40%; P < .001) and a higher comorbidity burden (Hematopoietic Cell Transplantation Comorbidity Index [HCT-CI] ≥3: 51% versus 38%; P < .001) in the TCD cohort. Analysis of outcomes at 3 years showed a higher chronic graft-versus-host disease (GVHD)/relapse-free survival (CRFS) (51% versus 7%; P < .001), lower incidences of grade II-IV acute GVHD (18% versus 46% at day +180) and chronic GVHD (6% versus 55% at 3 years; P < .001), and a lower incidence of relapse (19% versus 33% at 3 years; P = .001) in the TCD group compared with the RIC group. Relapse-free survival (RFS), overall survival (OS), and NRM were similar in the 2 groups. Combining transplantation approach (RIC versus TCD) and comorbidity burden (HCT-CI 0-2 versus ≥3), patients with an HCT-CI score of 0-2 seemed to benefit from the TCD approach. In conclusion, in this retrospective study, the use of a CD34+ cell-selected graft and a myeloablative conditioning regimen was associated with higher CRFS and similar RFS and OS compared with unmodified allo-RIC in patients age >50 years with AML and MDS.
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Affiliation(s)
- Pere Barba
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York; Hematology Department. Hospital Universitario Vall d'Hebron-Universidad Autonoma de Barcelona, Spain.
| | - Rodrigo Martino
- Hematology Department. Hospital de la Santa Creu i Sant Pau. Barcelona, Spain
| | - Qin Zhou
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Christina Cho
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College; New York, New York
| | - Hugo Castro-Malaspina
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College; New York, New York
| | - Sean Devlin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Albert Esquirol
- Hematology Department. Hospital de la Santa Creu i Sant Pau. Barcelona, Spain
| | - Sergio Giralt
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College; New York, New York
| | - Ann A Jakubowski
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College; New York, New York
| | - Dolores Caballero
- Hematology Department, Hospital Universitario Salamanca (CAUSA/IBSAL), Salamanca, Spain
| | - Molly Maloy
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Esperanza B Papadopoulos
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College; New York, New York
| | - José Luís Piñana
- Hematology Department, Hospital Clínico Universitario Valencia, Valencia, Spain
| | - María Laura Fox
- Hematology Department. Hospital Universitario Vall d'Hebron-Universidad Autonoma de Barcelona, Spain
| | | | - David Valcárcel
- Hematology Department. Hospital Universitario Vall d'Hebron-Universidad Autonoma de Barcelona, Spain
| | - Carlos Solano
- Hematology Department, Hospital Clínico Universitario Valencia, Valencia, Spain
| | - Lucía López-Corral
- Hematology Department, Hospital Universitario Salamanca (CAUSA/IBSAL), Salamanca, Spain
| | - Jorge Sierra
- Hematology Department. Hospital de la Santa Creu i Sant Pau. Barcelona, Spain
| | - Miguel-Angel Perales
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College; New York, New York.
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21
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Tamari R, Oran B, Hilden P, Maloy M, Kongtim P, Papadopoulos EB, Rondon G, Jakubowski AA, Andersson BS, Devlin SM, Ahmed S, Popat UR, Ponce D, Chen J, Sauter C, Young JW, de Lima M, Perales MA, O'Reilly RJ, Giralt SA, Champlin RE, Castro-Malaspina H. Allogeneic Stem Cell Transplantation for Advanced Myelodysplastic Syndrome: Comparison of Outcomes between CD34 + Selected and Unmodified Hematopoietic Stem Cell Transplantation. Biol Blood Marrow Transplant 2018; 24:1079-1087. [PMID: 29325829 DOI: 10.1016/j.bbmt.2018.01.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 01/01/2018] [Indexed: 11/17/2022]
Abstract
In this study, we compared transplantation outcomes of allogeneic hematopoietic stem cell transplantation (HSCT) in patients with advanced myelodysplastic syndrome (MDS) who received a CD34+ cell-selected and those who received an unmodified allograft. This analysis initially included 181 patients, 60 who received a CD34+ cell-selected transplant and 121 who received an unmodified transplant. Owing to significant differences in disease characteristics, the analysis was limited to patients with <10% blasts before HSCT (n = 145). Two groups were defined: low risk, with low- and intermediate-risk cytogenetics (CD34+, n = 39; unmodified, n = 46), and high risk: poor and very poor risk cytogenetics (CD34+, n = 19; unmodified, n = 41). In the low-risk group, the incidence of grade II-IV acute graft-versus-host disease (aGVHD) at 1 year post-transplantation was 18% in the CD34+ subgroup versus 41.3% in the unmodified subgroup (P = .015). There were no differences between the subgroups in the incidence of grade III-IV aGVHD. The incidence of chronic graft-versus-host disease (cGVHD) at 3 years in the 2 subgroups was 5.3% and 56%, respectively (P < .001). At 3 years post-transplantation, relapse, overall survival (OS), and relapse-free survival (RFS) were similar in the CD34+ and unmodified subgroups: 8.1% versus 19.4% (P = .187), 58.5% versus 53.7% (P = .51), and 59.5% versus 52.4% (P = .448). However, the composite outcome combining extensive cGVHD-free status and relapse-free status (CRFS) at 3 years was 59.5% in the CD34+ group versus 19.2% in the unmodified group (P < .001). In the high-risk group, grade II-IV aGVHD at 1 year was 31.6% in the CD34+ subgroup versus 24.4% in the unmodified subgroup (P = .752). There were no differences between the subgroups in the incidence of grade III-IV aGVHD. The incidence of cGVHD at 3 years in the 2 subgroups was 0% versus 27.6% (P = .013). At 3 years post-transplantation, relapse, OS, RFS, and CRFS in the 2 subgroups were 31.6% versus 69.3% (P = .007), 35.5% versus 14.5% (P = .068), 31.6% versus 10.7% (P = .045), and 31.6% versus 6.1% (P = .001), respectively. Cytogenetic abnormalities at diagnosis and transplant type had significant univariate associations with RFS in the high-risk cohort. Only cytogenetics (P = .03) remained associated with this outcome in a multivariate model. OS was similar in the 2 transplant groups; however, CRFS was superior in the CD34+ cell-selected transplant group.
