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Rehn S, Oertel M, Linde P, Mäurer M, Elsayad K, Pepper NB, Rolf D, Kahn JM, Plastaras JP, Gunther JR, Eich HT. Knowledge and competences in hematological malignancies amongst radiation oncology residents in Germany-results from a national survey. Strahlenther Onkol 2024:10.1007/s00066-024-02236-4. [PMID: 38683476 DOI: 10.1007/s00066-024-02236-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 04/07/2024] [Indexed: 05/01/2024]
Abstract
INTRODUCTION Radiation oncology is a pivotal modality in the treatment of hematologic malignancies. To enable state-of-the-art patient care, structured education during residency is essential. However, given the lack of detailed data, the scope of educational opportunities available to trainees remains elusive. This prompted our group to perform a national survey amongst radiation oncology residents in Germany assessing the status quo of competences in the treatment of lymphoma and leukemia patients. Furthermore, areas of potential improvement were identified to further the goal of competence-based education for residents. METHODS A survey-based analysis was conducted to assess the knowledge and competence of radiation oncology residents in Germany regarding hematological malignancies. A decisive questionnaire covering demographics, self-assessment of competences, and areas for improvement was developed in adaption of a survey by the Association of Residents in Radiation Oncology and distributed amongst 1439 members of the German Society of Radiation Oncology. Responses were collected anonymously via an online survey tool and analyzed using descriptive statistics and chi-square tests. RESULTS A total of 59 complete and 22 partial responses were collected, yielding a 5.6% response rate. Participants' competence varied, with notable experience gaps in pediatric cases, proton therapy, and large-field techniques like total-skin irradiation or pediatric total body irradiation. While participants felt confident in treatment planning and patient counseling, they showed deficiencies in the definition of the planning target volume for modern involved site radiotherapy. Resources for education included national and international guidelines, scientific reviews, and textbooks. Board-certified radiation oncologists and physicians from specialized lymphoma centers demonstrated higher overall competence levels. CONCLUSION This survey highlights the diversity of resident education regarding hematological malignancies in German radiation oncology programs. Knowledge gaps exist in key areas, including pediatric cases and specialized techniques. Competence-based education, interactive teaching formats, and rotations to specialized centers are potential strategies to address these gaps. The study contributes to the understanding of the federal educational landscape, underscoring the need for standardized and comprehensive training to ensure optimal patient care in hematological malignancies within the context of radiation oncology. Further research and collaborations are warranted to enhance training and expertise in this critical domain.
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Affiliation(s)
- Stephan Rehn
- Department of Radiation Oncology, University Hospital Muenster, Albert-Schweitzer-Campus 1, building A1, 48149, Muenster, Germany
| | - Michael Oertel
- Department of Radiation Oncology, University Hospital Muenster, Albert-Schweitzer-Campus 1, building A1, 48149, Muenster, Germany.
| | - Philipp Linde
- Department of Radiation Oncology, Cyberknife and Radiation Therapy, University Hospital of Cologne, Cologne, Germany
| | - Matthias Mäurer
- Department for Radiotherapy and Radiation Oncology, University Hospital Jena, Jena, Germany
| | - Khaled Elsayad
- Department of Radiation Oncology, University Hospital Muenster, Albert-Schweitzer-Campus 1, building A1, 48149, Muenster, Germany
