1
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Richardson T, Scheid C, Herling M, Frenzel LP, Herling C, Aguilar MRC, Theurich S, Hallek M, Holtick U. Post-transplant-cyclophosphamide and short-term Everolimus as graft-versus-host-prophylaxis in patients with relapsed/refractory lymphoma and myeloma-Final results of the phase II OCTET-EVER trial. Eur J Haematol 2024; 113:163-171. [PMID: 38616351 DOI: 10.1111/ejh.14210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 03/16/2024] [Accepted: 03/25/2024] [Indexed: 04/16/2024]
Abstract
BACKGROUND Conditioning regimens and the choice of immunosuppression have substantial impact on immune reconstitution after allogeneic hematopoietic stem cell transplantation (aHSCT). The pivotal mechanism to maintain remission is the induction of the graft-versus-tumor effect. Relapse as well as graft versus host disease remain common. Classic immunosuppressive strategies implementing calcineurin inhibitors (CNI) have significant toxicities, hamper the immune recovery, and reduce the anti-cancer immune response. METHODS We designed a phase II clinical trial for patients with relapsed and refractory lymphoid malignancies undergoing aHSCT using a CNI-free approach consisting of post-transplant cyclophosphamide (PTCy) and short-term Everolimus after reduced-intensity conditioning and matched peripheral blood stem cell transplantation. The results of the 19 planned patients are presented. Primary endpoint is the cumulative incidence and severity of acute GvHD. RESULTS Overall incidence of acute GvHD was 53% with no grade III or IV. Cumulative incidence of NRM at 1, 2, and 4 years was 11%, 11%, and 16%, respectively, with a median follow-up of 43 months. Cumulative incidence of relapse was 32%, 32%, and 42% at 1, 2, and 4 years after transplant, respectively. Four out of six early relapses were multiple myeloma patients. Overall survival was 79%, 74%, and 62% at 1, 2, and 4 years. GvHD-relapse-free-survival was 47% after 3 years. CONCLUSIONS Using PTCy and short-term Everolimus is safe with low rates of aGvHD and no severe aGvHD or cGvHD translating into a low rate of non-relapse mortality. Our results in this difficult to treat patient population are encouraging and warrant further studies.
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Affiliation(s)
- Tim Richardson
- Department I of Internal Medicine, Medical Faculty and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Christof Scheid
- Department I of Internal Medicine, Medical Faculty and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Marco Herling
- Department of Hematology, Cellular Therapy, and Hemostaseology, University Hospital Leipzig, Leipzig, Germany
| | - Lukas P Frenzel
- Department I of Internal Medicine, Medical Faculty and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Carmen Herling
- Department of Hematology, Cellular Therapy, and Hemostaseology, University Hospital Leipzig, Leipzig, Germany
| | - Marta Rebecca Cruz Aguilar
- Department I of Internal Medicine, Medical Faculty and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Sebastian Theurich
- Department of Medicine III, University Hospital, Ludwig Maximilian University (LMU) Munich, Munich, Germany
| | - Michael Hallek
- Department I of Internal Medicine, Medical Faculty and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Udo Holtick
- Department I of Internal Medicine, Medical Faculty and University Hospital of Cologne, University of Cologne, Cologne, Germany
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2
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Sanz MÁ, Montoro J, Balaguer-Roselló A, Chorão P, Villalba M, Gómez I, Solves P, Santiago M, Asensi P, Lamas B, Bataller A, Granados P, Eiris J, Martinez D, Lloret P, Louro A, Rebollar P, Perla A, de la Rubia J, Sanz J. Longitudinal outcome over four decades of allogeneic stem cell transplantation: a single center experience. Bone Marrow Transplant 2024:10.1038/s41409-024-02319-x. [PMID: 38918495 DOI: 10.1038/s41409-024-02319-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 04/09/2024] [Accepted: 05/22/2024] [Indexed: 06/27/2024]
Abstract
This 45-year study (1978-2022) at a single institution evaluated HSCT outcomes and complications, emphasizing recent advances, with to provide insights into HSCT's evolving field and ongoing efforts to enhance patient outcomes. Involving 1707 patients, the study revealed an initial phase (1978-1987) with a limited activity that yielded modest outcomes, a nearly three-decade span (1988-2016) with a substantial increase in transplant activity, emphasizing umbilical cord blood transplantation (UCBT) for patients lacking a suitable matched sibling donor. In addition to a gradual increase in recipient age, significant improvement in outcomes emerged in the recent period (2017-2022), marked by UCBT replacement with haploidentical transplants, introduction of PTCY-based GVHD prophylaxis for all type of transplants, and increased use of conditioning regimens with thiotepa, busulfan, and fludarabine. In this period, reductions in GVHD, non-relapse mortality, and relapse rates significantly contributed to improved overall survival, event-free survival, and GVHD-free/relapse-free survival. The study identified specific factors, including GVHD prophylaxis and donor selection changes, associated with these positive trends. This four-decade study provides a unique perspective on allogeneic HSCT, showcasing the dynamic evolution of transplantation practices and their impact on outcomes, offering valuable insights for personalized treatment approaches and emphasizing continual innovation in this critical therapeutic modality.
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Affiliation(s)
- Miguel Ángel Sanz
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain
- Department of Medicine, University of Valencia, València, Spain
| | - Juan Montoro
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto Carlos III, Madrid, Spain
- School of Medicine and Dentistry, Catholic University of Valencia, València, Spain
| | - Aitana Balaguer-Roselló
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto Carlos III, Madrid, Spain
| | - Pedro Chorão
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain
| | - Marta Villalba
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain
| | - Inés Gómez
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto Carlos III, Madrid, Spain
| | - Pilar Solves
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto Carlos III, Madrid, Spain
| | - Marta Santiago
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto Carlos III, Madrid, Spain
| | - Pedro Asensi
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain
| | - Brais Lamas
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain
| | - Ana Bataller
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain
| | - Pablo Granados
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain
| | - Juan Eiris
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain
| | - David Martinez
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain
| | - Pilar Lloret
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain
| | - Alberto Louro
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain
| | - Paula Rebollar
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain
| | - Aurora Perla
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain
| | - Javier de la Rubia
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto Carlos III, Madrid, Spain
- School of Medicine and Dentistry, Catholic University of Valencia, València, Spain
| | - Jaime Sanz
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain.
- Department of Medicine, University of Valencia, València, Spain.
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto Carlos III, Madrid, Spain.
