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Daetwyler E, Wallrabenstein T, König D, Cappelli LC, Naidoo J, Zippelius A, Läubli H. Corticosteroid-resistant immune-related adverse events: a systematic review. J Immunother Cancer 2024; 12:e007409. [PMID: 38233099 PMCID: PMC10806650 DOI: 10.1136/jitc-2023-007409] [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] [Accepted: 10/28/2023] [Indexed: 01/19/2024] Open
Abstract
Immune checkpoint inhibitor (ICI) treatment has become an important therapeutic option for various cancer types. Although the treatment is effective, ICI can overstimulate the patient's immune system, leading to potentially severe immune-related adverse events (irAEs), including hepatitis, colitis, pneumonitis and myocarditis. The initial mainstay of treatments includes the administration of corticosteroids. There is little evidence how to treat steroid-resistant (sr) irAEs. It is mainly based on small case series or single case reports. This systematic review summarizes available evidence about sr-irAEs. We conducted a systematic literature search in PubMed. Additionally, we included European Society for Medical Oncology, Society for Immunotherapy of Cancer, National Comprehensive Cancer Network and American Society of Clinical Oncology Guidelines for irAEs in our assessment. The study population of all selected publications had to include patients with cancer who developed hepatitis, colitis, pneumonitis or myocarditis during or after an immunotherapy treatment and for whom corticosteroid therapy was not sufficient. Our literature search was not restricted to any specific cancer diagnosis. Case reports were also included. There is limited data regarding life-threatening sr-irAEs of colon/liver/lung/heart and the majority of publications are single case reports. Most publications investigated sr colitis (n=26), followed by hepatitis (n=21), pneumonitis (n=17) and myocarditis (n=15). There is most data for mycophenolate mofetil (MMF) to treat sr hepatitis and for infliximab, followed by vedolizumab, to treat sr colitis. Regarding sr pneumonitis there is most data for MMF and intravenous immunoglobulins (IVIG) while data regarding infliximab are conflicting. In sr myocarditis, most evidence is available for the use of abatacept or anti-thymocyte globulin (ATG) (both with or without MMF) or ruxolitinib with abatacept. This review highlights the need for prompt recognition and treatment of sr hepatitis, colitis, pneumonitis and myocarditis. Guideline recommendations for sr situations are not defined precisely. Based on our search, we recommend-as first line treatment-(1) MMF for sr hepatitis, (2) infliximab for sr colitis, followed by vedolizumab, (3) MMF and IVIG for sr pneumonitis and (4) abatacept or ATG (both with or without MMF) or ruxolitinib with abatacept for sr myocarditis. These additional immunosuppressive agents should be initiated promptly if there is no sufficient response to corticosteroids within 3 days.
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Affiliation(s)
- Eveline Daetwyler
- Division of Medical Oncology, University Hospital Basel, Basel, Switzerland
| | - Till Wallrabenstein
- Division of Medical Oncology, University Hospital Basel, Basel, Switzerland
- Division of Hematology and Medical Oncology, University Medical Center Freiburg, Freiburg, Germany
| | - David König
- Division of Medical Oncology, University Hospital Basel, Basel, Switzerland
| | - Laura C Cappelli
- Divison of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Alfred Zippelius
- Division of Medical Oncology, University Hospital Basel, Basel, Switzerland
- Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Heinz Läubli
- Division of Medical Oncology, University Hospital Basel, Basel, Switzerland
- Department of Biomedicine, University of Basel, Basel, Switzerland
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Al Malki MM, London K, Baez J, Akahoshi Y, Hogan WJ, Etra A, Choe H, Hexner E, Langston A, Abhyankar S, Ponce DM, DeFilipp Z, Kitko CL, Adekola K, Reshef R, Ayuk F, Capellini A, Chanswangphuwana C, Eder M, Eng G, Gandhi I, Grupp S, Gleich S, Holler E, Javorniczky NR, Kasikis S, Kowalyk S, Morales G, Özbek U, Rösler W, Spyrou N, Yanik G, Young R, Chen YB, Nakamura R, Ferrara JLM, Levine JE. Phase 2 study of natalizumab plus standard corticosteroid treatment for high-risk acute graft-versus-host disease. Blood Adv 2023; 7:5189-5198. [PMID: 37235690 PMCID: PMC10505783 DOI: 10.1182/bloodadvances.2023009853] [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: 01/27/2023] [Revised: 04/05/2023] [Accepted: 04/10/2023] [Indexed: 05/28/2023] Open
Abstract
Graft-versus-host disease (GVHD) of the gastrointestinal (GI) tract is the main cause of nonrelapse mortality (NRM) after allogeneic hematopoietic cell transplantation. Ann Arbor (AA) scores derived from serum biomarkers at onset of GVHD quantify GI crypt damage; AA2/3 scores correlate with resistance to treatment and higher NRM. We conducted a multicenter, phase 2 study using natalizumab, a humanized monoclonal antibody that blocks T-cell trafficking to the GI tract through the α4 subunit of α4β7 integrin, combined with corticosteroids as primary treatment for patients with new onset AA2/3 GVHD. Seventy-five patients who were evaluable were enrolled and treated; 81% received natalizumab within 2 days of starting corticosteroids. Therapy was well tolerated with no treatment emergent adverse events in >10% of patients. Outcomes for patients treated with natalizumab plus corticosteroids were compared with 150 well-matched controls from the MAGIC database whose primary treatment was corticosteroids alone. There were no significant differences in overall or complete response between patients treated with natalizumab plus corticosteroids and those treated with corticosteroids alone (60% vs 58%; P = .67% and 48% vs 48%; P = 1.0, respectively) including relevant subgroups. There were also no significant differences in NRM or overall survival at 12 months in patients treated with natalizumab plus corticosteroids compared with controls treated with corticosteroids alone (38% vs 39%; P = .80% and 46% vs 54%; P = .48, respectively). In this multicenter biomarker-based phase 2 study, natalizumab combined with corticosteroids failed to improve outcome of patients with newly diagnosed high-risk GVHD. This trial was registered at www.clinicaltrials.gov as # NCT02133924.
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Affiliation(s)
- Monzr M. Al Malki
- Hematology/Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Kaitlyn London
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Janna Baez
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Yu Akahoshi
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Aaron Etra
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Hannah Choe
- Division of Hematology, James Cancer Center, The Ohio State University, Columbus, OH
| | - Elizabeth Hexner
- Blood and Marrow Transplantation Program, Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | | | - Sunil Abhyankar
- Division of Hematologic Malignancies and Cellular Therapeutics, University of Kansas Medical Center, Kansas City, KS
| | - Doris M. Ponce
- Division of Hematology/Oncology, Department of Medicine, Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering, New York, NY
| | - Zachariah DeFilipp
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - Carrie L. Kitko
- Pediatric Stem Cell Transplant Program, Vanderbilt University Medical Center, Nashville, TN
| | - Kehinde Adekola
- Division of Hematology/Oncology, Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Ran Reshef
- Blood and Marrow Transplantation, Columbia University Medical Center, New York, NY
| | - Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alexandra Capellini
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Chantiya Chanswangphuwana
- Department of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Matthias Eder
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Gilbert Eng
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Isha Gandhi
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Stephan Grupp
- Division of Oncology, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Sigrun Gleich
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Ernst Holler
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Nora Rebeka Javorniczky
- Department of Medicine I, Medical Center - University of Freiburg, Faculty of Medicine, Albert Ludwigs University, Freiburg, Germany
| | - Stelios Kasikis
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Steven Kowalyk
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - George Morales
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Umut Özbek
- Department of Population Health Science and Policy, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Wolf Rösler
- Department of Internal Medicine 5, University Hospital Erlangen, Erlangen, Germany
| | - Nikolaos Spyrou
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Gregory Yanik
- Blood and Marrow Transplant Program, Michigan Medicine, Ann Arbor, MI
| | - Rachel Young
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Yi-Bin Chen
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - Ryotaro Nakamura
- Hematology/Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - James L. M. Ferrara
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - John E. Levine
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
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Algeri M, Becilli M, Locatelli F. Ruxolitinib as the first post-steroid treatment for acute and chronic graft-versus-host disease. Expert Rev Clin Immunol 2023; 19:1299-1313. [PMID: 37606511 DOI: 10.1080/1744666x.2023.2249230] [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: 12/30/2022] [Accepted: 08/14/2023] [Indexed: 08/23/2023]
Abstract
INTRODUCTION Acute and chronic graft-versus-host disease (GvHD) are potentially life-threatening complications occurring after allogeneic stem cell transplantation (allo-HSCT). Although steroids represent the first-line treatment for both conditions, in those patients who do not adequately benefit from steroid therapy, standardized treatment algorithms are lacking. In recent years, ruxolitinib has emerged as the most promising agent for the second-line therapy of steroid-refractory (SR)-GvHD. AREAS COVERED This review will summarize the biological properties and the mechanistic aspects that justify the therapeutic role of ruxolitinib in GvHD. In addition, current treatment options for SR-GvHD will be briefly discussed. Finally, results of the most relevant clinical trials on the use of ruxolitinib for SR-GvHD will be analyzed, with a particular focus on two phase-III randomized trials in which ruxolitinib demonstrated its superiority in comparison with the best available therapy. EXPERT OPINION Ruxolitinib has considerably improved the outcome of patients with SR-acute/chronic-GvHD and should be regarded as the standard-of-care option when corticosteroids fail or cannot be tapered. Nevertheless, a number of questions still remain unanswered and significant room for improvement exists. Additional observations derived from a longer follow-up will certainly increase our expertise in the management of this powerful therapy.