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Affiliation(s)
- Roni Tamari
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York.
| | - Betul Oran
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Patrick Hilden
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Molly Maloy
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Piyanuch Kongtim
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Esperanza B Papadopoulos
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Gabriela Rondon
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Ann A Jakubowski
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Borje S Andersson
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Sean M Devlin
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sairah Ahmed
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Uday R Popat
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Doris Ponce
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Julianne Chen
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Craig Sauter
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - James W Young
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Marcos de Lima
- University Hospitals Seidman Cancer Center, Cleveland, Ohio
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Richard J O'Reilly
- Pediatric Bone Marrow Transplant Service, Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Sergio A Giralt
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Richard E Champlin
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Hugo Castro-Malaspina
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
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22
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Scordo M, Shah GL, Kosuri S, Herrera DA, Cho C, Devlin SM, Maloy MA, Nieves J, Borrill T, Avecilla ST, Meagher RC, Carlow DC, O'Reilly RJ, Papadopoulos EB, Jakubowski AA, Koehne G, Gyurkocza B, Castro-Malaspina H, Tamari R, Perales MA, Giralt SA, Shaffer BC. Effects of Late Toxicities on Outcomes in Long-Term Survivors of Ex-Vivo CD34 +-Selected Allogeneic Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2018; 24:133-141. [PMID: 28870777 PMCID: PMC6713288 DOI: 10.1016/j.bbmt.2017.08.033] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 08/29/2017] [Indexed: 01/28/2023]
Abstract
The late adverse events in long-term survivors after myeloablative-conditioned allogeneic hematopoietic cell transplantation (HCT) with ex vivo CD34+ cell selection are not well characterized. Using the National Cancer Institute's Common Terminology Criteria for Adverse Events, version 4.0, we assessed all grade ≥3 toxicities from the start of conditioning to the date of death, relapse, or last contact in 131 patients who survived >1 year post-HCT, identifying 285 individual toxicities among 17 organ-based toxicity groups. Pretransplantation absolute lymphocyte count >.5 K/µL and serum albumin >4.0 g/dL were associated with a reduced risk of toxicities, death, and nonrelapse mortality (NRM), whereas serum ferritin >1000 ng/mL was associated with an increased risk of toxicities and NRM after 1 year. An HCT Comorbidity Index (HCT-CI) score ≥3 was associated with an increased risk of all-cause death and NRM, but was not associated with a specific increased toxicity risk after 1 year. Patients who incurred more than the median number of toxicities (n = 7) among all patients within the first year subsequently had an increased risk of hematologic, infectious, and metabolic toxicities, as well as an increased risk of NRM and inferior 4-year overall survival (OS) (67% versus 86%; P = .003) after the 1-year landmark. The development of grade II-IV acute graft-versus-host disease (GVHD) within the first year was associated with incurring >7 toxicities within the first year (P = .016), and also with an increased risk of all-cause death and NRM after 1 year. In multivariate models, cardiovascular, hematologic, hepatic, infectious, metabolic, neurologic, and pulmonary toxicities incurred after 1 year were independently associated with increased risk of death and NRM when adjusting for both HCT-CI and grade II-IV acute GVHD within the first year. One-year survivors of ex vivo CD34+ selection had a favorable 4-year OS of 77%, although the development of grade ≥3 toxicities after the first year was associated with poorer outcomes, emphasizing the fundamental importance of improving survivorship efforts that may improve long-term toxicity burden and outcome.
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Affiliation(s)
- Michael Scordo
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.
| | - Gunjan L Shah
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Satyajit Kosuri
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Diego Adrianzen Herrera
- Department of Medical Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Christina Cho
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Sean M Devlin
- Department of Biostatistics and Epidemiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Molly A Maloy
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jimmy Nieves
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Taylor Borrill
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Scott T Avecilla
- Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Richard C Meagher
- Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Dean C Carlow
- Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Richard J O'Reilly
- Pediatric Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Pediatrics, Weill Cornell Medical College, New York, New York
| | - Esperanza B Papadopoulos
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Ann A Jakubowski
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Guenther Koehne
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Boglarka Gyurkocza
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Hugo Castro-Malaspina
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Roni Tamari
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Sergio A Giralt
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Brian C Shaffer
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
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23
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Long-term prognosis for 1-year relapse-free survivors of CD34+ cell-selected allogeneic hematopoietic stem cell transplantation: a landmark analysis. Bone Marrow Transplant 2017; 52:1629-1636. [PMID: 28991247 PMCID: PMC5718946 DOI: 10.1038/bmt.2017.197] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Revised: 08/02/2017] [Accepted: 08/03/2017] [Indexed: 11/12/2022]
Abstract
CD34 selection significantly improves GVHD-free survival in allogeneic hematopoietic cell transplantation (allo-HSCT). Specific information regarding long-term prognosis and risk factors for late mortality after CD34-selected allo-HSCT is lacking, however. We conducted a single-center landmark analysis in 276 patients alive without relapse 1 year after CD34-selected allo-HSCT for AML (n=164), ALL (n=33), or MDS (n=79). At 5 years' follow-up after the 1-year landmark (range 0.03-13 years), estimated RFS was 73% and OS 76%. The 5-year cumulative incidence of relapse and NRM were 11% and 16%, respectively. In multivariate analysis, HCT-CI score ≥ 3 correlated with marginally worse RFS (HR 1.78, 95% CI 0.97-3.28, p=0.06) and significantly worse OS (HR 2.53, 95% CI 1.26-5.08, p=0.004). Despite only 24% of patients with acute GVHD within 1 year, this also significantly correlated with worse RFS and OS, with increasing grades of acute GVHD associating with increasingly poorer survival on multivariate analysis (p<0.0001). Of 63 deaths after the landmark, GVHD accounted for 27% of deaths and was the most common cause of late mortality, followed by relapse and infection. While prognosis is excellent for patients alive without relapse 1 year after CD34-selected allo-HSCT, risks of late relapse and NRM persist, particularly due to GVHD.