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3
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Sanz J, Labopin M, Choi G, Kulagin A, Peccatori J, Vydra J, Reményi P, Versluis J, Rovira M, Blaise D, Labussière-Wallet H, Montoro J, Sica S, Meijer E, Itälä-Remes M, Schaap N, Bulabois CE, Piemontese S, Mohty M, Ciceri F. Younger unrelated donors may be preferable over HLA match in the PTCy era: a study from the ALWP of the EBMT. Blood 2024; 143:2534-2543. [PMID: 38657278 DOI: 10.1182/blood.2023023697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 02/22/2024] [Accepted: 03/02/2024] [Indexed: 04/26/2024] Open
Abstract
ABSTRACT There is a paucity of information on how to select the most appropriate unrelated donor (UD) in hematopoietic stem cell transplantation (HSCT) using posttransplant cyclophosphamide (PTCy). We retrospectively analyzed the characteristics of 10/10 matched UDs (MUDs) and 9/10 mismatched UDs (MMUDs) that may affect transplant outcomes in patients with acute myeloid leukemia (AML) in first or second complete remission (CR1 or CR2). The primary end point was leukemia-free survival (LFS). Overall, 1011 patients were included with a median age of 54 years (range, 18-77). Donors had a median age of 29 years (range, 18-64); 304 (30%) were females, of which 150 (15% of the whole group) were donors to male recipients, and 621 (61%) were MUDs; 522 (52%) had negative cytomegalovirus (CMV-neg) serostatus, of which 189 (19%) were used for CMV-neg recipients. Donor age older than 30 years had a negative impact on relapse (hazard ratio [HR], 1.38; 95% confidence interval [CI], 1.06-1.8), LFS (HR, 1.4; 95% CI, 1.12-1.74), overall survival (HR 1.45; 95% CI, 1.14-1.85) and graft-versus-host disease (GVHD) free, relapse-free survival (HR, 1.29; 95% CI, 1.07-1.56). In addition, CMV-neg donors for CMV-neg recipients were associated with improved LFS (HR, 0.74; 95% CI, 0.55-0.99). The use of MMUD and female donors for male recipients did not significantly impact any transplant outcomes. For patients undergoing HSCT from a UD with PTCy for AML, donor age <30 years significantly improves survival. In this context, donor age might be prioritized over HLA match considerations. In addition, CMV-neg donors are preferable for CMV-neg recipients. However, further research is needed to validate and refine these recommendations.
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Affiliation(s)
- Jaime Sanz
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; Department de Medicina de la Universitat de València; CIBERONC, Instituto Carlos III, Madrid, Spain
| | - Myriam Labopin
- EBMT Paris Office, Hospital Saint-Antoine, Paris, France
| | - Goda Choi
- University Medical Center Groningen, Groningen, The Netherlands
| | - Alexander Kulagin
- Raisa Memorial Gorbacheva Research Institute, Pavlov University, St. Petersburg, Russia
| | - Jacopo Peccatori
- Hematology and Bone Marrow Transplant Unit, San Raffaele Scientific Institute IRCCS, Milano, Italy
| | - Jan Vydra
- Institute of Hematology and Blood Transfusion-Prague, Prague, Czech Republic
| | | | | | - Montserrat Rovira
- BMT Unit, Department of Haematology, Institute of Haematology and Oncology, IDIBAPS, Hospital Clinic, Josep Carreras Leukaemia Research Foundation, University of Barcelona, Barcelona, Spain
| | - Didier Blaise
- Programme de Transplantation & Therapie Cellulaire-Marseille, Marseille, France
| | | | - Juan Montoro
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; Department de Medicina de la Universitat de València; CIBERONC, Instituto Carlos III, Madrid, Spain
| | - Simona Sica
- Universita Cattolica del Sacro Cuore, Rome, Italy
| | - Ellen Meijer
- VU University Medical Center, Amsterdam, The Netherlands
| | | | - Nicolaas Schaap
- Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Simona Piemontese
- Hematology and Bone Marrow Transplant Unit, San Raffaele Scientific Institute IRCCS, Milano, Italy
| | - Mohamad Mohty
- Hôpital Saint-Antoine, Sorbonne University, INSERM UMRs 938, Paris, France
| | - Fabio Ciceri
- Hematology and Bone Marrow Transplant Unit, San Raffaele Scientific Institute IRCCS, Milano, Italy
- Vita-Salute San Raffaele University, Milan, Italy
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4
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Chorão P, Henriques M, Villalba M, Montoro J, Balaguer-Roselló A, González EM, Gómez MD, Gómez I, Solves P, Santiago M, Asensi P, Lamas B, Bataller A, Granados P, Eiris J, Martínez D, Louro A, Rebollar P, Perla A, Salavert M, de la Rubia J, Sanz MÁ, Sanz J. Cytomegalovirus Reactivations in Allogeneic Hematopoietic Stem Cell Transplantation from HLA-Matched and Haploidentical Donors with Post-Transplantation Cyclophosphamide. Transplant Cell Ther 2024; 30:538.e1-538.e10. [PMID: 38331195 DOI: 10.1016/j.jtct.2024.01.082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 01/26/2024] [Accepted: 01/30/2024] [Indexed: 02/10/2024]
Abstract
Cytomegalovirus (CMV) reactivations cause significant morbidity in allogeneic hematopoietic stem cell transplantation (HSCT) recipients. Graft-versus-host disease (GVHD) prophylaxis with post-transplantation cyclophosphamide (PTCy) is associated with an increased risk of CMV infections. Data are limited comparing HSCT with PTCy performed from matched sibling donors (MSDs), matched unrelated donors (MUDs), and haploidentical (Haplo) donors. In the present study, we aimed to characterize CMV reactivation and recurrence in patients with hematologic malignancies undergoing HSCT from MSD, MUD, and Haplo donors using PTCy as GVHD prophylaxis in the pre-letermovir era. We also analyzed risk factors of CMV reactivation, including GVHD as a time-dependent variable, on the incidence and mortality associated with CMV infections. We analyzed CMV reactivation in patients undergoing HSCT from 160 MSDs, 124 MUDs, and 82 Haplo donors from a single institution. Uniform GVHD prophylaxis with PTCy, sirolimus, and mycophenolate mofetil was given irrespective of donor type. Overall, 46% of patients had at least 1 CMV reactivation. The 1-year cumulative incidence of CMV infection was 39% for MSD, 44% for MUD, and 62% for Haplo donors (P < .001), with 96% of reactivations occurring before day +100. Multivariate analysis identified factors associated with the first CMV reactivation, including Haplo donor, positive recipient CMV serology, older patient age, and grade II-IV acute GVHD. The 1-year cumulative incidence of second reactivation from HSCT was 13%. Recipient CMV seropositivity, older patient age, and grade II-IV acute GVHD, but not type of donor, were identified as adverse factors for second CMV reactivation in multivariate analysis. The 1-year cumulative incidence of a third reactivation post HSCT was 4.4%. Ten cases of CMV disease were recorded, with no attributable deaths. Nevertheless, the risk for nonrelapse mortality was greater for patients who experienced CMV reactivation in multivariate time-dependent Cox model analysis. CMV reactivation is frequent in HSCT with PTCy in patients not receiving letermovir prophylaxis. Identified risk factors include the use of a Haplo donor, recipient CMV seropositivity, and grade II-IV acute GVHD. The prevalence of recurrent CMV reactivations is a noteworthy issue, especially after acute GVHD, warranting trials of secondary prophylaxis strategies.