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Affiliation(s)
- Mattia Algeri
- Department of Haematology/Oncology and Cell and Gene Therapy, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
- Department of Health Science, Magna Grecia University of Catanzaro, Catanzaro, Italy
| | - Marco Becilli
- Department of Haematology/Oncology and Cell and Gene Therapy, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Franco Locatelli
- Department of Haematology/Oncology and Cell and Gene Therapy, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
- Department of Life Sciences and Public Health, Catholic University of the Sacred Heart, Rome, Italy
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Tkachev V, Vanderbeck A, Perkey E, Furlan SN, McGuckin C, Atria DG, Gerdemann U, Rui X, Lane J, Hunt DJ, Zheng H, Colonna L, Hoffman M, Yu A, Outen R, Kelly S, Allman A, Koch U, Radtke F, Ludewig B, Burbach B, Shimizu Y, Panoskaltsis-Mortari A, Chen G, Carpenter SM, Harari O, Kuhnert F, Thurston G, Blazar BR, Kean LS, Maillard I. Notch signaling drives intestinal graft-versus-host disease in mice and nonhuman primates. Sci Transl Med 2023; 15:eadd1175. [PMID: 37379368 PMCID: PMC10896076 DOI: 10.1126/scitranslmed.add1175] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 05/31/2023] [Indexed: 06/30/2023]
Abstract
Notch signaling promotes T cell pathogenicity and graft-versus-host disease (GVHD) after allogeneic hematopoietic cell transplantation (allo-HCT) in mice, with a dominant role for the Delta-like Notch ligand DLL4. To assess whether Notch's effects are evolutionarily conserved and to identify the mechanisms of Notch signaling inhibition, we studied antibody-mediated DLL4 blockade in a nonhuman primate (NHP) model similar to human allo-HCT. Short-term DLL4 blockade improved posttransplant survival with durable protection from gastrointestinal GVHD in particular. Unlike prior immunosuppressive strategies tested in the NHP GVHD model, anti-DLL4 interfered with a T cell transcriptional program associated with intestinal infiltration. In cross-species investigations, Notch inhibition decreased surface abundance of the gut-homing integrin α4β7 in conventional T cells while preserving α4β7 in regulatory T cells, with findings suggesting increased β1 competition for α4 binding in conventional T cells. Secondary lymphoid organ fibroblastic reticular cells emerged as the critical cellular source of Delta-like Notch ligands for Notch-mediated up-regulation of α4β7 integrin in T cells after allo-HCT. Together, DLL4-Notch blockade decreased effector T cell infiltration into the gut, with increased regulatory to conventional T cell ratios early after allo-HCT. Our results identify a conserved, biologically unique, and targetable role of DLL4-Notch signaling in intestinal GVHD.
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Affiliation(s)
- Victor Tkachev
- Massachusetts General Hospital, Center for Transplantation Sciences, Boston, MA 02114
- Division of Hematology/Oncology, Boston Children’s Hospital and Department of Pediatric Oncology, Dana Farber Cancer Institute, Department of Pediatrics, Harvard Medical School, Boston, MA 02115
| | - Ashley Vanderbeck
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104
- Immunology Graduate Group and Veterinary Medical Scientist Training Program, University of Pennsylvania, Philadelphia, PA 19104
| | - Eric Perkey
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104
- Graduate Program in Cellular and Molecular Biology, University of Michigan, Ann Arbor, MI 48109
| | - Scott N. Furlan
- Clinical Research Division, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA 98109
| | - Connor McGuckin
- Division of Hematology/Oncology, Boston Children’s Hospital and Department of Pediatric Oncology, Dana Farber Cancer Institute, Department of Pediatrics, Harvard Medical School, Boston, MA 02115
| | - Daniela Gómez Atria
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104
| | - Ulrike Gerdemann
- Division of Hematology/Oncology, Boston Children’s Hospital and Department of Pediatric Oncology, Dana Farber Cancer Institute, Department of Pediatrics, Harvard Medical School, Boston, MA 02115
| | - Xianliang Rui
- Division of Hematology/Oncology, Boston Children’s Hospital and Department of Pediatric Oncology, Dana Farber Cancer Institute, Department of Pediatrics, Harvard Medical School, Boston, MA 02115
| | - Jennifer Lane
- Division of Hematology/Oncology, Boston Children’s Hospital and Department of Pediatric Oncology, Dana Farber Cancer Institute, Department of Pediatrics, Harvard Medical School, Boston, MA 02115
| | - Daniel J. Hunt
- Ben Towne Center for Childhood Cancer Research, Seattle Children’s Research Institute, University of Washington, Seattle, WA 98101
| | - Hengqi Zheng
- Ben Towne Center for Childhood Cancer Research, Seattle Children’s Research Institute, University of Washington, Seattle, WA 98101
| | - Lucrezia Colonna
- Ben Towne Center for Childhood Cancer Research, Seattle Children’s Research Institute, University of Washington, Seattle, WA 98101
| | - Michelle Hoffman
- Clinical Research Division, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA 98109
| | - Alison Yu
- Ben Towne Center for Childhood Cancer Research, Seattle Children’s Research Institute, University of Washington, Seattle, WA 98101
| | - Riley Outen
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104
| | - Samantha Kelly
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104
| | - Anneka Allman
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104
| | - Ute Koch
- EPFL, 1015 Lausanne, Switzerland
| | | | - Burkhard Ludewig
- Medical Research Center, Kantonsspital St. Gallen, 9007 St. Gallen, Switzerland
| | - Brandon Burbach
- Department of Laboratory Medicine and Pathology, Center for Immunology, Masonic Cancer Center, University of Minnesota School of Medicine, Minneapolis, MN 55455
| | - Yoji Shimizu
- Department of Laboratory Medicine and Pathology, Center for Immunology, Masonic Cancer Center, University of Minnesota School of Medicine, Minneapolis, MN 55455
| | - Angela Panoskaltsis-Mortari
- Division of Blood & Marrow Transplant & Cellular Therapy, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis, MN 55455
| | - Guoying Chen
- Regeneron Pharmaceuticals Inc., Tarrytown, NY 10591
| | | | | | | | | | - Bruce R. Blazar
- Division of Blood & Marrow Transplant & Cellular Therapy, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis, MN 55455
| | - Leslie S. Kean
- Division of Hematology/Oncology, Boston Children’s Hospital and Department of Pediatric Oncology, Dana Farber Cancer Institute, Department of Pediatrics, Harvard Medical School, Boston, MA 02115
| | - Ivan Maillard
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104
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Luo C, Huang X, Wei L, Wu G, Huang Y, Ding Y, Huang Z, Chen J, Li X, Zou Y, Xu S. Second-line therapy for patients with steroid-refractory aGVHD: systematic review and meta-analysis of randomized controlled trials. Front Immunol 2023; 14:1211171. [PMID: 37409129 PMCID: PMC10318925 DOI: 10.3389/fimmu.2023.1211171] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 06/08/2023] [Indexed: 07/07/2023] Open
Abstract
Objective Steroids-refractory (SR) acute graft-versus-host disease (aGVHD) is a life-threatening condition in patients undergoing allogeneic hematopoietic stem cell transplantation (allo-HSCT), but the optimal second-line therapy still has not been established. We aimed to perform a systematic review and meta-analysis of randomized controlled trials (RCTs) to compare the efficacy and safety of different second-line therapy regimens. Methods Literature search in MEDLINE, Embase, Cochrane Library and China Biology Medicine databases were performed to retrieve RCTs comparing the efficacy and safety of different therapy regimens for patients with SR aGVHD. Meta-analysis was conducted with Review Manager version 5.3. The primary outcome is the overall response rate (ORR) at day 28. Pooled relative risk (RR) and 95% confidence interval (CI) were calculated with the Mantel-Haenszel method. Results Eight eligible RCTs were included, involving 1127 patients with SR aGVHD and a broad range of second-line therapy regimens. Meta-analysis of 3 trials investigating the effects of adding mesenchymal stroma cells (MSCs) to other second-line therapy regimens suggested that the addition of MSCs is associated with significantly improvement in ORR at day 28 (RR = 1.15, 95% CI = 1.01-1.32, P = 0.04), especially in patients with severe (grade III-IV or grade C-D) aGVHD (RR = 1.26, 95% CI = 1.04-1.52, P = 0.02) and patients with multiorgan involved (RR = 1.27, 95% CI = 1.05-1.55, P = 0.01). No significant difference was observed betwwen the MSCs group and control group in consideration of overall survival and serious adverse events. Treatment outcomes of the other trials were comprehensively reviewed, ruxolitinib showed significantly higher ORR and complete response rate at day 28, higher durable overall response at day 56 and longer failure-free survival in comparison with other regimens; inolimomab shows similar 1-year therapy success rate but superior long-term overall survial in comparison with anti-thymocyte globulin, other comparisons did not show significant differences in efficacy. Conclusions Adding MSCs to other second-line therapy regimens is associated with significantly improved ORR, ruxolitinib showed significantly better efficacy outcomes in comparison with other regimens in patients with SR aGVHD. Further well-designed RCTs and integrated studies are required to determine the optimal treatment. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022342487.