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24
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Jakubowski AA, Petrlik E, Maloy M, Hilden P, Papadopoulos E, Young JW, Boulad F, Castro-Malaspina H, Tamari R, Dahi PB, Goldberg J, Koehne G, Perales MA, Sauter CS, O'Reilly RJ, Giralt S. T Cell Depletion as an Alternative Approach for Patients 55 Years or Older Undergoing Allogeneic Stem Cell Transplantation as Curative Therapy for Hematologic Malignancies. Biol Blood Marrow Transplant 2017; 23:1685-1694. [PMID: 28734876 PMCID: PMC10715069 DOI: 10.1016/j.bbmt.2017.06.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 06/28/2017] [Indexed: 12/27/2022]
Abstract
T cell-depleted (TCD) allogeneic hematopoietic stem cell transplantation (HSCT) is curative treatment for hematologic malignancies in adults, shown to reduce graft-versus-host disease (GVHD) without increased relapse. We retrospectively reviewed a single-center, 11-year experience of 214 patients aged ≥ 55 years to determine tolerability and efficacy in the older adult. Most patients (70%) had myeloid diseases, and most acute leukemias were in remission. Median age was 61 years, with related and unrelated donors ≥8/10 HLA matched. Hematopoietic cell transplantation-specific comorbidity index scores were intermediate and high for 84%. Conditioning regimens were all myeloablative. Grafts were peripheral blood stem cells (97%) containing CD3 dose ≤103-4/kg body weight, without pharmacologic GVHD prophylaxis. With median follow-up of 70 months among survivors, Kaplan-Meier estimates of overall and relapse-free survival were 44% and 41%, respectively (4 years). Cumulative incidence of nonrelapse mortality at day +100 was only 10%. Incidence of GVHD for acute (grades II to IV) was 9% at day +100 and for chronic was 7% at 2 and 4 years (8 extensive, 1 overlap). Median Karnofsky performance status for patients > 2 years post-transplant was 90%. As 1 of the largest reports for patients ≥2 aged ≥55 years receiving TCD HSCTs, it demonstrates curative therapy with minimal GVHD, similar to that observed in a younger population.
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Affiliation(s)
- Ann A Jakubowski
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, Cornell University, New York, New York.
| | - Erica Petrlik
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Molly Maloy
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Patrick Hilden
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Esperanza Papadopoulos
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, Cornell University, New York, New York
| | - James W Young
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, Cornell University, New York, New York
| | - Farid Boulad
- Weill Cornell Medical College, Cornell University, New York, New York; Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Hugo Castro-Malaspina
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, Cornell University, New York, New York
| | - Roni Tamari
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, Cornell University, New York, New York
| | - Parastoo B Dahi
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, Cornell University, New York, New York
| | - Jenna Goldberg
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, Cornell University, New York, New York
| | - Guenther Koehne
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, Cornell University, New York, New York
| | - Miguel-Angel Perales
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, Cornell University, New York, New York
| | - Craig S Sauter
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, Cornell University, New York, New York
| | - Richard J O'Reilly
- Weill Cornell Medical College, Cornell University, New York, New York; Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sergio Giralt
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, Cornell University, New York, New York
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25
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Shah GL, Scordo M, Kosuri S, Herrera DA, Cho C, Devlin SM, Borrill T, Carlow DC, Avecilla ST, Meagher RC, O'Reilly RJ, Jakubowski AA, Papadopoulos EB, Koehne G, Gyurkocza B, Castro-Malaspina H, Shaffer BC, Perales MA, Giralt SA, Tamari R. Impact of Toxicity on Survival for Older Adult Patients after CD34 + Selected Allogeneic Hematopoietic Stem Cell Transplantation. Biol Blood Marrow Transplant 2017; 24:142-149. [PMID: 28951193 DOI: 10.1016/j.bbmt.2017.08.040] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 08/29/2017] [Indexed: 11/27/2022]
Abstract
Ex vivo CD34+ selection before allogeneic hematopoietic stem cell transplantation (allo-HCT) reduces graft-versus-host disease without increasing relapse but usually requires myeloablative conditioning. We aimed to identify toxicity patterns in older patients and the association with overall survival (OS) and nonrelapse mortality (NRM). We conducted a retrospective analysis of 200 patients who underwent CD34+ selection allo-HCT using the ClinicMACS® system between 2006 and 2012. All grade 3 to 5 toxicities by CTCAE v4.0 were collected. Eighty patients aged ≥ 60 years with a median age of 64 (range, 60 to 73) were compared with 120 patients aged < 60 years. Median follow-up in survivors was 48.2 months. OS and NRM were similar between ages ≥ 60 and <60, with 1-year OS 70% versus 78% (P = .07) and 1-year NRM 23% versus 13% (P = .38), respectively. In patients aged ≥ 60 the most common toxicities by day 100 were metabolic, with a cumulative incidence of 88% (95% CI, 78% to 93%), infectious 84% (95% CI, 73% to 90%), hematologic 80% (95% CI, 69% to 87%), oral/gastrointestinal (GI) 48% (95% CI, 36% to 58%), cardiovascular (CV) 35% (95% CI, 25% to 46%), and hepatic 25% (95% CI, 16% to 35%). Patients aged ≥ 60 had a higher risk of neurologic (HR, 2.63 [95% CI, 1.45 to 4.78]; P = .001) and CV (HR, 1.65 [95% CI, 1.04 to 2.63]; P = .03) toxicities but a lower risk of oral/GI (HR, .58 [95% CI, .41 to .83]; P = .003) compared with those aged < 60. CV, hepatic, neurologic, pulmonary, and renal toxicities remained independent risk factors for the risk of death and NRM in separate multivariate models adjusting for age and hematopoietic cell transplantation-specific comorbidity index. Overall, the toxicity of a more intense regimen is potentially balanced by the absence of toxicity related to methotrexate and calcineurin inhibitors in older patients. Prospective study of toxicities after allo-HCT in older patients is essential.