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Affiliation(s)
- Pedro Chorão
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain; Hematology Research Group, Institut d'Investigació Sanitària La Fe, València, Spain.
| | - Marta Henriques
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain
| | - Marta Villalba
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain; Hematology Research Group, Institut d'Investigació Sanitària La Fe, València, Spain
| | - Juan Montoro
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain; Hematology Research Group, Institut d'Investigació Sanitària La Fe, València, Spain; School of Medicine and Dentistry, Catholic University of Valencia, València, Spain
| | - Aitana Balaguer-Roselló
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain; Hematology Research Group, Institut d'Investigació Sanitària La Fe, València, Spain; Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto Carlos III, Madrid, Spain
| | - Eva María González
- Microbiology Department, Hospital Universitari i Politècnic La Fe, València, Spain
| | - María Dolores Gómez
- Microbiology Department, Hospital Universitari i Politècnic La Fe, València, Spain
| | - Inés Gómez
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain; Hematology Research Group, Institut d'Investigació Sanitària La Fe, València, Spain
| | - Pilar Solves
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain; Hematology Research Group, Institut d'Investigació Sanitària La Fe, València, Spain; Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto Carlos III, Madrid, Spain
| | - Marta Santiago
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain; Hematology Research Group, Institut d'Investigació Sanitària La Fe, València, Spain; Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto Carlos III, Madrid, Spain
| | - Pedro Asensi
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain
| | - Brais Lamas
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain
| | - Ana Bataller
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain
| | - Pablo Granados
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain
| | - Juan Eiris
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain
| | - David Martínez
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain
| | - Alberto Louro
- Hematology Research Group, Institut d'Investigació Sanitària La Fe, València, Spain
| | - Paula Rebollar
- Hematology Research Group, Institut d'Investigació Sanitària La Fe, València, Spain
| | - Aurora Perla
- Hematology Research Group, Institut d'Investigació Sanitària La Fe, València, Spain
| | - Miguel Salavert
- Infectious Diseases, Internal Medicine Department, Hospital Universitari i Politècnic La Fe, València, Spain
| | - Javier de la Rubia
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain; Hematology Research Group, Institut d'Investigació Sanitària La Fe, València, Spain; School of Medicine and Dentistry, Catholic University of Valencia, València, Spain; Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto Carlos III, Madrid, Spain
| | - Miguel Ángel Sanz
- Hematology Research Group, Institut d'Investigació Sanitària La Fe, València, Spain; School of Medicine, University of Valencia, València, Spain
| | - Jaime Sanz
- Hematology Department, Hospital Universitari i Politècnic La Fe, València, Spain; Hematology Research Group, Institut d'Investigació Sanitària La Fe, València, Spain; Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto Carlos III, Madrid, Spain; School of Medicine, University of Valencia, València, Spain
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5
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Piemontese S, Lupo Stanghellini MT, Sora F, Sica S, Peccatori J, Marcatti M, Metafuni E, Giammarco S, Greco R, Bruno A, Ciceri F, Bacigalupo A, Chiusolo P. Post-transplant cyclophosphamide with Sirolimus or Cyclosporine for GvHD prophylaxis in matched related and unrelated transplantation: a two-center analysis on 213 consecutive patients. Bone Marrow Transplant 2024; 59:692-694. [PMID: 38355909 DOI: 10.1038/s41409-024-02221-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 01/18/2024] [Accepted: 01/22/2024] [Indexed: 02/16/2024]
Affiliation(s)
- Simona Piemontese
- Hematology and Bone Marrow transplant Unit, San Raffaele Scientific Institute IRCCS, Milano, Italy.
| | | | - Federica Sora
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica e Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Roma, Italy
| | - Simona Sica
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica e Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Roma, Italy
| | - Jacopo Peccatori
- Hematology and Bone Marrow transplant Unit, San Raffaele Scientific Institute IRCCS, Milano, Italy
| | - Magda Marcatti
- Hematology and Bone Marrow transplant Unit, San Raffaele Scientific Institute IRCCS, Milano, Italy
| | - Elisabetta Metafuni
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica e Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Sabrina Giammarco
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica e Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Raffaella Greco
- Hematology and Bone Marrow transplant Unit, San Raffaele Scientific Institute IRCCS, Milano, Italy
| | - Alessandro Bruno
- Hematology and Bone Marrow transplant Unit, San Raffaele Scientific Institute IRCCS, Milano, Italy
| | - Fabio Ciceri
- Hematology and Bone Marrow transplant Unit, San Raffaele Scientific Institute IRCCS, Milano, Italy
- Vita-Salute San Raffaele University, Milano, Italy
| | - Andrea Bacigalupo
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica e Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Roma, Italy
| | - Patrizia Chiusolo
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica e Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Roma, Italy
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6
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Montoro J, Boumendil A, Finel H, Bramanti S, Castagna L, Blaise D, Dominietto A, Kulagin A, Yakoub-Agha I, Tbakhi A, Solano C, Giebel S, Gulbas Z, López Corral L, Pérez-Simón JA, Díez Martín JL, Sanz J, Farina L, Koc Y, Socié G, Arat M, Jurado M, Bermudez A, Labussière-Wallet H, Villalba M, Ciceri F, Martinez C, Nagler A, Sureda A, Glass B. Post-Transplantation Cyclophosphamide-Based Graft-versus-Host Disease Prophylaxis in HLA-Matched and Haploidentical Donor Transplantation for Patients with Hodgkin Lymphoma: A Comparative Study of the Lymphoma Working Party of the European Society for Blood and Marrow Transplantation. Transplant Cell Ther 2024; 30:210.e1-210.e14. [PMID: 38043802 DOI: 10.1016/j.jtct.2023.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 11/15/2023] [Accepted: 11/25/2023] [Indexed: 12/05/2023]
Abstract
Post-transplantation cyclophosphamide (PTCy) has emerged as a promising approach for preventing graft-versus-host disease (GVHD) in allogeneic hematopoietic stem cell transplantation (allo-HSCT). However, there is a lack of studies examining the impact of this GVHD prophylaxis when different donor types are used in patients with Hodgkin lymphoma (HL). This study compared the outcomes of patients with HL undergoing HSCT from HLA-matched donors, including matched sibling donors (MSDs) and matched unrelated donors (MUDs), and haploidentical donors, using PTCy as the GVHD prophylaxis approach in all cohorts. We retrospectively compared outcomes of allo-HSCT from 166 HLA-matched donors (96 sibling and 70 unrelated donors) and 694 haploidentical donors using PTCy-based GVHD prophylaxis in patients with HL registered in the European Society for Blood and Marrow Transplantation database from 2010 to 2020. Compared to HLA-matched HSCT, haploidentical donor HSCT was associated with a significantly lower rate of platelet engraftment (86% versus 94%; P < .001) and a higher rate of grade II-IV acute GVHD (34% versus 24%; P = .01). The 2-year cumulative incidence of nonrelapse mortality (NRM) was significantly lower in the HLA-matched cohort compared to the haploidentical cohort (10% versus 18%; P = .02), resulting in a higher overall survival (OS) rate (82% versus 70%; P = .002). There were no significant differences between the 2 cohorts in terms of relapse, progression-free survival, or GVHD-free relapse-free survival. In multivariable analysis, haploidentical HSCT was associated with an increased risk of grade II-IV acute GVHD and NRM and worse OS compared to HLA-matched HSCT. Our findings suggest that in the context of PTCy-based GVHD prophylaxis, transplantation from HLA-matched donors appears to be a more favorable option compared to haploidentical HSCT.