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Affiliation(s)
- Chengxin Luo
- Center for Hematology, Southwest Hospital, Third Military Medical University, Chongqing, China
- Chongqing Key Laboratory of Tumor Immunotherapy, Chongqing Science & Technology Commission, Chongqing, China
| | - Xiangtao Huang
- Center for Hematology, Southwest Hospital, Third Military Medical University, Chongqing, China
- Chongqing Key Laboratory of Tumor Immunotherapy, Chongqing Science & Technology Commission, Chongqing, China
| | - Ling Wei
- Center for Hematology, Southwest Hospital, Third Military Medical University, Chongqing, China
- Chongqing Key Laboratory of Tumor Immunotherapy, Chongqing Science & Technology Commission, Chongqing, China
| | - Guixian Wu
- Center for Hematology, Southwest Hospital, Third Military Medical University, Chongqing, China
- Chongqing Key Laboratory of Tumor Immunotherapy, Chongqing Science & Technology Commission, Chongqing, China
| | - Yarui Huang
- Center for Hematology, Southwest Hospital, Third Military Medical University, Chongqing, China
- Chongqing Key Laboratory of Tumor Immunotherapy, Chongqing Science & Technology Commission, Chongqing, China
| | - Yaqun Ding
- Center for Hematology, Southwest Hospital, Third Military Medical University, Chongqing, China
- Chongqing Key Laboratory of Tumor Immunotherapy, Chongqing Science & Technology Commission, Chongqing, China
| | - Zhen Huang
- Center for Hematology, Southwest Hospital, Third Military Medical University, Chongqing, China
- Chongqing Key Laboratory of Tumor Immunotherapy, Chongqing Science & Technology Commission, Chongqing, China
| | - Jieping Chen
- Center for Hematology, Southwest Hospital, Third Military Medical University, Chongqing, China
- Chongqing Key Laboratory of Tumor Immunotherapy, Chongqing Science & Technology Commission, Chongqing, China
| | - Xi Li
- Department of Hematology, Daping Hospital, Third Military Medical University, Chongqing, China
| | - Yunding Zou
- Center for Hematology, Southwest Hospital, Third Military Medical University, Chongqing, China
- Chongqing Key Laboratory of Tumor Immunotherapy, Chongqing Science & Technology Commission, Chongqing, China
| | - Shuangnian Xu
- Center for Hematology, Southwest Hospital, Third Military Medical University, Chongqing, China
- Chongqing Key Laboratory of Tumor Immunotherapy, Chongqing Science & Technology Commission, Chongqing, China
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Sacirbegovic F, Günther M, Greco A, Zhao D, Wang X, Zhou M, Rosenberger S, Oberbarnscheidt MH, Held W, McNiff J, Jain D, Höfer T, Shlomchik WD. Graft-versus-host disease is locally maintained in target tissues by resident progenitor-like T cells. Immunity 2023; 56:369-385.e6. [PMID: 36720219 PMCID: PMC10182785 DOI: 10.1016/j.immuni.2023.01.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 11/06/2022] [Accepted: 01/05/2023] [Indexed: 02/02/2023]
Abstract
In allogeneic hematopoietic stem cell transplantation, donor αβ T cells attack recipient tissues, causing graft-versus-host disease (GVHD), a major cause of morbidity and mortality. A central question has been how GVHD is sustained despite T cell exhaustion from chronic antigen stimulation. The current model for GVHD holds that disease is maintained through the continued recruitment of alloreactive effectors from blood into affected tissues. Here, we show, using multiple approaches including parabiosis of mice with GVHD, that GVHD is instead primarily maintained locally within diseased tissues. By tracking 1,203 alloreactive T cell clones, we fitted a mathematical model predicting that within each tissue a small number of progenitor T cells maintain a larger effector pool. Consistent with this, we identified a tissue-resident TCF-1+ subpopulation that preferentially engrafted, expanded, and differentiated into effectors upon adoptive transfer. These results suggest that therapies targeting affected tissues and progenitor T cells within them would be effective.
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Affiliation(s)
- Faruk Sacirbegovic
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Matthias Günther
- Division of Theoretical Systems Biology, German Cancer Research Center (DKFZ), Heidelberg, Germany; BioQuant Center, University of Heidelberg, Heidelberg, Germany
| | - Alessandro Greco
- Division of Theoretical Systems Biology, German Cancer Research Center (DKFZ), Heidelberg, Germany; BioQuant Center, University of Heidelberg, Heidelberg, Germany
| | - Daqiang Zhao
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Xi Wang
- Division of Theoretical Systems Biology, German Cancer Research Center (DKFZ), Heidelberg, Germany; BioQuant Center, University of Heidelberg, Heidelberg, Germany
| | - Meng Zhou
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sarah Rosenberger
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Martin H Oberbarnscheidt
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Immunology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Werner Held
- Department of Oncology, University of Lausanne, Lausanne, Switzerland
| | - Jennifer McNiff
- Department of Dermatology, Yale University School of Medicine, New Haven, CT, USA
| | - Dhanpat Jain
- Department of Pathology, Yale University School of Medicine, New Haven, CT, USA
| | - Thomas Höfer
- Division of Theoretical Systems Biology, German Cancer Research Center (DKFZ), Heidelberg, Germany; BioQuant Center, University of Heidelberg, Heidelberg, Germany.
| | - Warren D Shlomchik
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Immunology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA; UPMC Hillman Cancer Center, Pittsburgh, PA, USA.
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7
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Aldouby Bier G, Zaidman I, Dinur Schejter Y, NaserEddin A, Stepensky P, Even-Or E. Vedolizumab for pediatric patients with gastrointestinal acute graft-versus-host-disease. Pediatr Blood Cancer 2023; 70:e30061. [PMID: 36326084 DOI: 10.1002/pbc.30061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 09/06/2022] [Accepted: 09/26/2022] [Indexed: 11/06/2022]
Abstract
Vedolizumab, an anti-α4β7 integrin monoclonal antibody, impairs homing of T-cells to the gastrointestinal (GI) endothelium and acts as a gut-selective anti-inflammatory agent. Recent reports of the efficacy of vedolizumab in treating lower GI acute graft-versus-host disease (aGVHD) are promising, but experience in children is scarce. We present a cohort of 13 pediatric patients who were treated with vedolizumab for GI aGVHD. Ten of the patients were treated for steroid-refractory disease, out of which, six suffered from severe (stage 3 or 4) GI disease before the first dose of vedolizumab. In the other three patients, vedolizumab was introduced early in the disease course. Median time between GI GVHD onset to vedolizumab treatment was 23 days (range 7-59 days), with a median of 3 doses (range 1-5) per patient. GI GVHD staging was evaluated at various time points after the first vedolizumab dose, showing improvement in nine of the 13 patients. After a median follow-up time of 13 months (range 6-34 months), eight patients completely recovered, two had ongoing chronic colitis, and three patients died. During the vedolizumab treatment period, 38 infectious episodes were noted, most of them GI related. The unique activity profile of vedolizumab makes it an appealing treatment option for lower GI aGVHD, but caution for concurrent infections is warranted.
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Affiliation(s)
- Gefen Aldouby Bier
- Department of Bone Marrow Transplantation and Cancer Immunotherapy, Faculty of Medicine, Hebrew University of Jerusalem, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Pharmacy Division, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Irina Zaidman
- Department of Bone Marrow Transplantation and Cancer Immunotherapy, Faculty of Medicine, Hebrew University of Jerusalem, Hadassah Medical Center, Jerusalem, Israel
| | - Yael Dinur Schejter
- Department of Bone Marrow Transplantation and Cancer Immunotherapy, Faculty of Medicine, Hebrew University of Jerusalem, Hadassah Medical Center, Jerusalem, Israel
| | - Adeeb NaserEddin
- Department of Bone Marrow Transplantation and Cancer Immunotherapy, Faculty of Medicine, Hebrew University of Jerusalem, Hadassah Medical Center, Jerusalem, Israel
| | - Polina Stepensky
- Department of Bone Marrow Transplantation and Cancer Immunotherapy, Faculty of Medicine, Hebrew University of Jerusalem, Hadassah Medical Center, Jerusalem, Israel
| | - Ehud Even-Or
- Department of Bone Marrow Transplantation and Cancer Immunotherapy, Faculty of Medicine, Hebrew University of Jerusalem, Hadassah Medical Center, Jerusalem, Israel
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8
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Li ACW, Dong C, Tay ST, Ananthakrishnan A, Ma KSK. Vedolizumab for acute gastrointestinal graft-versus-host disease: A systematic review and meta-analysis. Front Immunol 2022; 13:1025350. [PMID: 36439135 PMCID: PMC9692080 DOI: 10.3389/fimmu.2022.1025350] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 09/26/2022] [Indexed: 04/05/2024] Open
Abstract
OBJECTIVE To determine the safety and efficacy of vedolizumab for the prophylaxis and treatment of gastrointestinal involvement of acute graft-versus-host disease (GVHD) (GI-aGVHD). METHODS Literature search within PubMed, EMBASE, Web of Science, and Cochrane Library for observational studies and clinical trials that evaluated the effect of vedolizumab on GI-aGVHD was done through 17 May 2022. A bivariate and random-effect meta-analysis derived the pooled observational percentages and pooled risk ratios (RRs) from baseline of primary endpoints including overall response, complete response, mortality, and adverse events. RESULTS There was a total of 122 participants in eight eligible studies, including one study on the prophylactic use of vedolizumab and seven studies on vedolizumab for the treatment of GI-aGVHD. Of seven studies that reported details on baseline grades of GI-aGVHD, a total of 47 patients (47.95%) were of stage 4, 31 patients (31.63%) were of stage 3, 10 patients (10.2%) were of stage 2, and 10 patients (10.2%) were of stage 1. The use of vedolizumab for the treatment of GI-aGVHD yielded a significantly improved objective response rate (ORR) at 14 days (pooled ORR = 60.53%, pooled RR = 14.14, 95% CI: 2.95-67.71), 28 days (pooled ORR = 50%, RR = 7.36, 95% CI = 2.14-25.37), and 12 months (pooled ORR = 76.92%, RR = 13.66, 95% CI = 3.5-53.35) from baseline. Likewise, the use of vedolizumab was followed by a significantly improved complete response (CR) at 12 months (pooled CR = 27.27%, RR = 5.50, 95% CI = 1.01-29.95), yet the CR at 14 days and 28 days did not reach statistical significance. Fifty-seven out of 87 (pooled overall survival, OS = 34.5%) and 46 out of 65 (pooled OS = 29.2%) patients expired at 6 and 12 months after the use of vedolizumab, respectively. Prophylactic use of vedolizumab was not associated with any specific type of reported adverse events, while patients with GI-aGVHD on vedolizumab presented with significantly increased risks of adverse events including infections (RR = 7.55) and impaired metabolism or nutritional complications (RR = 9.00). All analyses were of a low heterogeneity (all I-squares = 0%). CONCLUSION Vedolizumab was safe and effective for the prophylaxis and management of early grade GI-aGVHD. More clinical evidence is warranted to validate these findings. SYSTEMATIC REVIEW REGISTRATION https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=345584, identifier CRD42022345584.