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Affiliation(s)
- Gunjan L Shah
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York.
| | - Michael Scordo
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Satyajit Kosuri
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Section of Hematology/Oncology, Hematopoietic Stem Cell Transplantation Program, The University of Chicago, Chicago, Illinois
| | - Diego Adrianzen Herrera
- Department of Medical Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Christina Cho
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sean M Devlin
- Department of Biostatistics and Epidemiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Taylor Borrill
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Dean C Carlow
- Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Scott T Avecilla
- Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Richard C Meagher
- Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Richard J O'Reilly
- Pediatric Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Pediatrics, Weill Cornell Medical College, New York, New York
| | - Ann A Jakubowski
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Esperanza B Papadopoulos
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Guenther Koehne
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Boglarka Gyurkocza
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Hugo Castro-Malaspina
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Brian C Shaffer
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Sergio A Giralt
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Roni Tamari
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
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26
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Atilla E, Atilla PA, Toprak SK, Demirer T. A review of late complications of allogeneic hematopoietic stem cell transplantations. Clin Transplant 2017; 31. [PMID: 28753218 DOI: 10.1111/ctr.13062] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2017] [Indexed: 12/13/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is an effective and curative treatment of different malignant and non-malignant diseases. Early transplant-related mortality after allo-HSCT has decreased with reduced-intensity conditioning regimens and effective anti-infectious treatments, but late transplant-related mortality is still a problem. Physicians are now paying more attention to late complications that may worsen the quality of life of many transplant recipients. Chronic graft versus host disease (cGVHD) is one of the major causes of late transplant-related mortality after allo-HSCT. This review discusses recent advances that have been made in clinical evaluation and treatment of late transplant-related complications including cGVHD. The different sites of involvement are organs, especially the skin and eye, and the gastrointestinal, endocrinologic, metabolic, renal, cardiologic, pulmonary, connective tissue, and neurological systems. In addition, this review includes infections and secondary malignancies in post-transplant settings that worsen quality of life in long-term follow-ups.
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Affiliation(s)
- Erden Atilla
- Department of Hematology, Ankara University Medical School, Ankara, Turkey
| | - Pinar Ataca Atilla
- Department of Hematology, Ankara University Medical School, Ankara, Turkey
| | | | - Taner Demirer
- Department of Hematology, Ankara University Medical School, Ankara, Turkey
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27
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The Impact of Toxicities on First-Year Outcomes after Ex Vivo CD34 +-Selected Allogeneic Hematopoietic Cell Transplantation in Adults with Hematologic Malignancies. Biol Blood Marrow Transplant 2017; 23:2004-2011. [PMID: 28733264 DOI: 10.1016/j.bbmt.2017.07.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 07/10/2017] [Indexed: 11/21/2022]
Abstract
Factors that impact first-year morbidity and mortality in adults undergoing myeloablative allogeneic hematopoietic cell transplantation with ex vivo CD34+ selection have not been previously reported. We assessed all toxicities ≥ grade 3 from the start of conditioning to date of death, relapse, or last contact in 200 patients during the first year after transplantation, identifying 1885 individual toxicities among 17 organ-based toxicity groups. The most prevalent toxicities in the first year were of infectious, metabolic, hematologic, oral/gastrointestinal, hepatic, cardiac, and pulmonary etiologies. Renal complications were minimal. Grades II to IV and III and IV acute GVHD at day 100 were 11.5% and 3%, respectively. In separate multivariate models, cardiovascular, hematologic, hepatic, neurologic, pulmonary, and renal toxicities negatively impacted nonrelapse mortality (NRM) and overall survival during the first year. A higher-than-targeted busulfan level, patient cytomegalovirus seropositivity, and an Hematopoietic Cell Transplantation-Specific Comorbidity Index of ≥3 were associated with increased risk of NRM and all-cause death. Ex vivo CD34+ selection had a favorable 1-year OS of 75% and NRM of 17% and a low incidence of sinusoidal obstruction syndrome. These data establish a benchmark to focus efforts in reducing toxicity burden while improving patient outcomes.
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28
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Anandi P, Tian X, Ito S, Muranski P, Chokshi PD, Watters N, Chawla U, Hensel N, Stroncek DF, Battiwalla M, Barrett AJ. Ex vivo T-cell-depleted allogeneic stem cell transplantation for hematologic malignancies: The search for an optimum transplant T-cell dose and T-cell add-back strategy. Cytotherapy 2017; 19:735-743. [PMID: 28395942 DOI: 10.1016/j.jcyt.2017.03.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 03/09/2017] [Indexed: 11/12/2022]
Abstract
BACKGROUND T-cell depletion (TCD) of allogeneic stem cell transplants (SCT) can reduce graft-versus-host disease but may negatively affect transplant outcome by delaying immune recovery. To optimize TCD in HLA-matched siblings with hematologic malignancies, we explored varying the transplant CD3+ T-cell dose between 2 and 50 × 104/kg (corresponding to 3-4 log depletion) and studied the impact of 0-6 × 107/kg CD3+ donor lymphocyte infusion (DLI) "add-back" on immune recovery post-SCT. METHODS Two hundred seventeen consecutive patients (age range, 10-75 years) with hematologic malignancy (excluding chronic leukemias) underwent ex vivo TCD SCT from HLA-identical sibling donors from 1994-2015. Ninety-four patients had standard-risk disease (first remission acute leukemia [AL] and early stage myelodysplastic syndromes [MDS]) and 123 had high-risk disease (AL beyond first complete remission, advanced MDS or refractory B-cell malignancy). RESULTS Median follow-up was 8.5 years. At 20 years post-SCT, overall survival (OS) was 40%, nonrelapse mortality (NRM) was 27% and relapse incidence was 39%. Factors affecting outcome in multivariate analysis were transplantation era, with OS increasing from 38% in the period 1994-2000 to 58% in 2011-2015, disease risk (hazard ratio [HR], 1.68 for high risk) and increasing age (HR, 1.19 per decade). Neither the T-cell dose or the add back of T cells in the first 100 days had any effect on OS, NRM and relapse. CONCLUSIONS Outcomes for TCD SCT have greatly improved. However, our data do not support the need to precisely manipulate transplant CD3+ T-cell dose provided at least 3-log depletion is achieved or the use of T-cell add-back. Future improvements for TCD SCT await better strategies to prevent relapse, especially in high-risk recipients.