| | - Niklas B Pepper
- Department of Radiation Oncology, University Hospital Muenster, Albert-Schweitzer-Campus 1, building A1, 48149, Muenster, Germany
| | - Daniel Rolf
- Department of Radiation Oncology, University Hospital Muenster, Albert-Schweitzer-Campus 1, building A1, 48149, Muenster, Germany
| | - Jenna M Kahn
- Department of Radiation Medicine, Oregon Health and Science University, Portland, OR, USA
| | - John P Plastaras
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Jillian R Gunther
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hans T Eich
- Department of Radiation Oncology, University Hospital Muenster, Albert-Schweitzer-Campus 1, building A1, 48149, Muenster, Germany
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Echecopar C, Del Val Rey I, Galán-Gómez V, González-Pérez C, Mozo Del Castillo Y, González Martínez B, Pérez-Martínez A. The paradigm of total body irradiation in acute lymphoblastic leukaemia: Therapeutic effectiveness versus the challenges of toxicity. An Pediatr (Barc) 2024; 100:259-267. [PMID: 38548564 DOI: 10.1016/j.anpede.2024.03.011] [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: 06/14/2023] [Accepted: 01/18/2024] [Indexed: 04/28/2024] Open
Abstract
INTRODUCTION Total body irradiation (TBI) is part of the myeloablative conditioning for hematopoietic stem cell transplantation (HSCT) in malignant hematologic disorders. This therapy has recently shown improved survival in acute lymphoblastic leukemia (ALL) compared to chemotherapy-based regimens. However, side effects are a significant limitation, especially in the pediatric population. PATIENTS AND METHODS We retrospectively analyzed the survival of patients with ALL who underwent an HSCT at a tertiary hospital between 1996 and 2009 (N = 69 HSCT in 57 patients). We differentiated a cohort that received TBI (N = 44) from another that did not (N = 25). Subsequently, we interviewed the survivors from the TBI group with a minimum of 10 years of follow-up (N = 18), asking about the presence of side effects. RESULTS The overall survival (OS) at 2 and 5 years was 79.1% and 65.2% respectively for the TBI group and 66.2% and 55.8% for the non-TBI group, although this difference was not significant (P=.31). The event-free survival (EFS) at 2 and 5 years was 77.3% and 63.6% respectively for the TBI group and 56% and 32% for the non-TBI group (P=.02). The probability of relapse (PR) at 2 years for those who received TBI was 10% compared to 28.6% for those who did not receive TBI (P=.005). Survivors who received TBI developed secondary neoplasms (39%), dyslipidemia (67%), cognitive impairments affecting memory (44%), recurrent respiratory infections (39%), thyroid abnormalities (45%), premature ovarian failure (89%), cataracts (22%), and psychological problems (44%). However, the quality of life, as self-assessed by the patients, was considered good for 83% of the participants.. CONCLUSIONS Patients who received TBI had significantly higher EFS and lower PR. However, adverse effects are frequent and significant, although they do not subjectively affect quality of life.
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Affiliation(s)
- Carlos Echecopar
- Servicio de Hematología y Oncología Pediátrica, Hospital Universitario La Paz, Madrid, Spain
| | | | - Víctor Galán-Gómez
- Servicio de Hematología y Oncología Pediátrica, Hospital Universitario La Paz, Madrid, Spain
| | - Carlos González-Pérez
- Servicio de Hematología y Oncología Pediátrica, Hospital Universitario La Paz, Madrid, Spain
| | | | - Berta González Martínez
- Servicio de Hematología y Oncología Pediátrica, Hospital Universitario La Paz, Madrid, Spain
| | - Antonio Pérez-Martínez
- Servicio de Hematología y Oncología Pediátrica, Hospital Universitario La Paz, Madrid, Spain; Facultad de Medicina, Universidad Autónoma de Madrid, Madrid, Spain.