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Affiliation(s)
- Allen Cheng-Wei Li
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Medical Education, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Chen Dong
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Soon-Tzeh Tay
- Department of Medical Education, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ashwin Ananthakrishnan
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Kevin Sheng-Kai Ma
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, United States
- Department of Dermatology, Massachusetts General Hospital, Boston, MA, United States
- Center for Global Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
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9
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Verbeek AB, Jansen SA, von Asmuth EG, Lankester AC, Bresters D, Bierings M, Mohseny AB, Lindemans CA, Buddingh EP. Clinical Features, Treatment, and Outcome of Pediatric Steroid Refractory Acute Graft-Versus-Host Disease: A Multicenter Study. Transplant Cell Ther 2022; 28:600.e1-600.e9. [DOI: 10.1016/j.jtct.2022.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 05/31/2022] [Accepted: 06/07/2022] [Indexed: 11/17/2022]
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10
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Tsubokura Y, Yoshimura H, Satake A, Nasa Y, Tsuji R, Ito T, Nomura S. Early administration of lenalidomide after allogeneic hematopoietic stem cell transplantation suppresses graft-versus-host disease by inhibiting T-cell migration to the gastrointestinal tract. Immun Inflamm Dis 2022; 10:e688. [PMID: 36039651 PMCID: PMC9425011 DOI: 10.1002/iid3.688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 07/30/2022] [Accepted: 08/01/2022] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Allogeneic hematopoietic stem cell transplantation (aHSCT) is a curative treatment for hematopoietic malignancies. Graft-versus-host disease (GVHD) is a major complication of aHSCT. After transplantation, the balance of immune conditions, such as proinflammatory cytokine level and T-cell subset count, influences GVHD magnitude. Lenalidomide (LEN) is an immunomodulatory drug used for treating several hematological malignancies such as multiple myeloma, adult T-cell lymphoma/leukemia, and follicular lymphoma. However, the impact of LEN on immune responses after aHSCT has not been elucidated. METHODS We analyzed the lymphocyte composition in naïve mice treated with LEN. Subsequently, we treated host mice with LEN, soon after aHSCT, and analyzed GVHD severity as well as the composition and characteristics of lymphocytes associated with GVHD. RESULTS Using a mouse model, we demonstrated the beneficial effects of LEN for treating acute GVHD. Although natural killer cells were slightly increased by LEN, it did not significantly change T-cell proliferation and the balance of the T-cell subset in naïve mice. LEN did not modulate the suppressive function of regulatory T cells (Tregs). Unexpectedly, LEN prevented severe GVHD in a mouse acute GVHD model. Donor-derived lymphocytes were more numerous in host mice treated with LEN than in host mice treated with vehicle. Lymphocyte infiltration of the gastrointestinal tract in host mice treated with LEN was less severe compared to that in host mice treated with vehicle. The percentage of LPAM-1 (α4 β7 -integrin)-expressing Foxp3- CD4+ T cells was significantly lower in host mice treated with LEN than in host mice treated with vehicle, whereas that of LPAM-1-expressing Tregs was comparable. CONCLUSIONS LEN may be useful as a prophylactic agent for acute GVHD-induced mortality through the inhibition of lymphocyte migration to the gastrointestinal tract. Our data show the effect of LEN on immune responses early after aHSCT and suggest that cereblon, a molecular target of LEN, may be a therapeutic target for preventing acute GVHD-induced mortality.
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Affiliation(s)
- Yukie Tsubokura
- First Department of Internal MedicineKansai Medical UniversityHirakata CityOsakaJapan
| | - Hideaki Yoshimura
- First Department of Internal MedicineKansai Medical UniversityHirakata CityOsakaJapan
| | - Atsushi Satake
- First Department of Internal MedicineKansai Medical UniversityHirakata CityOsakaJapan
| | - Yutaro Nasa
- First Department of Internal MedicineKansai Medical UniversityHirakata CityOsakaJapan
| | - Ryohei Tsuji
- First Department of Internal MedicineKansai Medical UniversityHirakata CityOsakaJapan
| | - Tomoki Ito
- First Department of Internal MedicineKansai Medical UniversityHirakata CityOsakaJapan
| | - Shosaku Nomura
- First Department of Internal MedicineKansai Medical UniversityHirakata CityOsakaJapan
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11
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Song Q, Nasri U, Nakamura R, Martin PJ, Zeng D. Retention of Donor T Cells in Lymphohematopoietic Tissue and Augmentation of Tissue PD-L1 Protection for Prevention of GVHD While Preserving GVL Activity. Front Immunol 2022; 13:907673. [PMID: 35677056 PMCID: PMC9168269 DOI: 10.3389/fimmu.2022.907673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 04/26/2022] [Indexed: 11/30/2022] Open
Abstract
Allogeneic hematopoietic cell transplantation (Allo-HCT) is a curative therapy for hematological malignancies (i.e., leukemia and lymphoma) due to the graft-versus-leukemia (GVL) activity mediated by alloreactive T cells that can eliminate residual malignant cells and prevent relapse. However, the same alloreactive T cells can cause a serious side effect, known as graft-versus-host disease (GVHD). GVHD and GVL occur in distinct organ and tissues, with GVHD occurring in target organs (e.g., the gut, liver, lung, skin, etc.) and GVL in lympho-hematopoietic tissues where hematological cancer cells primarily reside. Currently used immunosuppressive drugs for the treatment of GVHD inhibit donor T cell activation and expansion, resulting in a decrease in both GVHD and GVL activity that is associated with cancer relapse. To prevent GVHD, it is important to allow full activation and expansion of alloreactive T cells in the lympho-hematopoietic tissues, as well as prevent donor T cells from migrating into the GVHD target tissues, and tolerize infiltrating T cells via protective mechanisms, such as PD-L1 interacting with PD-1, in the target tissues. In this review, we will summarize major approaches that prevent donor T cell migration into GVHD target tissues and approaches that augment tolerization of the infiltrating T cells in the GVHD target tissues while preserving strong GVL activity in the lympho-hematopoietic tissues.
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Affiliation(s)
- Qingxiao Song
- Arthur D. Riggs Diabetes and Metabolism Research Institute, The Beckman Research Institute, City of Hope National Medical Center, Duarte, CA, Unites States.,Hematologic Malignancies and Stem Cell Transplantation Institute, City of Hope National Medical Center, Duarte, CA, Unites States.,Fujian Medical University Center of Translational Hematology, Fujian Institute of Hematology, and Fujian Medical University Union Hospital, Fuzhou, China
| | - Ubaydah Nasri
- Arthur D. Riggs Diabetes and Metabolism Research Institute, The Beckman Research Institute, City of Hope National Medical Center, Duarte, CA, Unites States.,Hematologic Malignancies and Stem Cell Transplantation Institute, City of Hope National Medical Center, Duarte, CA, Unites States
| | - Ryotaro Nakamura
- Hematologic Malignancies and Stem Cell Transplantation Institute, City of Hope National Medical Center, Duarte, CA, Unites States
| | - Paul J Martin
- Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA, United States
| | - Defu Zeng
- Arthur D. Riggs Diabetes and Metabolism Research Institute, The Beckman Research Institute, City of Hope National Medical Center, Duarte, CA, Unites States.,Hematologic Malignancies and Stem Cell Transplantation Institute, City of Hope National Medical Center, Duarte, CA, Unites States
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12
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A Promising Insight: The Potential Influence and Therapeutic Value of the Gut Microbiota in GI GVHD. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:2124627. [PMID: 35571252 PMCID: PMC9098338 DOI: 10.1155/2022/2124627] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 04/13/2022] [Indexed: 02/07/2023]
Abstract
Allogeneic hematopoietic cell transplantation (allo-HSCT) is a reconstruction process of hematopoietic and immune functions that can be curative in patients with hematologic malignancies, but it carries risks of graft-versus-host disease (GVHD), thrombotic microangiopathy (TMA), Epstein–Barr virus (EBV) infection, cytomegalovirus infection, secondary hemophagocytic lymphohistiocytosis (sHLH), macrophage activation syndrome (MAS), bronchiolitis obliterans, and posterior reversible encephalopathy syndrome (PRES). Gastrointestinal graft-versus-host disease (GI GVHD), a common complication of allo-HSCT, is one of the leading causes of transplant-related death because of its high treatment difficulty, which is affected by preimplantation, antibiotic use, dietary changes, and intestinal inflammation. At present, human trials and animal studies have proven that a decrease in intestinal bacterial diversity is associated with the occurrence of GI GVHD. Metabolites produced by intestinal bacteria, such as lipopolysaccharides, short-chain fatty acids, and secondary bile acids, can affect the development of GVHD through direct or indirect interactions with immune cells. The targeted damage of GVHD on intestinal stem cells (ISCs) and Paneth cells results in intestinal dysbiosis or dysbacteriosis. Based on the effect of microbiota metabolites on the gastrointestinal tract, the clinical treatment of GI GVHD can be further optimized. In this review, we describe the mechanisms of GI GVHD and the damage it causes to intestinal cells and we summarize recent studies on the relationship between intestinal microbiota and GVHD in the gastrointestinal tract, highlighting the role of intestinal microbiota metabolites in GI GVHD. We hope to elucidate strategies for immunomodulatory combined microbiota targeting in the clinical treatment of GI GVHD.
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13
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Biliński J, Jasiński M, Basak GW. The Role of Fecal Microbiota Transplantation in the Treatment of Acute Graft-versus-Host Disease. Biomedicines 2022; 10:biomedicines10040837. [PMID: 35453587 PMCID: PMC9027325 DOI: 10.3390/biomedicines10040837] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 03/25/2022] [Accepted: 03/28/2022] [Indexed: 12/11/2022] Open
Abstract
The number of allogeneic hematopoietic stem cell transplantations conducted worldwide is constantly rising. Together with that, the absolute number of complications after the procedure is increasing, with graft-versus-host disease (GvHD) being one of the most common. The standard treatment is steroid administration, but only 40–60% of patients will respond to the therapy and some others will be steroid-dependent. There is still no consensus regarding the best second-line option, but fecal microbiota transplantation (FMT) has shown encouraging preliminary and first clinically relevant results in recent years and seems to offer great hope for patients. The reason for treatment of steroid-resistant acute GvHD using this method derives from studies showing the significant immunomodulatory role played by the intestinal microbiota in the pathogenesis of GvHD. Depletion of commensal microbes is accountable for aggravation of the disease and is associated with decreased overall survival. In this review, we present the pathogenesis of GvHD, with special focus on the special role of the gut microbiota and its crosstalk with immune cells. Moreover, we show the results of studies and case reports to date regarding the use of FMT in the treatment of steroid-resistant acute GvHD.
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Affiliation(s)
- Jarosław Biliński
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, 02-091 Warsaw, Poland; (M.J.); (G.W.B.)
- Human Biome Institute, 80-137 Gdansk, Poland
- Correspondence:
| | - Marcin Jasiński
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, 02-091 Warsaw, Poland; (M.J.); (G.W.B.)
- Doctoral School, Medical University of Warsaw, 02-091 Warsaw, Poland
| | - Grzegorz W. Basak
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, 02-091 Warsaw, Poland; (M.J.); (G.W.B.)