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Affiliation(s)
- Prathima Anandi
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Xin Tian
- Office of Biostatistics Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Sawa Ito
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Pawel Muranski
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Puja D Chokshi
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Noelle Watters
- Office of Biostatistics Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Upneet Chawla
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Nancy Hensel
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - David F Stroncek
- Department of Transfusion Medicine, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Minoo Battiwalla
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - A John Barrett
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA.
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29
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Ex vivo T-cell depletion in allogeneic hematopoietic stem cell transplant: past, present and future. Bone Marrow Transplant 2017; 52:1241-1248. [PMID: 28319073 PMCID: PMC5589981 DOI: 10.1038/bmt.2017.22] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 12/05/2016] [Accepted: 12/15/2016] [Indexed: 01/06/2023]
Abstract
The most common cause of post-transplant mortality in patients with hematological malignancy is relapse, followed by GvHD, infections, organ toxicity and second malignancy. Immune-mediated complications such as GvHD continue to be challenging, yet amenable to control through manipulation of the T-cell compartment of the donor graft with subsequent immunomodulation after transplant. However, risk of both relapse and infection increase concomitantly with T-cell depletion (TCD) strategies that impair immune recovery. In this review, we discuss the clinical outcome of current and emerging strategies of TCD in allogeneic hematopoietic stem cell transplant that have developed during the modern transplantation era, focusing specifically on ex vivo strategies that target selected T-cell subsets.
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30
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Glezerman IG, Devlin S, Maloy M, Bui M, Jaimes EA, Giralt SA, Jakubowski AA. Long term renal survival in patients undergoing T-Cell depleted versus conventional hematopoietic stem cell transplants. Bone Marrow Transplant 2017; 52:733-738. [PMID: 28092350 PMCID: PMC5415423 DOI: 10.1038/bmt.2016.343] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 11/04/2016] [Accepted: 11/14/2016] [Indexed: 12/04/2022]
Abstract
Calcineurin inhibitor-sparing T cell depleted (TCD) hematopoietic stem cell transplants HSCTs are presumed less nephrotoxic than conventional HSCTs. We evaluated incidence and risk factors for kidney failure and chronic kidney disease (CKD) in 231 TCD and 212 conventional HSCT recipients. Kidney failure required a median glomerular filtration rate (GFR) <60 mL/min/1.73 m2 for ≥ 100 days anytime after 180 days post-HSCT. Two year cumulative incidence (CI) of kidney failure was 42% in the conventional vs. 31% in the TCD group (p=0.005). TCD, age, acute kidney injury and number of toxic CNI levels all impacted on kidney failure, which was associated with increased all-cause mortality (hazard ratio 2.86 (95% CI: 1.88–4.36), p <0.001). Renal recovery occurred in 28% of kidney failure patients, while the remaining patients were defined to have chronic kidney disease (CKD). In those with baseline GFR>60 mL/min/1.73 m2 only exposure to nephrotoxic medications was associated with CKD (p=0.033). In the myeloablative conditioning subgroup only total body irradiation was associated with CKD (p=0.013). Of all patients, five (1.13%) required dialysis. These results confirm an impact of TCD on kidney failure but not CKD for which other risk factors such as radiation or nephrotoxic drug exposure may play a role.
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Affiliation(s)
- I G Glezerman
- Department of Medicine, Renal Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - S Devlin
- Department of Epidemiology Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - M Maloy
- Department of Medicine, Adult Bone Marrow Transplant Services, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - M Bui
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - E A Jaimes
- Department of Medicine, Renal Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - S A Giralt
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA.,Department of Medicine, Adult Bone Marrow Transplant Services, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - A A Jakubowski
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA.,Department of Medicine, Adult Bone Marrow Transplant Services, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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31
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Goldberg JD, Zheng J, Ratan R, Small TN, Lai KC, Boulad F, Castro-Malaspina H, Giralt SA, Jakubowski AA, Kernan NA, O'Reilly RJ, Papadopoulos EB, Young JW, van den Brink MRM, Heller G, Perales MA. Early recovery of T-cell function predicts improved survival after T-cell depleted allogeneic transplant. Leuk Lymphoma 2017; 58:1859-1871. [PMID: 28073320 DOI: 10.1080/10428194.2016.1265113] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Infection, relapse, and GVHD can complicate allogeneic hematopoietic stem cell transplantation (allo-HSCT). Although the effect of poor immune recovery on infection risk is well-established, there are limited data on the effect of immune reconstitution on relapse and survival, especially following T-cell depletion (TCD). To characterize the pattern of immune reconstitution in the first year after transplant and its effects on survival and relapse, we performed a retrospective study in 375 recipients of a myeloablative TCD allo-HSCT for hematologic malignancies. We noted that different subsets recover sequentially, CD8 + T cells first, followed by total CD4 + and naïve CD4 + T cells, indicating thymic recovery during the first year after HSCT. In the multivariate model, a fully HLA-matched donor and recovery of T-cell function, assessed by PHA response at 6 months, were the only factors independently associated with OS and EFS. In conclusion, T-cell recovery is an important predictor of outcome after TCD allo-HSCT.