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Affiliation(s)
- Juan Montoro
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain; Universidad Católica de Valencia, Spain.
| | - Ariane Boumendil
- European Society for Blood and Marrow Transplantation Lymphoma Working Party, Paris, France
| | - Hervé Finel
- European Society for Blood and Marrow Transplantation Lymphoma Working Party, Paris, France
| | - Stefania Bramanti
- Department of Oncology/Hematology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Luca Castagna
- Department of Oncology/Hematology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Didier Blaise
- Programme de Transplantation and Therapie Cellulaire, Marseille, France
| | - Alida Dominietto
- UO Ematologia e Terapie Cellulari, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Aleksandr Kulagin
- RM Gorbacheva Research Institute, Pavlov University, Saint Petersburg, Russia
| | | | | | - Carlos Solano
- Hematology Department, Hospital Clínico Universitario-INCLIVA, Valencia, Spain
| | - Sebastian Giebel
- The Department of Bone Marrow Transplantation and Onco-Hematology, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Gliwice, Poland
| | - Zafer Gulbas
- Anadolu Health Center Avliated John Hopkins, Kocaeli, Gebze, Turkey
| | | | - José A Pérez-Simón
- Servicio de Hematología, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla (IBIS), CSIC, Universidad de Sevilla, Spain
| | | | - Jaime Sanz
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Lucia Farina
- University of Milan. Hematology Division, Fondazione IRCCS Istituto. Nazionale dei Tumori di Milano, Milan, Italy
| | - Yener Koc
- Medical Park Hospitals, Beylikduzu, Istanbul, Turkey
| | - Gerard Socié
- Department of Hematology - BMT, Hematology Transplantation, Paris, France
| | - Mutlu Arat
- Demiroglu Bilim University Istanbul Florence Nightingale Hospital, Hematopoietic SCT Unit, Istanbul, Turkey
| | | | | | | | - Marta Villalba
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Fabio Ciceri
- Hematology and Bone Marrow Transplantation Unit, Milano, Italy
| | - Carmen Martinez
- Hematopoietic Stem Cell Transplantation Unit, Hospital Clínic de Barcelona, Institute of Cancer and Blood Diseases, Barcelona, Spain
| | - Arnon Nagler
- Hematology Division, Chaim Sheba Medical Center, Tel-Hashomer, Ramat-Gan, Israel
| | - Anna Sureda
- Hematology Department. Institut Català d'Oncologia, Hospital Duran i Reynals. Institut d'Investigació Biomèdica de Bellvitge, Universitat de Barcelona, Barcelona, Spain
| | - Bertram Glass
- Department of Hematology, Oncology and Stem Cell Transplantation, Asklepios Klinik St. Georg, Hamburg, Germany
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Eirís J, Aguilar C, Guerreiro M. Cytomegalovirus-driven early-onset lymphocytosis in hematopoietic allogeneic transplant mimicking a T-cell lymphoma progression. Transpl Infect Dis 2024; 26:e14170. [PMID: 37830407 DOI: 10.1111/tid.14170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 10/01/2023] [Indexed: 10/14/2023]
Abstract
Hepatosplenic T-cell lymphoma (HSTCL) is an uncommon and highly aggressive subtype of peripheral T-cell lymphoma characterized by liver, spleen, and bone marrow involvement. Allogeneic hematopoietic stem cell transplantation (alloHSCT) is the only curative treatment for HSTCL, but it carries a significant risk of relapse. Cytomegalovirus (CMV) reactivation is a frequent complication after alloHSCT, particularly in patients undergoing lymphocyte-toxic therapies. A 27-year-old man diagnosed with HSTCL underwent an alloHSCT with active disease after six lines of therapy. A CMV reactivation was successfully treated with foscarnet. A sudden reappearance of symptomatic lymphocytosis (15,550/μL) by day +20, prior to engraftment, raised suspicion of disease progression. A comprehensive diagnostic work-up revealed an oligoclonal expansion of donor lymphocytes along with complete donor chimerism, leading to an alternative diagnosis of a CMV-driven T-cell expansion. This was confirmed by an in vitro assay testing T-cell specificity against CMV. The patient achieved both complete response and complete donor chimerism despite persisting lymphocytosis, but ultimately relapsed. This case highlights the importance of diagnostic tools in understanding disease progression and guiding treatment decisions.