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Saglio F, Pagliara D, Zecca M, Balduzzi A, Cattoni A, Prete A, Tambaro FP, Faraci M, Calore E, Locatelli F, Fagioli F. Long-Term Complications after Allogeneic Hematopoietic Stem Cell Transplantation with Treosulfan- or Busulfan-Based Conditioning in Pediatric Patients with Acute Leukemia or Myelodysplastic Syndrome: Results of an Associazione Italiana Ematologia Oncologia Pediatrica Retrospective Study. Transplant Cell Ther 2024; 30:433.e1-433.e10. [PMID: 38176654 DOI: 10.1016/j.jtct.2023.12.671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 12/19/2023] [Accepted: 12/27/2023] [Indexed: 01/06/2024]
Abstract
Patients undergoing hematopoietic stem cell transplantation (HSCT) for hematologic malignancies during childhood have an increased risk of developing long-term sequelae that are in part attributable to the conditioning regimen. The present study aimed to assess the occurrence of long-term toxicities in a population of children who underwent HSCT for hematologic malignancies using either treosulfan or busulfan in the conditioning regimen. The cumulative incidences of growth impairment, altered gonadal function, altered thyroid function, cataracts, secondary malignant neoplasia, and altered pulmonary function were evaluated retrospectively by univariable and multivariable analyses in a population of 521 pediatric patients with acute leukemias or myelodysplastic syndromes treated in 20 Italian transplant centers affiliated with the Associazione Italiana Ematologia ed Oncologia Pediatrica (AIEOP). The median duration of follow-up for the entire study population was 7.1 years (range, 1 to 16 years). Overall, a larger proportion of patients given busulfan developed long-term toxicities compared to patients treated with treosulfan (34% versus 20%; P = .01). In univariable analysis, gonadal toxicity developed in 10% of patients who received treosulfan (95% confidence interval [CI], 3% to 15%), compared with 38% (95% CI, 24% to 39%) of busulfan-treated patients (P = .02), and this finding was confirmed by multivariable analysis (relative risk, .51; 95% CI, .34 to .76; P = .0009). We did not find any statistically significant associations between the occurrence of other long-term toxicities and the use of either busulfan or treosulfan. This study provides evidence that the use of treosulfan is correlated with a reduced incidence of gonadal toxicity in children undergoing HSCT for hematologic malignancies.
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Affiliation(s)
- Francesco Saglio
- Paediatric Onco-Haematology Division, Regina Margherita Children's Hospital AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Daria Pagliara
- Department of Hematology/Oncology, Cell and Gene Therapy, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Marco Zecca
- Pediatric Hematology/Oncology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Adriana Balduzzi
- Department of Pediatrics, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy; School of Medicine and Surgery, University of di Milano-Bicocca, Monza, Italy
| | - Alessandro Cattoni
- Department of Pediatrics, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy; School of Medicine and Surgery, University of di Milano-Bicocca, Monza, Italy
| | - Arcangelo Prete
- Pediatric Oncology and Hematology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | - Maura Faraci
- Hematopoietic stem cell Transplant Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Elisabetta Calore
- Pediatric Hematology, Oncology and Stem Cell Transplant Division, University Hospital of Padua, Padua, Italy
| | - Franco Locatelli
- Department of Hematology/Oncology, Cell and Gene Therapy, IRCCS Bambino Gesù Children's Hospital, Rome, Italy; Catholic University of the Sacred Heart, Rome, Italy
| | - Franca Fagioli
- Paediatric Onco-Haematology Division, Regina Margherita Children's Hospital AOU Città della Salute e della Scienza di Torino, Turin, Italy; Università degli Studi di Torino, Turin, Italy.
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Loschi M, Alsuliman T, Cabrera Q, Desbrosses Y, Desmier D, Yakoub Agha I, Guillaume T. [Secondary cancers following allogeneic hematopoietic stem cell transplantation: Guidelines from the Francophone Society of Bone Marrow Transplantation and Cellular Therapy (SFGM-TC)]. Bull Cancer 2024; 111:S22-S28. [PMID: 36922321 DOI: 10.1016/j.bulcan.2023.02.016] [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: 12/26/2022] [Revised: 02/10/2023] [Accepted: 02/26/2023] [Indexed: 03/15/2023]
Abstract
The Francophone Society of Bone Marrow Transplantation and Cellular Therapy (SFGM-TC) held the 13th edition of the Clinical Practices Harmonization Workshops. Our workgroup reviewed the current data on the incidence, screening methods and international guidelines for the prevention of secondary solid cancers following allogeneic hematopoietic stem cell transplantation. The purpose of this workshop was to provide recommendations for the screening and prevention of secondary malignancies to Francophone transplantation centers.