- Human Biome Institute, 80-137 Gdansk, Poland
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14
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Zhao K, Lin R, Fan Z, Chen X, Wang Y, Huang F, Xu N, Zhang X, Zhang X, Xuan L, Wang S, Lin D, Deng L, Nie D, Weng J, Li Y, Zhang X, Li Y, Xiang AP, Liu Q. Mesenchymal stromal cells plus basiliximab, calcineurin inhibitor as treatment of steroid-resistant acute graft-versus-host disease: a multicenter, randomized, phase 3, open-label trial. J Hematol Oncol 2022; 15:22. [PMID: 35255929 PMCID: PMC8900437 DOI: 10.1186/s13045-022-01240-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 02/19/2022] [Indexed: 12/20/2022] Open
Abstract
Background Steroid-resistant (SR) acute graft-versus-host disease (aGVHD) lacks standard second-line treatment. Mesenchymal stromal cells (MSCs) have potential efficacy in SR aGVHD. We aimed to assess the efficacy and safety of MSCs combined with basiliximab and calcineurin inhibitor as second-line therapy for SR aGVHD.
Methods A randomized phase 3 trial involved 203 SR aGVHD patients at nine centers in China (September 2014–March 2019). Participants were randomized at a 1:1 ratio to receive second-line therapy with (n = 101) or without (n = 102) MSCs. The primary endpoint was the overall response (OR) at day 28. Secondary and safety endpoints included durable OR at day 56, failure-free survival, overall survival (OS), chronic GVHD (cGVHD), infection, hematological toxicity and relapse. Results Of 203 patients, 198 (97.5%; mean age, 30.1 years; 40.4% women) completed the study. The OR at day 28 was higher in the MSC group than the control group (82.8% [82 patients] vs. 70.7% [70]; odds ratio, 2.00; 95% confidence interval [CI], 1.01–3.94; P = 0.043). The durable OR at day 56 was also higher in the MSC group (78.8% [78 patients] vs. 64.6% [64]; odds ratio, 2.02; 95% CI, 1.08–3.83; P = 0.027). The median failure-free survival was longer in the MSC group compared with control (11.3 months vs. 6.0 months; hazard ratio (HR) 0.68; 95% CI, 0.48–0.95, P = 0.024). The 2-year cumulative incidence of cGVHD was 39.5% (95% CI, 29.3–49.4%) and 62.7% (51.4–72.1%) in the MSC and control groups (HR 0.55, 95% CI, 0.36–0.84; P = 0.005). Within 180 days after study treatments, the most common grade 3 and 4 adverse events were infections (65 [65.7%] in the MSC group vs. 78 [78.8%] in the control group) and hematological toxicity (37 [37.4%] vs. 53 [53.5%]). The 3-year cumulative incidence of tumor relapse was 10.1% (95% CI, 5.2–17.1) and 13.5% (7.5–21.2%) in the MSC and control groups, respectively (HR 0.75, 95% CI, 0.34–1.67, P = 0.610). Conclusions MSCs plus second-line treatments increase the efficacy of SR aGVHD, decrease drug toxicity of second-line drugs and cGVHD without increasing relapse, and are well-tolerated. MSCs could be recommended as a second-line treatment option for aGVHD patients. Trial registration clinicaltrials.gov identifier: NCT02241018. Registration date: September 16, 2014, https://clinicaltrials.gov/ct2/show/NCT02241018. Supplementary Information The online version contains supplementary material available at 10.1186/s13045-022-01240-4.
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Affiliation(s)
- Ke Zhao
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Ren Lin
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Zhiping Fan
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Xiaoyong Chen
- Center for Stem Cell Biology and Tissue Engineering, Sun Yat-Sen University, Guangzhou, 510080, China
| | - Yu Wang
- Department of Hematology, Peking University People's Hospital, Beijing, 100044, China
| | - Fen Huang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Na Xu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Xi Zhang
- Medical Center of Hematology, Xinqiao Hospital, Army Medical University, Chongqing, 400037, China
| | - Xin Zhang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Li Xuan
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Shunqing Wang
- Department of Hematology, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, 510180, China
| | - Dongjun Lin
- Department of Hematology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, China.,Department of Hematology, The Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen, China
| | - Lan Deng
- Department of Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, 510282, China.,Department of Hematology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Danian Nie
- Department of Hematology, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, 510120, China
| | - Jianyu Weng
- Department of Hematology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
| | - Yonghua Li
- Department of Hematology, General Hospital of Southern Theatre Command, Guangzhou, 440104, China
| | - Xiaohui Zhang
- Department of Hematology, Peking University People's Hospital, Beijing, 100044, China
| | - Yuhua Li
- Department of Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, 510282, China
| | - A P Xiang
- Center for Stem Cell Biology and Tissue Engineering, Sun Yat-Sen University, Guangzhou, 510080, China.
| | - Qifa Liu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China.
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15
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Song Q, Nasri U, Zeng D. Steroid-Refractory Gut Graft-Versus-Host Disease: What We Have Learned From Basic Immunology and Experimental Mouse Model. Front Immunol 2022; 13:844271. [PMID: 35251043 PMCID: PMC8894323 DOI: 10.3389/fimmu.2022.844271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 01/26/2022] [Indexed: 11/23/2022] Open
Abstract
Intestinal graft-versus-host disease (Gut-GVHD) is one of the major causes of mortality after allogeneic hematopoietic stem cell transplantation (allo-HSCT). While systemic glucocorticoids (GCs) comprise the first-line treatment option, the response rate for GCs varies from 30% to 50%. The prognosis for patients with steroid-refractory acute Gut-GVHD (SR-Gut-aGVHD) remains dismal. The mechanisms underlying steroid resistance are unclear, and apart from ruxolitinib, there are no approved treatments for SR-Gut-aGVHD. In this review, we provide an overview of the current biological understanding of experimental SR-Gut-aGVHD pathogenesis, the advanced technology that can be applied to the human SR-Gut-aGVHD studies, and the potential novel therapeutic options for patients with SR-Gut-aGVHD.
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Affiliation(s)
- Qingxiao Song
- Arthur D. Riggs Diabetes and Metabolism Research Institute, The Beckman Research Institute, City of Hope National Medical Center, Duarte, CA, United States
- Hematologic Malignancies and Stem Cell Transplantation Institute, City of Hope National Medical Center, Duarte, CA, United States
- Fujian Medical University Center of Translational Hematology, Fujian Institute of Hematology, and Fujian Medical University Union Hospital, Fuzhou, China
- *Correspondence: Qingxiao Song,
| | - Ubaydah Nasri
- Arthur D. Riggs Diabetes and Metabolism Research Institute, The Beckman Research Institute, City of Hope National Medical Center, Duarte, CA, United States
- Hematologic Malignancies and Stem Cell Transplantation Institute, City of Hope National Medical Center, Duarte, CA, United States
| | - Defu Zeng
- Arthur D. Riggs Diabetes and Metabolism Research Institute, The Beckman Research Institute, City of Hope National Medical Center, Duarte, CA, United States
- Hematologic Malignancies and Stem Cell Transplantation Institute, City of Hope National Medical Center, Duarte, CA, United States
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16
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AT A, T GD, HM R, ES B, FL J. Calprotectin expressing donor-derived macrophages increase in acute gastrointestinal graft versus host disease. Transplant Cell Ther 2022; 28:248.e1-248.e8. [DOI: 10.1016/j.jtct.2022.01.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 01/18/2022] [Accepted: 01/28/2022] [Indexed: 10/19/2022]
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17
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Acute Graft Versus Host Disease Following Liver Transplantation: Case Report With Review of Current Literature. J Clin Exp Hepatol 2022; 12:1244-1251. [PMID: 35814515 PMCID: PMC9257876 DOI: 10.1016/j.jceh.2022.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 03/26/2022] [Indexed: 12/12/2022] Open
Abstract
Graft verus host disease (GVHD) following Liver transplantation is rare life threatening complication with very high mortality rate around 85%. Due to increased recognition of this condition management approach is rapidly evolving due to newer diagnostic methods and drugs. Etiology, risk factors, pathogenesis, preventive strategies, management approach and newer drugs are discussed. We present our experience of 2 cases from a large cohort of 1052 Liver transplant operations over a decade.
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Key Words
- ATG, Anti thymocyte globulin
- BD, Twice a day
- CMV, Cytomegalovirus
- CODIS, Combined DNA Index System
- DBD, Donation after brain death
- DCLD, Decompensated chronic liver disease
- DNA, Deoxy ribonucleic acid
- EBV, Ebstein bar virus
- G-CSF, Granulocyte colony stimulating factor
- GVHD, Graft versus host disease
- HLA, Human Leukocyte antigen
- HPS, Hepatopulmonary syndrome
- HRS, Hepatorenal syndrome
- IL, Interferon
- IVIG, Intravenous immunoglobulin
- JAK, Janus kinase
- LT, Liver transplantation
- MAD CAM, Mucosal addressin cell adhesion molecule
- MDR, Multi drug resistant
- MELD, Model for end stage liver disease
- NAFLD, Non Alcoholic fatty liver disease
- NASH, Non Alcoholic steatohepatitis
- POD, Post operative day
- QD, quaque die, stands for once a day
- STR-PCR, Single tandem repeat polymerase chain reaction
- chain reaction
- combined DNA index system
- deceased donor liver transplantation
- graft versus host disease
- single tanden repeat polymerase
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18
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Rayasam A, Drobyski WR. Translational Clinical Strategies for the Prevention of Gastrointestinal Tract Graft Versus Host Disease. Front Immunol 2021; 12:779076. [PMID: 34899738 PMCID: PMC8662938 DOI: 10.3389/fimmu.2021.779076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 11/08/2021] [Indexed: 11/15/2022] Open
Abstract
Graft versus host disease (GVHD) is the major non-relapse complication associated with allogeneic hematopoietic stem cell transplantation (HSCT). Unfortunately, GVHD occurs in roughly half of patients following this therapy and can induce severe life-threatening side effects and premature mortality. The pathophysiology of GVHD is driven by alloreactive donor T cells that induce a proinflammatory environment to cause pathological damage in the skin, gastrointestinal (GI) tract, lung, and liver during the acute phase of this disease. Recent work has demonstrated that the GI tract is a pivotal target organ and a primary driver of morbidity and mortality in patients. Prevention of this complication has therefore emerged as an important goal of prophylaxis strategies given the primacy of this tissue site in GVHD pathophysiology. In this review, we summarize foundational pre-clinical studies that have been conducted in animal models to prevent GI tract GVHD and examine the efficacy of these approaches upon subsequent translation into the clinic. Specifically, we focus on therapies designed to block inflammatory cytokine pathways, inhibit cellular trafficking of alloreactive donor T cells to the GI tract, and reconstitute impaired regulatory networks for the prevention of GVHD in the GI tract.