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Affiliation(s)
- Juan Eirís
- Servicio de Hematología y Hemoterapia, Hospital Universitari I Politècnic La Fe, Valencia, Spain
| | - Cristóbal Aguilar
- Servicio de Hematología y Hemoterapia, Instituto de Investigación Sanitaria La Fe (IIS-La Fe), Valencia, Spain
| | - Manuel Guerreiro
- Servicio de Hematología y Hemoterapia, Hospital Universitari I Politècnic La Fe, Valencia, Spain
- Servicio de Hematología y Hemoterapia, Instituto de Investigación Sanitaria La Fe (IIS-La Fe), Valencia, Spain
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8
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El-Sayed HA, Othman M, Azzam H, Bucciol R, Ebrahim MA, El-Agdar MAMA, Tera Y, Sakr DH, Ghoneim HR, Selim TES. Assessing the risk of venous thromboembolism in patients with haematological cancers using three prediction models. J Cancer Res Clin Oncol 2023; 149:17771-17780. [PMID: 37935936 DOI: 10.1007/s00432-023-05475-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 10/11/2023] [Indexed: 11/09/2023]
Abstract
PURPOSE Assessment of individual VTE risk in cancer patients prior to chemotherapy is critical for determining necessity of interventions. Risk assessment models (RAM) are available but have not been validated for haematological malignancy. We aimed to assess the validity of the Vienna Cancer and Thrombosis Study (V-CATS) score in prediction of VTE in a variety of haematological malignancies. METHODS This is a prospective cohort study conducted on 81 newly diagnosed cancer patients undergoing chemotherapy. Demographic, clinical and cancer related data were collected, patients were followed up for 6 months, and VTE events were recorded. Khorana score (KS) was calculated. Plasma D-dimer and sP-selectin were measured, and then, V-CATS score was calculated. Receiver operator curve (ROC) was used to assess the sensitivity and specificity of RAMs. A modified V-CATS was generated and subsequently assessed by using new cut-off levels of d-dimer and sP-selectin based on ROC curve of the patients' results and compared the probability of VTE occurrence using all three RAMs. RESULTS Among the 81 patients included in this study, a total of 2.7% were diagnosed with advanced metastatic cancer. The most frequent cancer was non-Hodgkin lymphoma (39.5%), and 8 patients (9.8%) developed VTE events. The calculated probability of VTE occurrence using KS, V-CATS and modified V-CATS scores at cut-off levels ≥ 3 was 87.5%, 87.5% and 100%, respectively. The AUC in ROC curve of modified Vienna CATS score showed significant difference when compared to that of V-CATS and KS (P = 0.047 and 0.029, respectively). CONCLUSION The findings of our study highlight the value of three VTE risk assessment models in haematological malignancies. The modified V-CATS score demonstrated higher specificity compared to both V-CATS and KS, while all three scores exhibited similar sensitivity. We encourage the implementation of RAMs in haematological cancers for an appropriate use of thromboprophylaxis.
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Affiliation(s)
- Hanaa Ali El-Sayed
- Clinical Pathology Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Maha Othman
- Clinical Pathology Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt.
- Department of Biomedical and Molecular Sciences, School of Medicine, Queen's University, Kingston, ON, Canada.
- School of Baccalaureate Nursing, St Lawrence College, Kingston, ON, Canada.
| | - Hanan Azzam
- Clinical Pathology Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Regan Bucciol
- Department of Biomedical and Molecular Sciences, School of Medicine, Queen's University, Kingston, ON, Canada
| | | | | | - Yousra Tera
- Clinical Pathology Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
- Department of Biomedical and Molecular Sciences, School of Medicine, Queen's University, Kingston, ON, Canada
| | - Doaa H Sakr
- Oncology Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Hayam Rashad Ghoneim
- Clinical Pathology Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Tarek El-Sayed Selim
- Clinical Pathology Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
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9
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Montoro J, Balaguer-Roselló A, Sanz J. Recent advances in allogeneic transplantation for acute myeloid leukemia. Curr Opin Oncol 2023; 35:564-573. [PMID: 37820092 DOI: 10.1097/cco.0000000000000992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
PURPOSE OF REVIEW This review highlights recent advancements in allogeneic hematopoietic stem cell transplantation (allo-HSCT) for patients with acute myeloid leukemia (AML). RECENT FINDINGS Important improvements have been observed throughout the allo-HSCT procedure and patient management. Universal donor availability and reduced risk of graft-versus-host disease (GVHD) have been achieved with the introduction of posttransplant cyclophosphamide for GVHD prophylaxis. It has contributed, together with advances in conditioning regimens, GVHD treatment and supportive care, to a reduced overall toxicity of the procedure. Relapse is now the most frequent cause of transplant failure. With increased knowledge of the biological characterization of AML, better prediction of transplant risks and more profound and standardized minimal residual disease (MRD) monitoring, pharmacological, and immunological strategies to prevent relapse are been developed. SUMMARY Allo-HSCT remains the standard of care for high-risk AML. Increased access to transplant, reduced toxicity and relapse are improving patient outcomes. Further research is needed to optimize MRD monitoring, refine conditioning regimens, and explore new GVHD management and relapse prevention therapies.
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Affiliation(s)
- Juan Montoro
- Hematology Department, Hospital Universitario y Politécnico La Fe
- Departamento de Medicina, Universidad Católica de Valencia
| | - Aitana Balaguer-Roselló
- Hematology Department, Hospital Universitario y Politécnico La Fe
- CIBERONC, Instituto Carlos III, Madrid
| | - Jaime Sanz
- Hematology Department, Hospital Universitario y Politécnico La Fe
- CIBERONC, Instituto Carlos III, Madrid
- Departamento de Medicina, Universidad de Valencia, Spain
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10
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Stueck AE, Fiel MI. Hepatic graft-versus-host disease: what we know, when to biopsy, and how to diagnose. Hum Pathol 2023; 141:170-182. [PMID: 37541449 DOI: 10.1016/j.humpath.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 04/19/2023] [Accepted: 07/24/2023] [Indexed: 08/06/2023]
Abstract
Graft-versus-host disease (GVHD) is one of the serious complications that may develop after hematopoietic cell transplantation (HCT), for hematologic malignancies, solid organ transplantation, and other hematologic disorders. GVHD develops due to T lymphocytes present in the graft attacking the host antigens, which results in tissue damage. A significant number of HCT patients develop acute or chronic GVHD, which may affect multiple organs including the liver. The diagnosis of hepatic GVHD (hGVHD) is challenging as many other conditions in HCT patients may lead to liver dysfunction. Particularly challenging among the various conditions that give rise to liver dysfunction is differentiating sinusoidal obstruction syndrome and drug-induced liver injury (DILI) from hGVHD on clinical grounds and laboratory tests. Despite the minimal risks involved in performing a liver biopsy, the information gleaned from the histopathologic changes may help in the management of these very complex patients. There is a spectrum of histologic features found in hGVHD, and most involve histopathologic changes affecting the interlobular bile ducts. These include nuclear and cytoplasmic abnormalities including dysmorphic bile ducts, apoptosis, and cholangiocyte necrosis, among others. The hepatitic form of hGVHD typically shows severe acute hepatitis. With chronic hGVHD, there is progressive bile duct loss and eventually fibrosis. Accurate diagnosis of hGVHD is paramount so that timely treatment and management can be initiated. Techniques to prevent and lower the risk of GVHD from developing have recently evolved. If a diagnosis of acute GVHD is made, the first-line of treatment is steroids. Recurrence is common and steroid resistance or dependency is not unusual in this setting. Second-line therapies differ among institutions and have not been uniformly established. The development of GVHD, particularly hGVHD, is associated with increased morbidity and mortality.