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Affiliation(s)
- Jenna D Goldberg
- a Department of Medicine , Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center , New York , NY , USA.,b Department of Medicine , Weill Cornell Medical College , New York , NY , USA
| | - Junting Zheng
- c Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center , New York , NY , USA
| | - Ravin Ratan
- b Department of Medicine , Weill Cornell Medical College , New York , NY , USA
| | - Trudy N Small
- b Department of Medicine , Weill Cornell Medical College , New York , NY , USA.,d Department of Pediatrics, Bone Marrow Transplantation Service , Memorial Sloan Kettering Cancer Center , New York , NY , USA
| | - Kuan-Chi Lai
- a Department of Medicine , Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center , New York , NY , USA
| | - Farid Boulad
- b Department of Medicine , Weill Cornell Medical College , New York , NY , USA.,d Department of Pediatrics, Bone Marrow Transplantation Service , Memorial Sloan Kettering Cancer Center , New York , NY , USA
| | - Hugo Castro-Malaspina
- a Department of Medicine , Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center , New York , NY , USA.,b Department of Medicine , Weill Cornell Medical College , New York , NY , USA
| | - Sergio A Giralt
- a Department of Medicine , Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center , New York , NY , USA.,b Department of Medicine , Weill Cornell Medical College , New York , NY , USA
| | - Ann A Jakubowski
- a Department of Medicine , Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center , New York , NY , USA.,b Department of Medicine , Weill Cornell Medical College , New York , NY , USA
| | - Nancy A Kernan
- b Department of Medicine , Weill Cornell Medical College , New York , NY , USA.,d Department of Pediatrics, Bone Marrow Transplantation Service , Memorial Sloan Kettering Cancer Center , New York , NY , USA
| | - Richard J O'Reilly
- b Department of Medicine , Weill Cornell Medical College , New York , NY , USA.,d Department of Pediatrics, Bone Marrow Transplantation Service , Memorial Sloan Kettering Cancer Center , New York , NY , USA
| | - Esperanza B Papadopoulos
- a Department of Medicine , Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center , New York , NY , USA.,b Department of Medicine , Weill Cornell Medical College , New York , NY , USA
| | - James W Young
- a Department of Medicine , Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center , New York , NY , USA.,b Department of Medicine , Weill Cornell Medical College , New York , NY , USA
| | - Marcel R M van den Brink
- a Department of Medicine , Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center , New York , NY , USA.,b Department of Medicine , Weill Cornell Medical College , New York , NY , USA
| | - Glenn Heller
- b Department of Medicine , Weill Cornell Medical College , New York , NY , USA.,c Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center , New York , NY , USA
| | - Miguel-Angel Perales
- a Department of Medicine , Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center , New York , NY , USA.,b Department of Medicine , Weill Cornell Medical College , New York , NY , USA
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32
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Barba P, Hilden P, Devlin SM, Maloy M, Dierov D, Nieves J, Garrett MD, Sogani J, Cho C, Barker JN, Kernan NA, Castro-Malaspina H, Jakubowski AA, Koehne G, Papadopoulos EB, Prockop S, Sauter C, Tamari R, van den Brink MRM, Avecilla ST, Meagher R, O'Reilly RJ, Goldberg JD, Young JW, Giralt S, Perales MA, Ponce DM. Ex Vivo CD34 +-Selected T Cell-Depleted Peripheral Blood Stem Cell Grafts for Allogeneic Hematopoietic Stem Cell Transplantation in Acute Leukemia and Myelodysplastic Syndrome Is Associated with Low Incidence of Acute and Chronic Graft-versus-Host Disease and High Treatment Response. Biol Blood Marrow Transplant 2016; 23:452-458. [PMID: 28017734 DOI: 10.1016/j.bbmt.2016.12.633] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 12/20/2016] [Indexed: 11/29/2022]
Abstract
Ex vivo CD34+-selected T cell depletion (TCD) has been developed as a strategy to reduce the incidence of graft-versus-host disease (GVHD) after allogeneic (allo) hematopoietic stem cell transplantation (HSCT). Clinical characteristics, treatment responses, and outcomes of patients developing acute (aGVHD) and chronic GVHD (cGVHD) after TCD allo-HSCT have not been well established. We evaluated 241 consecutive patients (median age, 57 years) with acute leukemia (n = 191, 79%) or myelodysplastic syndrome (MDS) (n = 50, 21%) undergoing CD34+-selected TCD allo-HSCT without post-HCST immunosuppression in a single institution. Cumulative incidences of grades II-IV and III-IV aGVHD at 180 days were 16% (95% confidence interval [CI], 12 to 21) and 5% (95% CI, 3 to 9), respectively. The skin was the most frequent organ involved, followed by the gastrointestinal tract. Patients were treated with topical corticosteroids, poorly absorbed corticosteroids (budesonide), and/or systemic corticosteroids. The overall day 28 treatment response was high at 82%. The cumulative incidence of any cGVHD at 3 years was 5% (95% CI, 3 to 9), with a median time of onset of 256 days (range, 95 to 1645). The 3-year transplant-related mortality, relapse, overall survival, and disease-free survival were 24% (95% CI, 18 to 30), 22% (95% CI, 17 to 27), 57% (95% CI, 50 to 64), and 54% (95% CI, 47 to 61), respectively. The 1-year and 3-year probabilities of cGVHD-free/relapse-free survival were 65% (95% CI, 59 to 71) and 52% (95% CI, 45 to 59), respectively. Our findings support the use of ex vivo CD34+-selected TCD allograft as a calcineurin inhibitor-free intervention for the prevention of GVHD in patients with acute leukemia and MDS.