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Affiliation(s)
- Aditya Rayasam
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | - William R Drobyski
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, United States.,Bone Marrow Transplant Program, Medical College of Wisconsin, Milwaukee, WI, United States
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19
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Isshiki K, Kamiya T, Endo A, Okamoto K, Osumi T, Kawai T, Arai K, Tomizawa D, Ohtsuka K, Nagahori M, Imai K, Kato M, Kanegane H. Vedolizumab therapy for pediatric steroid-refractory gastrointestinal acute graft-versus-host disease. Int J Hematol 2021; 115:590-594. [PMID: 34724153 DOI: 10.1007/s12185-021-03245-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 10/19/2021] [Accepted: 10/19/2021] [Indexed: 11/28/2022]
Abstract
Vedolizumab, an immunosuppressive drug that acts locally on the gastrointestinal tract, is mainly used for the treatment of inflammatory bowel disease, and has been reported to be effective against gastrointestinal acute graft-versus-host disease (GI-aGVHD) in adults. However, there is insufficient evidence for pediatric GI-aGVHD. We used vedolizumab to treat three cases of GI-aGVHD in patients aged 1.5-4.4 years. It was significantly effective in two patients and did not cause serious side effects in any patient. Vedolizumab might be effective and safe for pediatric GI-aGVHD refractory to other treatments, but this must be confirmed in future studies.
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Affiliation(s)
- Kyohei Isshiki
- Children's Cancer Center, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Takahiro Kamiya
- Department of Pediatrics, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Akifumi Endo
- Department of Pediatrics, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Kentaro Okamoto
- Department of Pediatric Surgery, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Tomoo Osumi
- Children's Cancer Center, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Toshinao Kawai
- Division of Immunology, National Center for Child Health and Development, Tokyo, Japan
| | - Katsuhiro Arai
- Division of Gastroenterology, National Center for Child Health and Development, Tokyo, Japan
| | - Daisuke Tomizawa
- Children's Cancer Center, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Kazuo Ohtsuka
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Masakazu Nagahori
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Kohsuke Imai
- Department of Pediatrics, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Motohiro Kato
- Children's Cancer Center, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan.
| | - Hirokazu Kanegane
- Department of Pediatrics, Tokyo Medical and Dental University Hospital, Tokyo, Japan
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20
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Westdorp H, Sweep MWD, Gorris MAJ, Hoentjen F, Boers-Sonderen MJ, van der Post RS, van den Heuvel MM, Piet B, Boleij A, Bloemendal HJ, de Vries IJM. Mechanisms of Immune Checkpoint Inhibitor-Mediated Colitis. Front Immunol 2021; 12:768957. [PMID: 34777387 PMCID: PMC8586074 DOI: 10.3389/fimmu.2021.768957] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 10/11/2021] [Indexed: 12/12/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) have provided tremendous clinical benefit in several cancer types. However, systemic activation of the immune system also leads to several immune-related adverse events. Of these, ICI-mediated colitis (IMC) occurs frequently and is the one with the highest absolute fatality. To improve current treatment strategies, it is important to understand the cellular mechanisms that induce this form of colitis. In this review, we discuss important pathways that are altered in IMC in mouse models and in human colon biopsy samples. This reveals a complex interplay between several types of immune cells and the gut microbiome. In addition to a mechanistic understanding, patients at risk should be identifiable before ICI therapy. Here we propose to focus on T-cell subsets that interact with bacteria after inducing epithelial damage. Especially, intestinal resident immune cells are of interest. This may lead to a better understanding of IMC and provides opportunities for prevention and management.
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Affiliation(s)
- Harm Westdorp
- Department of Tumor Immunology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
- Department of Medical Oncology, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Mark W. D. Sweep
- Department of Tumor Immunology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
- Department of Medical Oncology, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Mark A. J. Gorris
- Department of Tumor Immunology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
- Oncode Institute, Nijmegen, Netherlands
| | - Frank Hoentjen
- Department of Gastroenterology, Radboud University Medical Centre, Nijmegen, Netherlands
- Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
| | | | - Rachel S. van der Post
- Department of Pathology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
| | | | - Berber Piet
- Department of Tumor Immunology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
- Department of Pulmonary Diseases, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Annemarie Boleij
- Department of Pathology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Haiko J. Bloemendal
- Department of Medical Oncology, Radboud University Medical Centre, Nijmegen, Netherlands
| | - I. Jolanda M. de Vries
- Department of Tumor Immunology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
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21
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Choe H, Ferrara JLM. New therapeutic targets and biomarkers for acute graft-versus-host disease (GVHD). Expert Opin Ther Targets 2021; 25:761-771. [PMID: 34669521 PMCID: PMC8602762 DOI: 10.1080/14728222.2021.1992383] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 10/08/2021] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Acute Graft-versus-Host Disease (GVHD) is the major toxicity of allogeneic hematopoietic cell transplantation (HCT). Systemic steroids are the standard primary treatment but only half of the patients will respond completely and the survival of steroid-refractory patients is poor. The gastrointestinal (GI) tract is a key target organ that usually determines a patient's response to therapy. AREAS COVERED This review summarizes the use of clinical grading systems and biomarkers in GVHD treatment and highlights pathophysiologic phases of acute GVHD as context for the mechanisms of action and therapeutic targets of various approaches. We reviewed >100 publications and performed a search of ongoing, current clinical trials on the emerging therapeutic targets for prophylaxis and treatment of acute GVHD. Search databases included clinicaltrials.gov and PUBMED. Search terms and keywords included 'acute graft-versus-host disease,' 'GVHD,' 'graft versus host,' 'treatment.' EXPERT OPINION Future strategies will employ a risk-adapted therapy using biomarkers, which more accurately predict 6-month NRM. Strategies for high-risk patients will inhibit GI tract damage by selective targeting of effectors (e.g. inhibition of JAK signaling in T cells), blockade of trafficking through mAbs against integrin receptors, or enhancement of target cell survival. Future strategieswill reduce immunosuppression to avoid risk of infections and relapse.
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Affiliation(s)
- Hannah Choe
- Division of Hematology, Blood and Marrow Transplant Program, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - James L M Ferrara
- Icahn School of Medicine at Mount Sinai, The Tisch Cancer Institute, New York, NY, USA
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22
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Ibrahimova A, Davies SM, Lane A, Jordan MB, Lake K, Litts B, Chaturvedi V, Owsley E, Myers KC, Nelson AS, Mehta PA, Marsh RA, Khandelwal P. α4β7 Integrin expression and blockade in pediatric and young adult gastrointestinal graft-versus-host disease. Pediatr Blood Cancer 2021; 68:e28968. [PMID: 33861521 DOI: 10.1002/pbc.28968] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 02/04/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND We hypothesized that α4β7 integrin expression on effector memory T cells (TEMs) would be elevated in pediatric hematopoietic stem cell transplant (HSCT) patients before and at diagnosis of acute gastrointestinal graft-versus-host disease (GI GVHD) symptoms compared to patients without GVHD, and that clinical blockade of α4β7 integrin with vedolizumab would be effective in pediatric GI GVHD. METHODS We analyzed surface expression of α4β7 integrin on T cells from 48 pediatric allogeneic HSCT recipients from our biorepository with known clinical outcomes as follows: acute GI GVHD (n = 22), isolated skin GVHD (n = 12), and no GVHD (n = 14). T-cell analyses were performed 1 week before and at GVHD diagnosis in patients with GVHD, and day +30 after HSCT in patients without GVHD. We describe clinical outcomes of seven additional patients, different from above-described 48 patients, who received vedolizumab (anti-α4β7 integrin antibody) for the treatment of steroid-refractory acute GI GVHD. RESULTS Expression of α4β7 integrin on CD8+ TEMs was upregulated in patients with GI GVHD compared to the no GI GVHD (skin GVHD + no GVHD) group 1 week prior to clinical symptoms (p = .02) and at acute GI GVHD diagnosis (p = .05). Four of seven treated patients with clinical steroid-refractory acute GI GVHD were evaluable for response to vedolizumab. One patient had a complete response at day +28, while two had a partial response, and one had no response. No adverse effects directly attributable to vedolizumab were observed. CONCLUSION Our data suggest a rationale for the blockade of α4β7 integrin for acute GI GVHD management in children.
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Affiliation(s)
- Azada Ibrahimova
- Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Stella M Davies
- Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Adam Lane
- Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Michael B Jordan
- Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA.,Division of Immunobiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Kelly Lake
- Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Bridget Litts
- Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Vijaya Chaturvedi
- Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Erika Owsley
- Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Kasiani C Myers
- Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Adam S Nelson
- Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Parinda A Mehta
- Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Rebecca A Marsh
- Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Pooja Khandelwal
- Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
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23
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Saad A, de Lima M, Anand S, Bhatt VR, Bookout R, Chen G, Couriel D, Di Stasi A, El-Jawahri A, Giralt S, Gutman J, Ho V, Horwitz M, Hsu J, Juckett M, Kharfan-Dabaja MA, Loren A, Meade J, Mielcarek M, Moreira J, Nakamura R, Nieto Y, Roddy J, Satyanarayana G, Schroeder M, Tan CR, Tzachanis D, Burn J, Pluchino L. Hematopoietic Cell Transplantation, Version 2.2020, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2021; 18:599-634. [PMID: 32519831 DOI: 10.6004/jnccn.2020.0021] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Hematopoietic cell transplantation (HCT) involves the infusion of hematopoietic progenitor cells into patients with hematologic disorders with the goal of re-establishing normal hematopoietic and immune function. HCT is classified as autologous or allogeneic based on the origin of hematopoietic cells. Autologous HCT uses the patient's own cells while allogeneic HCT uses hematopoietic cells from a human leukocyte antigen-compatible donor. Allogeneic HCT is a potentially curative treatment option for patients with certain types of hematologic malignancies, and autologous HCT is primarily used to support patients undergoing high-dose chemotherapy. Advances in HCT methods and supportive care in recent decades have led to improved survival after HCT; however, disease relapse and posttransplant complications still commonly occur in both autologous and allogeneic HCT recipients. Allogeneic HCT recipients may also develop acute and/or chronic graft-versus-host disease (GVHD), which results in immune-mediated cellular injury of several organs. The NCCN Guidelines for Hematopoietic Cell Transplantation focus on recommendations for pretransplant recipient evaluation and the management of GVHD in adult patients with malignant disease.