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Affiliation(s)
- Ashley E Stueck
- Department of Pathology, Dalhousie University, 715 - 5788 University Avenue, Halifax, NS, B3H 2Y9, Canada.
| | - M Isabel Fiel
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, 1468 Madison Ave, New York, NY, 10029, USA.
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11
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Balaguer-Roselló A, Gil-Perotín S, Montoro J, Bataller L, Lamas B, Villalba M, Facal A, Guerreiro M, Chorão P, Bataller A, Granados P, Gómez I, Solves P, Louro A, de la Rubia J, Sanz MÁ, Sanz J. Reduced Incidence of Neurologic Complications after Allogeneic Hematopoietic Stem Cell Transplantation with Calcineurin-Free Graft-versus-Host Disease Prophylaxis. Transplant Cell Ther 2023; 29:610.e1-610.e12. [PMID: 37451486 DOI: 10.1016/j.jtct.2023.07.008] [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: 05/22/2023] [Revised: 06/26/2023] [Accepted: 07/05/2023] [Indexed: 07/18/2023]
Abstract
Calcineurin inhibitors (CNIs), including cyclosporine and tacrolimus, are frequently associated with neurologic complications after allogeneic hematopoietic stem cell transplantation (HSCT). However, there is a lack of studies comparing the incidence and characteristics of neurologic complications in patients undergoing HSCT based on CNI-free or CNI-based GVHD prophylaxis. This retrospective single-center study analyzed the neurologic complications in 2 cohorts of patients undergoing HSCT with either CNI-based GVHD prophylaxis (n = 523) or CNI-free prophylaxis with post-transplantation cyclophosphamide, sirolimus, and mycophenolate mofetil (n = 371). The latter cohort included older patients and received more reduced-intensity conditioning and transplants from matched unrelated and haploidentical donors. The 2-year cumulative incidence of neurologic complications was significantly lower in the CNI-free cohort (6.9% versus 11.9%; P = .016), and GVHD prophylaxis was the sole statistically significant variable in multivariate analysis (hazard ratio, 2.2; 95% confidence interval [CI], .25 to 3.13; P = .0017). The distribution of neurologic types was similar in the 2 cohorts, with encephalopathy the most prevalent complication, except for headaches and myopathy, which decreased equally from 15% in the CNI-based cohort to 4% in the CNI-free cohort. Neurologic complications had negative impacts on mortality and survival rates, with a significantly higher 2-year cumulative incidence of nonrelapse mortality (NRM) (44% [95% CI, 34% to 54%] versus 16% [95% CI, 13% to 18%]; P < .0001) and inferior overall survival (66% [95% CI, 62% to 69%] versus 46% [95% CI, 37% to 58%]; P < .0001) in patients with neurologic complications. This study suggests that CNI-free GVHD prophylaxis with post-transplantation cyclophosphamide, sirolimus, and mycophenolate mofetil may reduce not only the incidence of GVHD incidence, but also the rates of neurologic complications and NRM, leading to improved survival outcomes in patients undergoing HSCT.
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Affiliation(s)
- Aitana Balaguer-Roselló
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; CIBERONC, Instituto Carlos III, Madrid, Spain.
| | - Sara Gil-Perotín
- Neurology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Juan Montoro
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Luis Bataller
- Neurology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Brais Lamas
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Marta Villalba
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Ana Facal
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Manuel Guerreiro
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Pedro Chorão
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Ana Bataller
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Pablo Granados
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Inés Gómez
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; CIBERONC, Instituto Carlos III, Madrid, Spain
| | - Pilar Solves
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; CIBERONC, Instituto Carlos III, Madrid, Spain
| | - Alberto Louro
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Javier de la Rubia
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; CIBERONC, Instituto Carlos III, Madrid, Spain
| | - Miguel Ángel Sanz
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Jaime Sanz
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; CIBERONC, Instituto Carlos III, Madrid, Spain
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12
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Solves P, Marco-Ayala J, Sanz MÁ, Gómez-Seguí I, Balaguer-Roselló A, Facal A, Villalba M, Montoro J, Sanz G, de la Rubia J, Sanz J. Transfusion Burden in Allogeneic Hematopoietic Stem Cell Transplantation over Time: Experience from a Single Institution. J Clin Med 2023; 12:jcm12103467. [PMID: 37240573 DOI: 10.3390/jcm12103467] [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: 02/21/2023] [Revised: 05/09/2023] [Accepted: 05/10/2023] [Indexed: 05/28/2023] Open
Abstract
INTRODUCTION Transfusion plays a main role in supportive treatment for patients who receive an allogeneic hematopoietic stem cell transplantation (HSCT). In this study, we compare the transfusion requirements of patients undergoing different modalities of HSCT according to different time periods. The objective is to assess the evolution of HSCT transfusion requirements over time, from a single institution. METHODS The clinical charts and transfusion records of patients who underwent HSCT of different modalities at La Fe University Hospital during a twelve-year period were reviewed (2009-2020). For analysis, we divided the overall time into three periods: 1 from 2009 to 2012, 2 from 2013 to 2016 and 3 from 2017 to 2020. The study included 855 consecutive adult HSCT: 358 HLA-matched related donors (MRD), 134 HLA-matched unrelated donors (MUD), 223 umbilical cord blood transplantation (UCBT) and 140 haploidentical transplants (Haplo-HSCT). RESULTS There were no significant differences in RBC and PLT requirements or transfusion independence among the three time periods for MUD and Haplo-HSCT. However, the transfusion burden increased significantly for MRD HSCT during the 2017-2020 period. CONCLUSION despite HSCT modalities having evolved and changed over time, overall transfusion requirements have not significantly decreased and continue to be a cornerstone of transplantation-supportive care.