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Affiliation(s)
- Michael Loschi
- CHU de Nice, université Cote d'Azur, Inserm 1065, service d'hématologie clinique et thérapie cellulaire, 06000 Nice, France.
| | - Tamim Alsuliman
- AP-HP, Sorbonne université, hôpital Saint-Antoine, service d'hématologie, 75012 Paris, France
| | - Quentin Cabrera
- CHU Réunion Sud, service d'hématologie clinique, site de Saint-Pierre, Saint-Pierre, Réunion
| | | | - Deborah Desmier
- CHU de Poitiers, onco-hématologie clinique et thérapie cellulaire, 86000 Poitiers, France
| | | | - Thierry Guillaume
- CHU de Nantes, Hôtel-Dieu, service d'hématologie clinique, 44000 Nantes, France
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Bader P, Pötschger U, Dalle JH, Moser LM, Balduzzi A, Ansari M, Buechner J, Güngör T, Ifversen M, Krivan G, Pichler H, Renard M, Staciuk R, Sedlacek P, Stein J, Heusel JR, Truong T, Wachowiak J, Yesilipek A, Locatelli F, Peters C. Low rate of nonrelapse mortality in under-4-year-olds with ALL given chemotherapeutic conditioning for HSCT: a phase 3 FORUM study. Blood Adv 2024; 8:416-428. [PMID: 37738088 PMCID: PMC10827403 DOI: 10.1182/bloodadvances.2023010591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 09/05/2023] [Accepted: 09/08/2023] [Indexed: 09/23/2023] Open
Abstract
ABSTRACT Allogeneic hematopoietic stem cell transplantation (HSCT) is highly effective for treating pediatric high-risk or relapsed acute lymphoblastic leukemia (ALL). For young children, total body irradiation (TBI) is associated with severe late sequelae. In the FORUM study (NCT01949129), we assessed safety, event-free survival (EFS), and overall survival (OS) of 2 TBI-free conditioning regimens in children aged <4 years with ALL. Patients received fludarabine (Flu), thiotepa (Thio), and either busulfan (Bu) or treosulfan (Treo) before HSCT. From 2013 to 2021, 191 children received transplantation and were observed for ≥6 months (median follow-up: 3 years). The 3-year OS was 0.63 (95% confidence interval [95% CI], 0.52-0.72) and 0.76 (95% CI, 0.64-0.84) for Flu/Thio/Bu and Flu/Thio/Treo (P = .075), respectively. Three-year EFS was 0.52 (95% CI, 0.41-0.61) and 0.51 (95% CI, 0.39-0.62), respectively (P = .794). Cumulative incidence of nonrelapse mortality (NRM) and relapse at 3 years were 0.06 (95% CI, 0.02-0.12) vs 0.03 (95% CI: <0.01-0.09) (P = .406) and 0.42 (95% CI, 0.31-0.52) vs 0.45 (95% CI, 0.34-0.56) (P = .920), respectively. Grade >1 acute graft-versus-host disease (GVHD) occurred in 29% of patients receiving Flu/Thio/Bu and 17% of those receiving Flu/Thio/Treo (P = .049), whereas grade 3/4 occurred in 10% and 9%, respectively (P = .813). The 3-year incidence of chronic GVHD was 0.07 (95% CI, 0.03-0.13) vs 0.05 (95% CI, 0.02-0.11), respectively (P = .518). In conclusion, both chemotherapeutic conditioning regimens were well tolerated and NRM was low. However, relapse was the major cause of treatment failure. This trial was registered at www.clinicaltrials.gov as #NCT01949129.