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Affiliation(s)
- Ayman Saad
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | - Marcos de Lima
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | | | | | | | | | | | | | | | | | | | - Vincent Ho
- Dana-Farber/Brigham and Women's Cancer Center
| | | | | | | | | | - Alison Loren
- Abramson Cancer Center at the University of Pennsylvania
| | - Javier Meade
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | - Marco Mielcarek
- Fred Hutchinson Cancer Research Center/ Seattle Cancer Care Alliance
| | - Jonathan Moreira
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | - Yago Nieto
- The University of Texas MD Anderson Cancer Center
| | - Juliana Roddy
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | | | - Mark Schroeder
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
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24
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A phase 2a randomized clinical trial of intravenous vedolizumab for the treatment of steroid-refractory intestinal acute graft-versus-host disease. Bone Marrow Transplant 2021; 56:2477-2488. [PMID: 34108672 PMCID: PMC8486663 DOI: 10.1038/s41409-021-01356-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 04/23/2021] [Accepted: 05/12/2021] [Indexed: 01/10/2023]
Abstract
Steroid-refractory (SR) acute graft-versus-host disease (aGvHD) remains a significant complication after allogeneic hematopoietic cell transplantation. Systemic corticosteroids are first-line therapy for aGvHD, but apart from ruxolitinib, there are no approved treatments for SR aGvHD. Vedolizumab is approved for treatment of ulcerative colitis and Crohn’s disease, and may be effective for treatment of SR intestinal aGvHD. We conducted a phase 2a trial (NCT02993783) to evaluate the clinical efficacy, tolerability, and safety of vedolizumab 300 and 600 mg for SR intestinal aGvHD. This study was terminated before full enrollment was completed because early results failed to demonstrate positive proof-of-concept in efficacy. Before termination, 17 participants had enrolled and an early response in intestinal aGvHD was observed in 11 and eight participants at days 15 and 28, respectively. All adverse events observed were consistent with those expected in a population with SR intestinal aGvHD. Overall, vedolizumab did not meet the primary efficacy endpoint (overall response at day 28), likely owing to premature study drug discontinuation, lack of efficacy, and the competing risks inherent with a population with advanced SR intestinal aGvHD. Nevertheless, this study provides valuable insights into the considerations needed when conducting studies in patients with SR intestinal aGvHD.
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25
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Immunopathology and biology-based treatment of steroid-refractory graft-versus-host disease. Blood 2021; 136:429-440. [PMID: 32526035 DOI: 10.1182/blood.2019000953] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 01/24/2020] [Indexed: 12/12/2022] Open
Abstract
Acute graft-versus-host disease (GVHD) is 1 of the major life-threating complications after allogeneic cell transplantation. Although steroids remain first-line treatment, roughly one-half of patients will develop steroid-refractory GVHD (SR-GVHD), which portends an extremely poor prognosis. Many agents that have shown encouraging response rates in early phase 1/2 trials for prevention and treatment have been unsuccessful in demonstrating a survival advantage when applied in the setting of SR-GVHD. The discovery of novel treatments has been further complicated by the absence of clinically informative animal models that address what may reflect a distinct pathophysiology. Nonetheless, the combined knowledge of established bone marrow transplantation models and recent human trials in SR-GVHD patients are beginning to illuminate novel mechanisms for inhibiting T-cell signaling and promoting tissue tolerance that provide an increased understanding of the underlying biology of SR-GVHD. Here, we discuss recent findings of newly appreciated cellular and molecular mechanisms and provide novel translational opportunities for advancing the effectiveness of treatment in SR-GVHD.
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26
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Wölfl M, Qayed M, Benitez Carabante MI, Sykora T, Bonig H, Lawitschka A, Diaz-de-Heredia C. Current Prophylaxis and Treatment Approaches for Acute Graft-Versus-Host Disease in Haematopoietic Stem Cell Transplantation for Children With Acute Lymphoblastic Leukaemia. Front Pediatr 2021; 9:784377. [PMID: 35071133 PMCID: PMC8771910 DOI: 10.3389/fped.2021.784377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 12/09/2021] [Indexed: 11/13/2022] Open
Abstract
Acute graft-versus-host disease (aGvHD) continues to be a leading cause of morbidity and mortality following allogeneic haematopoietic stem cell transplantation (HSCT). However, higher event-free survival (EFS) was observed in patients with acute lymphoblastic leukaemia (ALL) and grade II aGvHD vs. patients with no or grade I GvHD in the randomised, controlled, open-label, international, multicentre Phase III For Omitting Radiation Under Majority age (FORUM) trial. This finding suggests that moderate-severity aGvHD is associated with a graft-versus-leukaemia effect which protects against leukaemia recurrence. In order to optimise the benefits of HSCT for leukaemia patients, reduction of non-relapse mortality-which is predominantly caused by severe GvHD-is of utmost importance. Herein, we review contemporary prophylaxis and treatment options for aGvHD in children with ALL and the key challenges of aGvHD management, focusing on maintaining the graft-versus-leukaemia effect without increasing the severity of GvHD.
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Affiliation(s)
- Matthias Wölfl
- Pediatric Hematology, Oncology and Stem Cell Transplantation, Children's Hospital, Würzburg University Hospital, Würzburg, Germany
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Atlanta, GA, United States
| | - Maria Isabel Benitez Carabante
- Department of Pediatric Hematology and Oncology, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Tomas Sykora
- Haematopoietic Stem Cell Transplantation Unit, Department of Pediatric Haematology and Oncology, Comenius University Children's Hospital, Bratislava, Slovakia
| | - Halvard Bonig
- Institute for Transfusion Medicine and Immunohematology, Goethe-University Frankfurt/Main, Frankfurt, Germany.,German Red Cross Blood Service BaWüHe, Frankfurt, Germany
| | - Anita Lawitschka
- Department of Pediatrics, St. Anna Kinderspital and Children's Cancer Research Institute, Medical University of Vienna, Vienna, Austria
| | - Cristina Diaz-de-Heredia
- Department of Pediatric Hematology and Oncology, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
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27
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Abstract
Acute graft-versus-host disease (GVHD), the major complication after allogeneic hematopoietic cell transplant (HCT), develops in approximately 50% of patients. The primary treatment is high-dose systemic steroids, but treatment failure is common, and steroid-refractory (SR) GVHD is the leading cause of non-relapse mortality after allogeneic HCT. Ruxolitinib became the first treatment for SR GVHD to obtain US Food and Drug Administration approval, and other new treatments are actively being studied. We searched the literature using the PubMed database and clinical trials using ClinicalTrials.gov to identify the most promising new treatments for GVHD. In this review, we categorize potential new treatments for GVHD by their mechanism of action (e.g., antibodies that deplete T cells or prevent their trafficking to target tissues, proteasome inhibitors, tyrosine kinase inhibitors, and other agents) and summarize the results from clinical trials.
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Affiliation(s)
- Stelios Kasikis
- Icahn School of Medicine at Mount Sinai, Tisch Cancer Institute, New York, NY, USA
| | - Aaron Etra
- Icahn School of Medicine at Mount Sinai, Tisch Cancer Institute, New York, NY, USA
| | - John E Levine
- Icahn School of Medicine at Mount Sinai, Tisch Cancer Institute, New York, NY, USA.
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28
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Berger M, Pessolano R, Carraro F, Saglio F, Vassallo E, Fagioli F. Steroid-refractory acute graft-versus-host disease graded III-IV in pediatric patients. A mono-institutional experience with a long-term follow-up. Pediatr Transplant 2020; 24:e13806. [PMID: 32844519 DOI: 10.1111/petr.13806] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 05/28/2020] [Accepted: 07/09/2020] [Indexed: 12/17/2022]
Abstract
aGvHD remains a major obstacle to successful HSCT. We report our experience on steroid-refractory aGvHD III and IV from 1989 to 2017. Ninety patients with aGvHD III or IV were stratified according to the HSCT year: 1989-1998, 1999-2007, and 2008-2017 and to aGvHD extension (GvHD III vs IV) and finally the probability of OS, RI, and TRM was calculated accordingly. aGvHD III patients had a substantial improvement over time: day 100 OS raised from 64% (95% CI 39-89) in the first cohort to 100% in the latest (P = .022), and it was mainly due to a reduction of TRM (it was 28% [95% CI 12-65] in the first cohort to 0% in the latest (P = .01). The aGvHD IV patients did not present a significant improvement. Day 100 OS was 42% (95% CI 16-68) in the first group and 54% (95% CI 25-83) in the year 2008-2017 (P = NS), and the day-100 TRM was very similar (it was 57% [95% CI 36-90] in the first cohort and 45% [95% CI 23-89] in the latest (P = NS). We report significant improvements in OS and TRM in patients diagnosed with grade III aGvHD. Patients with the most severe aGvHD appear to have no or fewer benefits on long-term outcomes.