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Affiliation(s)
- Pilar Solves
- Haematology Department, Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain
- Centro de Investigación Biomédica en red Cancer, Instituto Carlos III, 28029 Madrid, Spain
| | - Javier Marco-Ayala
- Haematology Department, Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain
- Haematology Department, University Hospital "Morales Meseguer", 30007 Murcia, Spain
| | - Miguel Ángel Sanz
- Haematology Department, Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain
- Centro de Investigación Biomédica en red Cancer, Instituto Carlos III, 28029 Madrid, Spain
| | - Inés Gómez-Seguí
- Haematology Department, Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain
- Centro de Investigación Biomédica en red Cancer, Instituto Carlos III, 28029 Madrid, Spain
| | - Aitana Balaguer-Roselló
- Haematology Department, Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain
- Centro de Investigación Biomédica en red Cancer, Instituto Carlos III, 28029 Madrid, Spain
| | - Ana Facal
- Haematology Department, Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain
| | - Marta Villalba
- Haematology Department, Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain
| | - Juan Montoro
- Haematology Department, Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain
- Centro de Investigación Biomédica en red Cancer, Instituto Carlos III, 28029 Madrid, Spain
| | - Guillermo Sanz
- Haematology Department, Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain
- Centro de Investigación Biomédica en red Cancer, Instituto Carlos III, 28029 Madrid, Spain
| | - Javier de la Rubia
- Haematology Department, Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain
- Centro de Investigación Biomédica en red Cancer, Instituto Carlos III, 28029 Madrid, Spain
- School of Medicine and Dentistry, Catholic University of Valencia, 46010 Valencia, Spain
| | - Jaime Sanz
- Haematology Department, Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain
- Centro de Investigación Biomédica en red Cancer, Instituto Carlos III, 28029 Madrid, Spain
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13
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Iqbal M, Nieto FAM, Brannick KM, Li Z, Murthy H, Foran J, Roy V, Kharfan-Dabaja MA, Ayala E. A Calcineurin Inhibitor Free Graft Versus Host Disease Prophylaxis for Patients Undergoing Matched Related and Matched Unrelated Donor Allogeneic Hematopoietic Cell Transplant. Transplant Cell Ther 2023; 29:327.e1-327.e9. [PMID: 36758832 DOI: 10.1016/j.jtct.2023.02.001] [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: 01/05/2023] [Revised: 02/01/2023] [Accepted: 02/01/2023] [Indexed: 02/10/2023]
Abstract
Post-transplantation cyclophosphamide (PTCy) and calcineurin inhibitor (CNI)-based graft versus host disease (GVHD) prophylaxis has been associated with lower rates of acute and chronic GVHD compared with the traditional prophylaxis of CNI and methotrexate (MTX) in matched related donor (MRD) and matched unrelated donor (MUD) allogeneic hematopoietic cell transplantation (allo-HCT). The combination of PTCy with sirolimus (PTCy-Siro) as CNI-free GVHD prophylaxis has shown promising results, with cumulative rates of grade II-IV acute and chronic GVHD in the range of 15% to 27% and 20% to 27%, respectively, in patients undergoing MRD, MUD, and haploidentical allo-HCT. We report a single-center, nonrandomized comparison of patients undergoing matched donor allo-HCT receiving PTCy-Siro with those receiving the standard GVHD prophylaxis of tacrolimus and methotrexate (Tac-MTX). One hundred and sixteen consecutive patients who had undergone an MRD or MUD allo-HCT between January 2018 and January 2021 and received either PTCy-Siro (n = 29) or Tac-MTX (n = 87) as GVHD prophylaxis regimens were eligible for inclusion. Patients receiving PTCy-Siro had a significantly shorter median time to immunosuppression withdrawal than patients receiving Tac-MTX (138 days [range, 37 to 312 days] versus 232 days [range, 66 to 1120 days]; P < .001). There was no significant difference between the 2 arms in the incidence of grade II-IV acute GVHD, grade III-IV acute GVHD, steroid-refractory acute GVHD, or clinical infections. At a median follow-up of 1.1 years (range, 0 to 1.8 years), patients receiving PTCy-Siro were significantly less likely to have chronic GVHD, with 2-year freedom from GVHD of 75% (95% confidence interval [CI], 58% to 98%) versus 20% (95% CI, 10% to 40%) for those receiving Tac-MTX (P = .005).
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Affiliation(s)
- Madiha Iqbal
- Department of Hematology-Oncology, Mayo Clinic, Jacksonville, Florida.
| | | | | | - Zhuo Li
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, Florida
| | - Hemant Murthy
- Department of Hematology-Oncology, Mayo Clinic, Jacksonville, Florida
| | - James Foran
- Department of Hematology-Oncology, Mayo Clinic, Jacksonville, Florida
| | - Vivek Roy
- Department of Hematology-Oncology, Mayo Clinic, Jacksonville, Florida
| | | | - Ernesto Ayala
- Department of Hematology-Oncology, Mayo Clinic, Jacksonville, Florida
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14
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Lazzari L, Balaguer-Roselló A, Montoro J, Greco R, Hernani R, Lupo-Stanghellini MT, Villalba M, Giglio F, Facal A, Lorentino F, Guerreiro M, Bruno A, Pérez A, Xue E, Clerici D, Piemontese S, Piñana JL, Sanz MÁ, Solano C, de la Rubia J, Ciceri F, Peccatori J, Sanz J. Post-transplant cyclophosphamide and sirolimus based graft-versus-host disease prophylaxis after allogeneic stem cell transplantation for acute myeloid leukemia. Bone Marrow Transplant 2022; 57:1389-1398. [PMID: 35680995 PMCID: PMC9439951 DOI: 10.1038/s41409-022-01725-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 05/16/2022] [Accepted: 05/25/2022] [Indexed: 11/30/2022]
Abstract
Post-transplant cyclophosphamide (PTCy) has emerged as a promising graft-versus-host disease (GvHD) prophylaxis in allogeneic hematopoietic stem cell transplantation (allo-HSCT). However, no studies have reported the efficacy of a GvHD prophylaxis based on PTCy with sirolimus (Sir-PTCy) in patients with acute myeloid leukemia (AML). In this retrospective study, we analyze the use of sirolimus in combination with PTCy, with or without mycophenolate mofetil (MMF), on 242 consecutive adult patients with AML undergoing a myeloablative first allo-HSCT from different donor types, in three European centers between January 2017 and December 2020. Seventy-seven (32%) patients received allo-HSCT from HLA-matched sibling donor, 101 (42%) from HLA-matched and mismatched unrelated donor, and 64 (26%) from haploidentical donor. Except for neutrophil and platelet engraftment, which was slower in the haploidentical cohort, no significant differences were observed in major transplant outcomes according to donor type in univariate and multivariate analysis. GvHD prophylaxis with Sir-PTCy, with or without MMF, is safe and effective in patients with AML undergoing myeloablative allo-HSCT, resulting in low rates of transplant-related mortality, relapse/progression, and acute and chronic GvHD in all donor settings.