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Affiliation(s)
- Peter Bader
- Goethe University, University Hospital, Department of Pediatrics, Division for Stem Cell Transplantation, Immunology and Intensive Care Medicine, Frankfurt, Germany
| | | | - Jean-Hugues Dalle
- Pediatric Hematology and Immunology Department, Robert Debré Hospital, Groupe Hospitalo-Universitaire Assistance Publique Hôpitaux de Paris (GHU AP-HP) Nord, Université Paris Cité, Paris, France
| | - Laura M. Moser
- Goethe University, University Hospital, Department of Pediatrics, Division for Stem Cell Transplantation, Immunology and Intensive Care Medicine, Frankfurt, Germany
| | - Adriana Balduzzi
- Università degli Studi di Milano-Fondazione, FONDAZIONE MONZA E BRIANZA PER IL BAMBINO E LA SUA MAMMA (MBBM), Department for Pediatric Hematology and Oncology, Monza, Italy
| | - Marc Ansari
- CANSEARCH Research Platform for Pediatric Oncology and Hematology, Faculty of Medicine, Department of Pediatrics, Gynecology and Obstetrics, University of Geneva, Switzerland
- Division of Pediatric Oncology and Hematology, Department of Women, Child and Adolescent, University Geneva Hospitals, Geneva, Switzerland
| | - Jochen Buechner
- Department of Pediatric Hematology and Oncology, Oslo University Hospital, Oslo, Norway
| | - Tayfun Güngör
- Department of Hematology/Oncology/Immunology, Gene Therapy, and Stem Cell Transplantation, University Children's Hospital Zürich, Eleonore Foundation & Children’s Research Center, Zürich, Switzerland
| | - Marianne Ifversen
- Copenhagen University Hospital Rigshospitalet, Department for Pediatric Hematology and Oncology, Copenhagen, Denmark
| | - Gergely Krivan
- Pediatric Hematology and Stem Cell Transplantation Department, Central Hospital of Southern Pest, National Institute of Hematology and Infectious Diseases, Budapest, Hungary
| | - Herbert Pichler
- St. Anna Children's Hospital, University Vienna, Vienna, Austria
| | - Marleen Renard
- Department of Paediatric Oncology, University Hospital Leuven, Leuven, Belgium
| | - Raquel Staciuk
- Hospital de Pediatría “Prof. Dr. Juan P. Garrahan,” Buenos Aires, Buenos Aires, Argentina
| | - Petr Sedlacek
- Department of Pediatric Hematology and Oncology, Motol University Hospital, Prague, Czech Republic
| | - Jerry Stein
- Schneider Children's Medical Center of Israel and Sackler Faculty of Medicine, Tel Aviv University, Petah Tikva, Israel
| | - Jan Robert Heusel
- Goethe University, University Hospital, Department of Pediatrics, Division for Stem Cell Transplantation, Immunology and Intensive Care Medicine, Frankfurt, Germany
| | - Tony Truong
- Division of Pediatric Oncology and Cellular Therapy, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Jacek Wachowiak
- Department of Pediatric Oncology, Hematology and Transplantology, Poznań University of Medical Sciences, Poznań, Poland
| | | | - Franco Locatelli
- Department of Pediatric Hematology and Oncology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale Pediatrico Bambino Gesù, Catholic University of the Sacred Heart, Rome, Italy
| | - Christina Peters
- St. Anna Children's Cancer Research Institute, Vienna, Austria
- St. Anna Children's Hospital, University Vienna, Vienna, Austria
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Rossig C, Pearson AD, Vassal G, Scobie N, Bird N, Blanc P, Vormoor HJ, Calkoen FG, Locatelli F, Bufalo FD, Rives S, Jacoby E, Balduzzi A, Bourquin JP, Baruchel A. Chimeric Antigen Receptor (CAR) T-Cell Products for Pediatric Cancers: Why Alternative Development Paths Are Needed. J Clin Oncol 2024; 42:253-257. [PMID: 38011605 DOI: 10.1200/jco.23.01314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 09/14/2023] [Accepted: 10/02/2023] [Indexed: 11/29/2023] Open
Affiliation(s)
- Claudia Rossig
- Department of Pediatric Hematology and Oncology, University Children's Hospital Muenster, Muenster, Germany
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | | | - Gilles Vassal
- ACCELERATE, Brussels, Belgium
- Department of Paediatric and Adolescent Oncology, Institut Gustave Roussy and Paris-Saclay University, Villejuif, France
| | | | - Nick Bird
- Solving Kids' Cancer UK, London, United Kingdom
| | | | - H Josef Vormoor
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- University Medical Center Utrecht, Utrecht, the Netherlands
| | - Friso G Calkoen
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Franco Locatelli
- Department of Pediatric Haematology/Oncology and Cell and Gene Therapy, IRCCS Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Francesca Del Bufalo
- Department of Pediatric Haematology/Oncology and Cell and Gene Therapy, IRCCS Ospedale Pediatrico Bambino Gesù, Rome, Italy
- AND Catholic University of the Sacred Heart, Rome, Italy
| | - Susana Rives
- CAR T-cell Unit, Leukemia and Lymphoma Department, Pediatric Cancer Center Barcelona /Hospital Sant Joan de Déu, Barcelona, Spain
- Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | - Elad Jacoby
- The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Adriana Balduzzi
- Pediatrics, Hematopoietic Stem Cell Transplantation Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Jean-Pierre Bourquin
- Department of Pediatric Hematology and Oncology, Immunology and Stem Cell Transplantation, University Children's Hospital, Zurich, Switzerland
| | - André Baruchel
- Department of Pediatric Hemato-Immunology, Hôpital Universitaire Robert Debré (APHP and Université Paris Cité), Paris, France
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Winestone LE, Bhojwani D, Ghorashian S, Muffly L, Leahy AB, Chao K, Steineck A, Rössig C, Lamble A, Maude SL, Myers R, Rheingold SR. INSPIRED Symposium Part 4A: Access to CAR T Cell Therapy in Unique Populations with B Cell Acute Lymphoblastic Leukemia. Transplant Cell Ther 2024; 30:56-70. [PMID: 37821078 DOI: 10.1016/j.jtct.2023.10.005] [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: 08/28/2023] [Revised: 10/06/2023] [Accepted: 10/06/2023] [Indexed: 10/13/2023]
Abstract
The approval of tisagenlecleucel (tisa-cel) for use in children with B cell acute lymphoblastic leukemia (B-ALL) was based on the phase 2 ELIANA trial, a global registration study. However, the ELIANA trial excluded specific subsets of patients facing unique challenges and did not include a sufficient number of patients to adequately evaluate outcomes in rare subpopulations. Since the commercialization of tisa-cel, data have become available that support therapeutic indications beyond the specific cohorts previously eligible for chimeric antigen receptor (CAR) T cells targeted to CD19 (CD19 CAR-T) therapy on the registration clinical trial. Substantial real-world data and aggregate clinical trial data have addressed gaps in our understanding of response rates, longer-term efficacy, and toxicities associated with CD19 CAR-T in special populations and rare clinical scenarios. These include patients with central nervous system relapsed disease, who were excluded from ELIANA and other early CAR-T trials owing to concerns about risk of neurotoxicity that have not been born out. There is also interest in the use of CD19 CAR-T for very-high-risk patients earlier in the course of therapy, such as patients with persistent minimal residual disease after 2 cycles of upfront chemotherapy and patients with first relapse of B-ALL. However, these indications are not specified on the label for tisa-cel and historically were not included in eligibility criteria for most clinical trials; data addressing these populations are needed. Populations at high risk of relapse, including patients with high-risk cytogenetic lesions, infants with B-ALL, patients with trisomy 21, and young adults with B-ALL, also may benefit from earlier treatment with CD19 CAR-T. It is important to prospectively study patient-reported outcomes given the differential toxicity expected between CD19 CAR-T and the historic standard of care, hematopoietic cell transplantation. Now that CD19 CAR-T therapy is commercially available, studies evaluating potential access disparities created by this very expensive novel therapy are increasingly pressing.
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Affiliation(s)
- Lena E Winestone
- Division of Allergy, Immunology, and BMT, Department of Pediatrics, UCSF Benioff Children's Hospitals, UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California.
| | - Deepa Bhojwani
- Division of Pediatric Hematology-Oncology, Children's Hospital Los Angeles, Norris Comprehensive Cancer Center and Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Sara Ghorashian
- Haematology Department, Great Ormond Street Hospital, London UK, Developmental Biology and Cancer, UCL-Great Ormond Street Institute of Child Health, University College London, London United Kingdom
| | - Lori Muffly
- Division of Blood and Marrow Transplantation and Cellular Therapy, Stanford University, Stanford, California
| | - Allison Barz Leahy
- Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Karen Chao
- Division of Hematology, Oncology, Stem Cell Transplantation and Regenerative Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Angela Steineck
- MACC Fund Center for Cancer and Blood Disorders, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Claudia Rössig
- University Children's Hospital Muenster, Pediatric Hematology and Oncology, Muenster, Germany; Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Adam Lamble
- Division of Hematology and Oncology, Seattle Children's Hospital, Department of Pediatrics, University of Washington, Seattle, Washington
| | - Shannon L Maude
- Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Regina Myers
- Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Susan R Rheingold
- Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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