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Affiliation(s)
- Pere Barba
- Adult Bone Marrow Transplant Service, Division of Hematology/Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Hematology Department, Hospital Universitario Vall d'Herbon-Universidad Autonoma de Barcelona, Spain
| | - Patrick Hilden
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sean M Devlin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Molly Maloy
- Adult Bone Marrow Transplant Service, Division of Hematology/Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Djamilia Dierov
- Adult Bone Marrow Transplant Service, Division of Hematology/Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jimmy Nieves
- Adult Bone Marrow Transplant Service, Division of Hematology/Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Matthew D Garrett
- Adult Bone Marrow Transplant Service, Division of Hematology/Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Julie Sogani
- Adult Bone Marrow Transplant Service, Division of Hematology/Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Christina Cho
- Adult Bone Marrow Transplant Service, Division of Hematology/Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Juliet N Barker
- Adult Bone Marrow Transplant Service, Division of Hematology/Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
| | - Nancy A Kernan
- Bone Marrow Transplant Service, Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Hugo Castro-Malaspina
- Adult Bone Marrow Transplant Service, Division of Hematology/Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
| | - Ann A Jakubowski
- Adult Bone Marrow Transplant Service, Division of Hematology/Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
| | - Guenther Koehne
- Adult Bone Marrow Transplant Service, Division of Hematology/Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
| | - Esperanza B Papadopoulos
- Adult Bone Marrow Transplant Service, Division of Hematology/Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
| | - Susan Prockop
- Bone Marrow Transplant Service, Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Craig Sauter
- Adult Bone Marrow Transplant Service, Division of Hematology/Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
| | - Roni Tamari
- Adult Bone Marrow Transplant Service, Division of Hematology/Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
| | - Marcel R M van den Brink
- Adult Bone Marrow Transplant Service, Division of Hematology/Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
| | - Scott T Avecilla
- Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Richard Meagher
- Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Richard J O'Reilly
- Bone Marrow Transplant Service, Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jenna D Goldberg
- Adult Bone Marrow Transplant Service, Division of Hematology/Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
| | - James W Young
- Adult Bone Marrow Transplant Service, Division of Hematology/Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
| | - Sergio Giralt
- Adult Bone Marrow Transplant Service, Division of Hematology/Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplant Service, Division of Hematology/Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
| | - Doris M Ponce
- Adult Bone Marrow Transplant Service, Division of Hematology/Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York.
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33
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Barba P, Ratan R, Cho C, Ceberio I, Hilden P, Devlin SM, Maloy MA, Barker JN, Castro-Malaspina H, Jakubowski AA, Koehne G, Papadopoulos EB, Ponce DM, Sauter C, Tamari R, van den Brink MRM, Young JW, O'Reilly RJ, Giralt SA, Perales MA. Hematopoietic Cell Transplantation Comorbidity Index Predicts Outcomes in Patients with Acute Myeloid Leukemia and Myelodysplastic Syndromes Receiving CD34 + Selected Grafts for Allogeneic Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2016; 23:67-74. [PMID: 27789361 DOI: 10.1016/j.bbmt.2016.10.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 10/15/2016] [Indexed: 12/20/2022]
Abstract
To evaluate the association between the hematopoietic cell transplantation-comorbidity index (HCT-CI) and the recently developed age-adjusted HCT-CI (HCT-CI/age) and transplant outcomes in the setting of CD34-selected allogeneic HCT, we analyzed a homogeneous population of patients undergoing allogeneic HCT with CD34-selected grafts for acute myeloid leukemia and myelodysplastic syndrome (n = 346). Median HCT-CI and HCT-CI/age scores were 2 (percentile 25 to 75, 1 to 4) and 3 (percentile 25 to 75, 1 to 5), respectively. Higher HCT-CI and HCT-CI/age scores were associated with higher nonrelapse mortality (NRM) and lower overall survival (OS). The HCT-CI distinguished 2 risk groups (0 to 2 versus ≥3), whereas, with the HCT-CI/age, there was a progressive increase in NRM and decrease in OS with increasing scores in all 4 groups (0 versus 1 to 2 versus 3 to 4 versus ≥5). Higher scores in both models were associated with lower chronic graft-versus-host disease relapse-free survival but not with higher relapse. Both models showed a promising predictive accuracy for NRM (c- = .616 for HCT-CI and c- = .647 for HCT-CI/age). In conclusion, the HCT-CI and HCT-CI/age predict transplant outcomes in CD34-selected allo-HCT, including NRM, OS, and chronic graft-versus-host disease relapse-free survival and may be used to select appropriate patients for this approach.
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Affiliation(s)
- Pere Barba
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Hematology Department, Hospital Universitario Vall d'Hebron-Universidad Autonoma de Barcelona, Barcelona, Spain
| | - Ravin Ratan
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Christina Cho
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Izaskun Ceberio
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Hematology Department of Hospital Universitario Donostia, Donostia, Spain
| | - Patrick Hilden
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sean M Devlin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Molly A Maloy
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Juliet N Barker
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Hugo Castro-Malaspina
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Ann A Jakubowski
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Guenther Koehne
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Esperanza B Papadopoulos
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Doris M Ponce
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Craig Sauter
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Roni Tamari
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Marcel R M van den Brink
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - James W Young
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Richard J O'Reilly
- Department of Medicine, Weill Cornell Medical College, New York, New York; Department of Pediatrics, Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sergio A Giralt
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York.
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34
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Isa F, Saito K, Huang YT, Schuetz A, Babady NE, Salvatore S, Pessin M, van Besien K, Perales MA, Giralt S, Sepkowitz K, Papanicolaou GA, Soave R, Kamboj M. Implementation of Molecular Surveillance After a Cluster of Fatal Toxoplasmosis at 2 Neighboring Transplant Centers. Clin Infect Dis 2016; 63:565-8. [PMID: 27199460 DOI: 10.1093/cid/ciw330] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 05/12/2016] [Indexed: 11/14/2022] Open
Abstract
After a cluster of fatal toxoplasmosis among stem cell transplant recipients at 2 hospitals, surveillance with polymerase chain reaction (PCR) (blood) was instituted. Rate of reactivation among seropositive recipients was 2.2 and 16%. Parasitemia was successfully managed with preemptive treatment. For seropositive recipients unable to take prophylaxis, toxoplasma PCR surveillance should be routinely performed.