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Affiliation(s)
- Massimo Berger
- Pediatric Onco-Hematology, City of Health and Science, Regina Margherita Children Hospital, University of Turin, Turin, Italy
| | - Rosanna Pessolano
- Pediatric Onco-Hematology, City of Health and Science, Regina Margherita Children Hospital, University of Turin, Turin, Italy
| | - Francesca Carraro
- Pediatric Onco-Hematology, City of Health and Science, Regina Margherita Children Hospital, University of Turin, Turin, Italy
| | - Francesco Saglio
- Pediatric Onco-Hematology, City of Health and Science, Regina Margherita Children Hospital, University of Turin, Turin, Italy
| | - Elena Vassallo
- Pediatric Onco-Hematology, City of Health and Science, Regina Margherita Children Hospital, University of Turin, Turin, Italy
| | - Franca Fagioli
- Pediatric Onco-Hematology, City of Health and Science, Regina Margherita Children Hospital, University of Turin, Turin, Italy
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29
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Phase II trial of natalizumab with corticosteroids as initial treatment of gastrointestinal acute graft-versus-host disease. Bone Marrow Transplant 2020; 56:1006-1012. [PMID: 32895491 DOI: 10.1038/s41409-020-01049-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 08/10/2020] [Accepted: 08/25/2020] [Indexed: 11/08/2022]
Abstract
The α4ß7 integrin is upregulated on naive and memory T cell subsets in patients who subsequently develop gastrointestinal (GI) acute GVHD. Natalizumab (Tysabri®, Biogen Inc.) acts against the α4 subunit that mediates homing of lymphocytes to the GI tract. We initiated a phase II study of natalizumab with corticosteroids for initial treatment of acute GI GVHD. In total, 300 mg IV of natalizumab was given, with steroids initiated up to 3 days prior. Twenty-one subjects were treated, median age was 63 years (range 38-74), and 15 (71%) were male. Eighteen (86%) underwent RIC, 15 (71%) received MUD, and all received PBSCs. Overall GVHD at enrollment was grade II in 4 and grade III in 17. The primary endpoint, day 56 GVHD-free survival rate, was attained in 33.3%. The overall response rate at day 28 and 56 was 57% and 52%, respectively. Six of eight CRs were durable for 1 year. Five experienced toxicity possibly related to natalizumab and ten had infections before day 100. 2-year OS was 43% (95% CI 22-62%) and 2-year NRM was 52% (95% CI 29-71%). Natalizumab with corticosteroids as initial treatment of acute GI GVHD is safe, effective, and durable.
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Pai V, Abu-Arja R, Auletta JJ, Rangarajan HG. Successful treatment of steroid-refractory gastrointestinal acute graft-versus-host disease with adjuvant vedolizumab therapy in a pediatric allogeneic stem cell transplant recipient. Pediatr Blood Cancer 2020; 67:e28298. [PMID: 32472970 DOI: 10.1002/pbc.28298] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 02/29/2020] [Accepted: 03/16/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Vinita Pai
- College of Pharmacy, The Ohio State University, Columbus, Ohio.,Pharmacy Department, Nationwide Children's Hospital, Columbus, Ohio
| | - Rolla Abu-Arja
- Division of Hematology, Oncology, Blood and Marrow Transplant, Nationwide Children's Hospital, Columbus, Ohio.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
| | - Jeffery J Auletta
- Division of Hematology, Oncology, Blood and Marrow Transplant, Nationwide Children's Hospital, Columbus, Ohio.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
| | - Hemalatha G Rangarajan
- Division of Hematology, Oncology, Blood and Marrow Transplant, Nationwide Children's Hospital, Columbus, Ohio.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
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DiMaggio E. Acute Graft-versus-Host Disease: Emerging Insights and Updates into Detection, Prevention, and Treatment. Pharmacotherapy 2020; 40:788-807. [PMID: 32530080 DOI: 10.1002/phar.2436] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Acute graft-versus-host disease remains a devastating complication following hematopoietic cell transplantation, resulting in increased morbidity and mortality. Vast research efforts continue to refine or develop new means of prediction, assessment, prevention, and treatment of this syndrome. Recent updates in acute graft-versus-host disease include more definitive guidance and definitions for its grading and diagnosis. Biomarker use is being incorporated into early stages following hematopoietic cell transplantation to aid in the detection and prediction of long-term outcomes. New preventive strategies under investigation include the use of vedolizumab or tocilizumab as upfront prophylaxis. Finally, although steroids remain the backbone of therapy once treatment is warranted, the efficacy of several agents including vedolizumab, tocilizumab, ruxolitinib, and α1 antitrypsin are being evaluated as potential therapeutic options.
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Malard F, Huang XJ, Sim JPY. Treatment and unmet needs in steroid-refractory acute graft-versus-host disease. Leukemia 2020; 34:1229-1240. [PMID: 32242050 PMCID: PMC7192843 DOI: 10.1038/s41375-020-0804-2] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 03/03/2020] [Accepted: 03/12/2020] [Indexed: 02/06/2023]
Abstract
Acute graft-versus-host disease (aGVHD) is a common complication of allogeneic hematopoietic stem cell transplantation (alloHCT) and is a major cause of morbidity and mortality. Systemic steroid therapy is the first-line treatment for aGVHD, although about half of patients will become refractory to treatment. As the number of patients undergoing alloHCT increases, developing safe and effective treatments for aGVHD will become increasingly important, especially for those whose disease becomes refractory to systemic steroid therapy. This paper reviews current treatment options for patients with steroid-refractory aGVHD and discusses data from recently published clinical studies to outline emerging therapeutic strategies.
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Affiliation(s)
- Florent Malard
- Sorbonne Université, INSERM, Centre de Recherche Saint-Antoine (CRSA), UMRS_938, AP-HP Hôpital Saint-Antoine, F-75012, Paris, France.
| | - Xiao-Jun Huang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Joycelyn P Y Sim
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
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Prophylaxis and management of graft versus host disease after stem-cell transplantation for haematological malignancies: updated consensus recommendations of the European Society for Blood and Marrow Transplantation. LANCET HAEMATOLOGY 2020; 7:e157-e167. [PMID: 32004485 DOI: 10.1016/s2352-3026(19)30256-x] [Citation(s) in RCA: 285] [Impact Index Per Article: 71.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 10/30/2019] [Accepted: 10/31/2019] [Indexed: 01/02/2023]
Abstract
Graft-versus-host disease (GVHD) is a major factor contributing to mortality and morbidity after allogeneic stem-cell transplantation. Because of the small number of results from well designed, large-scale, clinical studies there is considerable variability in the prevention and treatment of GVHD worldwide. In 2014, to standardise treatment approaches the European Society of Blood and Marrow Transplantation published recommendations on the management of GVHD in the setting of HLA-identical sibling or unrelated donor transplantation in adult patients with haematological malignancies. Here we update these recommendations including the results of study published after 2014. Evidence was searched in three steps: first, a widespread scan of published trials, meta-analyses, and systematic reviews; second, expert opinion was added for specific issues following several rounds of debate; and third, a refined search to target debated or rapidly updating issues. On the basis of this evidence and the 2014 recommendations, five members of the EBMT Transplant Complications Working Party created 38 statements on GVHD prophylaxis, drug management, and treatment of acute and chronic GVHD. Subsequently, they created the EBMT GVHD management recommendation expert panel by recruiting 20 experts with expertise in GVHD management. An email-based, two-round Delphi panel approach was used to manage the consensus. Modified National Comprehensive Cancer Network categories for evidence and consensus were applied to the approved statements. We reached 100% consensus for 29 recommendations and 95% consensus for nine recommendations. Key updates to these recommendations include a broader use of rabbit anti-T-cell globulin; lower steroid doses for the management of grade 2 acute GVHD with isolated skin or upper gastrointestinal tract manifestations; fluticasone, azithromycin, and montelukast should be used for bronchiolitis obliterans syndrome; and the addition of newer treatment options for resteroid-refractory acute and chronic GVHD. In addition, we discuss specific aspects of GVHD prophylaxis and management in the setting of haploidentical transplantation and in paediatric patients, but no formal recommendations on those procedures have been provided in this Review. The European Society of Blood and Marrow Transplantation proposes to use these recommendations as a basis for the routine management of GVHD during stem-cell transplantation.
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Fløisand Y, Lazarevic VL, Maertens J, Mattsson J, Shah NN, Zachée P, Taylor A, Akbari M, Quadri S, Parfionovas A, Chen YB. Safety and Effectiveness of Vedolizumab in Patients with Steroid-Refractory Gastrointestinal Acute Graft-versus-Host Disease: A Retrospective Record Review. Biol Blood Marrow Transplant 2019; 25:720-727. [PMID: 30468919 DOI: 10.1016/j.bbmt.2018.11.013] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 11/13/2018] [Indexed: 01/01/2023]
Abstract
Allogeneic hematopoietic cell transplantation (allo-HCT) can be curative in patients with hematologic malignancies but carries a significant risk of graft-versus-host disease (GVHD). There are no standard treatments for steroid-refractory (SR) gastrointestinal (GI) acute GVHD (aGVHD). This multicenter, international, retrospective medical record review aimed to evaluate the off-label use of vedolizumab, a gut-selective immunomodulator, for treating SR GI aGVHD. Data were collected from patients' medical records; criteria for extraction included no more than 1 allo-HCT and at least 1 dose of vedolizumab as treatment for SR GI aGVHD (ie, stage 1 to 4 GI aGVHD following ≥1 previous treatment regimen(s) containing ≥1 mg/kg methylprednisolone or equivalent). Descriptive analyses of response rate, overall survival (OS), and serious adverse effects (SAEs) were performed. Twenty-nine patients were identified from 7 sites who had received 1 to 10 doses of vedolizumab 300 mg i.v. (median 3 doses) as treatment for SR GI aGVHD. The overall response rate at 6 to 10 weeks after vedolizumab initiation was 64%, and OS at 6 months was 54%. There were 29 SAEs, including 12 infections; 3 SAEs were considered possibly related to vedolizumab, 2 of which were infections. Thirteen SAEs were fatal, 1 of which was possibly vedolizumab-related. There were 8 nonserious infections and 1 serious infection with confirmed GI origin in 8 patients; there was no apparent pattern in the timing of these infections relative to the initiation of vedolizumab treatment. Further data on the efficacy and safety of vedolizumab in this setting from prospective trials are needed.
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Affiliation(s)
- Yngvar Fløisand
- Department of Hematology, Oslo University Hospital, Oslo, Norway.
| | - Vladimir Lj Lazarevic
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund University, Lund, Sweden
| | - Johan Maertens
- Department of Hematology, University Hospitals Leuven, Leuven, Belgium
| | - Jonas Mattsson
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
| | - Nirav N Shah
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Pierre Zachée
- Hematology Service, ZNA Stuivenberg, Antwerp, Belgium
| | - Aliki Taylor
- Takeda Development Centre Europe Ltd, London, UK
| | - Mona Akbari
- Takeda Pharmaceuticals International Co., Cambridge, Massachusetts
| | - Syed Quadri
- Takeda Pharmaceuticals International Co., Cambridge, Massachusetts
| | | | - Yi-Bin Chen
- Blood and Marrow Transplant Program, Massachusetts General Hospital, Boston, Massachusetts
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