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Affiliation(s)
- Flonza Isa
- Infectious Diseases Department of Medicine
| | | | | | - Audrey Schuetz
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical College
| | - N Esther Babady
- Department of Clinical Laboratories, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Steven Salvatore
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical College
| | - Melissa Pessin
- Department of Clinical Laboratories, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Miguel-Angel Perales
- Department of Medicine Department of Bone Marrow Transplant Service Department of Medicine
| | - Sergio Giralt
- Department of Medicine Department of Bone Marrow Transplant Service Department of Medicine
| | - Kent Sepkowitz
- Department of Medicine Department of Infection Control Department of Infectious Disease Service Department of Medicine
| | | | | | - Mini Kamboj
- Department of Medicine Department of Infection Control Department of Infectious Disease Service Department of Medicine
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35
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Spitzer B, Perales MA, Kernan NA, Prockop SE, Zabor EC, Webb N, Castro-Malaspina H, Papadopoulos EB, Young JW, Scaradavou A, Kobos R, Giralt SA, O'Reilly RJ, Boulad F. Second Allogeneic Stem Cell Transplantation for Acute Leukemia Using a Chemotherapy-Only Cytoreduction with Clofarabine, Melphalan, and Thiotepa. Biol Blood Marrow Transplant 2016; 22:1449-1454. [PMID: 27184623 DOI: 10.1016/j.bbmt.2016.05.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 05/02/2016] [Indexed: 01/07/2023]
Abstract
Relapse after allogeneic hematopoietic stem cell transplantation (alloHSCT) remains one of the leading causes of mortality in patients with leukemia. Treatment options in this population remain limited, with concern for both increased toxicity and further relapse. We treated 18 patients with acute leukemia for marrow ± extramedullary relapse after a previous alloHSCT with a myeloablative cytoreductive regimen including clofarabine, melphalan, and thiotepa followed by a second or third transplantation from the same or a different donor. All patients were in remission at the time of the second or third transplantation. All evaluable patients engrafted. The most common toxicity was reversible transaminitis associated with clofarabine. Two patients died from transplantation-related causes. Seven patients relapsed after their second or third transplanation and died of disease. Nine of 18 patients are alive and disease free, with a 3-year 49% probability of overall survival (OS). Patients whose remission duration after initial alloHSCT was >6 months achieved superior outcomes (3-year OS, 74%, 95% confidence interval, 53% to 100%), compared with those relapsing within 6 months (0%) (P < .001). This new cytoreductive regimen has yielded promising results with acceptable toxicity for second or third transplantations in patients with high-risk acute leukemia who relapsed after a prior transplantation, using various graft and donor options. This approach merits further evaluation in collaborative group studies.
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Affiliation(s)
- Barbara Spitzer
- Bone Marrow Transplant Service, Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York.
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Nancy A Kernan
- Bone Marrow Transplant Service, Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Pediatrics, Weill Cornell Medical College, New York, New York
| | - Susan E Prockop
- Bone Marrow Transplant Service, Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Pediatrics, Weill Cornell Medical College, New York, New York
| | - Emily C Zabor
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nicholas Webb
- Bone Marrow Transplant Service, Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Hugo Castro-Malaspina
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Esperanza B Papadopoulos
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - James W Young
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Andromachi Scaradavou
- Bone Marrow Transplant Service, Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Rachel Kobos
- Bone Marrow Transplant Service, Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sergio A Giralt
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Richard J O'Reilly
- Bone Marrow Transplant Service, Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Pediatrics, Weill Cornell Medical College, New York, New York
| | - Farid Boulad
- Bone Marrow Transplant Service, Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Pediatrics, Weill Cornell Medical College, New York, New York
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36
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Smith E, Devlin SM, Kosuri S, Orlando E, Landau H, Lesokhin AM, Chung DJ, Hassoun H, Lendvai N, Landgren O, Giralt S, Chari A, Jagannath S, Koehne G. CD34-Selected Allogeneic Hematopoietic Stem Cell Transplantation for Patients with Relapsed, High-Risk Multiple Myeloma. Biol Blood Marrow Transplant 2015; 22:258-267. [PMID: 26325439 DOI: 10.1016/j.bbmt.2015.08.025] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 08/19/2015] [Indexed: 10/23/2022]
Abstract
We report results of a retrospective analysis of 44 patients with relapsed and high-risk multiple myeloma (MM) undergoing allogeneic CD34-selected hematopoietic stem cell transplantation (HSCT) from HLA-compatible donors. Patients had multiply relapsed disease including relapse at <15 months after autologous transplantation and most patients (28 of 44; 65%) also had high-risk cytogenetics. Before transplantation, patients received busulfan (.8 mg/kg × 10 doses), melphalan (70 mg/m(2) × 2 days), fludarabine (25 mg/m(2) × 5 days), and rabbit antithymocyte globulin (2.5 mg/kg × 2 days). Patients with 10/10 HLA- matched donors were treated prophylactically with low doses of donor lymphocyte infusions (.5 to 1 × 10(6) CD3(+)/kg) starting 4 to 6 months after CD34-selected HSCT. Acute (grade II to IV) graft-versus-host disease (GVHD) and transplantation-related mortality at 12 months were 2% and 18%, respectively. Chronic GVHD was not observed in any patient. Overall and progression-free survival at 2 years were 54% and 31%, respectively. By multivariate analyses, the outcomes of CD34-selected HSCT were influenced by presence of extramedullary disease, disease status before CD34-selected HSCT, and age. This study demonstrates notable safety and efficacy of CD34-selected HSCT in patients with multiply relapsed MM, including those with high-risk cytogenetics.
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Affiliation(s)
- Eric Smith
- Hematology/Oncology/BMT Fellowship Program, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sean M Devlin
- Department of Biostatistics and Epidemiology, Memorial Sloan Kettering Cancer Center, New York, New York; Memorial Sloan Kettering Cancer Center, New York, New York
| | - Satyajit Kosuri
- Hematology/Oncology/BMT Fellowship Program, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Memorial Sloan Kettering Cancer Center, New York, New York
| | - Evelyn Orlando
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Memorial Sloan Kettering Cancer Center, New York, New York
| | - Heather Landau
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Multiple Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York; Memorial Sloan Kettering Cancer Center, New York, New York
| | - Alex M Lesokhin
- Multiple Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York; Memorial Sloan Kettering Cancer Center, New York, New York
| | - David J Chung
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Multiple Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York; Memorial Sloan Kettering Cancer Center, New York, New York
| | - Hani Hassoun
- Multiple Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York; Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nikoletta Lendvai
- Multiple Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York; Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ola Landgren
- Multiple Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York; Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sergio Giralt
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Multiple Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York; Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ajai Chari
- Multiple Myeloma Program, Mount Sinai Hospital, New York, New York
| | - Sundar Jagannath
- Multiple Myeloma Program, Mount Sinai Hospital, New York, New York
| | - Guenther Koehne
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Multiple Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York; Memorial Sloan Kettering Cancer Center, New York, New York.
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