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Affiliation(s)
- Lorenzo Lazzari
- Hematology and Bone Marrow Transplantation Unit, IRCCS Ospedale San Raffaele, Milan, Italy.
| | | | - Juan Montoro
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Raffaella Greco
- Hematology and Bone Marrow Transplantation Unit, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Rafael Hernani
- Department of Hematology, Hospital Clínico Universitario, Valencia, Spain
| | | | - Marta Villalba
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Fabio Giglio
- Hematology and Bone Marrow Transplantation Unit, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Ana Facal
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Francesca Lorentino
- Hematology and Bone Marrow Transplantation Unit, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Manuel Guerreiro
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Alessandro Bruno
- Hematology and Bone Marrow Transplantation Unit, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Ariadna Pérez
- Department of Hematology, Hospital Clínico Universitario, Valencia, Spain
| | - Elisabetta Xue
- Hematology and Bone Marrow Transplantation Unit, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Daniela Clerici
- Hematology and Bone Marrow Transplantation Unit, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Simona Piemontese
- Hematology and Bone Marrow Transplantation Unit, IRCCS Ospedale San Raffaele, Milan, Italy
| | - José Luis Piñana
- Department of Hematology, Hospital Clínico Universitario, Valencia, Spain
| | - Miguel Ángel Sanz
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Carlos Solano
- Department of Hematology, Hospital Clínico Universitario, Valencia, Spain.,Department of Medicine, School of Medicine, University of Valencia, Valencia, Spain
| | - Javier de la Rubia
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Fabio Ciceri
- Hematology and Bone Marrow Transplantation Unit, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Jacopo Peccatori
- Hematology and Bone Marrow Transplantation Unit, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Jaime Sanz
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain.,Department of Medicine, School of Medicine, University of Valencia, Valencia, Spain
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15
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PTCY and Tacrolimus for GVHD Prevention for Older Adults Undergoing HLA-Matched Sibling and Unrelated Donor AlloHCT. Transplant Cell Ther 2022; 28:489.e1-489.e9. [PMID: 35577323 DOI: 10.1016/j.jtct.2022.05.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 04/20/2022] [Accepted: 05/09/2022] [Indexed: 12/19/2022]
Abstract
INTRODUCTION The use of PTCY for graft-versus-host disease (GHVD) prevention is becoming prevalent in the transplant community when HLA-identical sibling (MSD) and 10/10 HLA-matched (MUD) and 9/10 mismatched (MMUD) unrelated donors are selected for alloHSCT. However, reported evidence on outcomes from elderly receiving PTCY-containing GVHD prophylaxis remains limited. OBJECTIVES This study aims to compare the outcomes of PTCY-TK prophylaxis and conventional GVHD prophylaxis in patients aged >50 years undergoing peripheral blood alloHSCT from a single institution. STUDY DESIGN A total of 161 consecutive patients aged >50 years undergoing alloHSCT between Jan-2014 and Feb-2021 were included. Data was collected retrospectively and updated in December 2021. Patients received grafts from HLA-identical sibling (MSD), and from 10/10 and 9/10 HLA matched and mismatched unrelated donors (UD). RESULTS Overall, median age was 60 years and 91 (54.8%) received PTCY-TK for GVHD prevention. Time to neutrophil and platelet engraftment was longer in the PTCY-TK group (20 vs. 16 days and 19 vs. 11 days, P< 0.001). The cumulative incidences of grade II-IV and III-IV aGVHD at day +100 and moderate/severe cGVHD at 2 years were 18.2%, 5.7% and 9.5% for patients receiving PTCY-TK, and 26.0%, 9.6% and 39.5% for those that did not. The multivariate analysis showed that PTCY-TK reduced the probability of grade II-IV aGVHD (HR 0.41, p=0.035), of cGVHD [any grade: HR 0.43 (p=0.014), and of moderate/severe cGVHD (HR 0.15 (p<0.001)]. At 2-years, the overall survival (65.4% vs. 65.6%, p=0.472), non-relapse mortality (17.4% vs. 13.7%, p=0.967), and cumulative incidence of relapse rates (24.2% vs. 27.5%, p=0.712) were comparable between both cohorts; GVHD-Free/Relapse-free survival (GRFS) was higher in the PTCY-TK group (2-years: 50.2% vs. 21.8%; HR 0.42, p=0.001). In patients aged ≥50 years, Conclusion: PTCY-TK was safe and a more effective drug combination than non-PTCY containing GVHD prophylaxis, even with the use of matched and mismatched UD, and resulted in comparable relapse rates and better GRFS.
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16
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Ngo D, Samuels D, Chen J, Koller PB, Al Malki MM. A Clinical Review of the Different Strategies to Minimize Hemorrhagic Cystitis Associated with the Use of Post-Transplant Cyclophosphamide in an Allogeneic Transplant. Transplant Cell Ther 2022; 28:349-354. [PMID: 35580733 DOI: 10.1016/j.jtct.2022.05.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/05/2022] [Accepted: 05/09/2022] [Indexed: 12/15/2022]
Abstract
Post-transplantation cyclophosphamide (PTCy) has improved hematopoietic stem cell transplantation outcomes for patients with major HLA disparities. Although PTCy in combination with calcineurin inhibitors is a successful graft-versus-host disease regimen, giving high doses of cyclophosphamide may cause hemorrhagic cystitis (HC). The strategies used to prevent HC are adapted from published data in the pre-transplantation conditioning setting. However, there is no consensus on what the optimal strategy is to prevent PTCy-associated HC. This review provides a summary of the different preventative strategies used in this setting. Based on the results published in current literature, hyperhydration is an effective preventative strategy, but it may cause fluid overload and other complications. Additionally, mesna at least 100% of the PTCy dose should be administered as a continuous infusion or frequent intermittent bolus infusion. More comparative studies between these strategies are needed to provide a definitive solution for preventing HC associated with PTCy.
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Affiliation(s)
- Dat Ngo
- Department of Pharmacy, City of Hope, City of Hope Medical Center, Duarte, California
| | - Diana Samuels
- Department of Pharmacy, City of Hope, City of Hope Medical Center, Duarte, California
| | - Jason Chen
- Department of Pharmacy, City of Hope, City of Hope Medical Center, Duarte, California.
| | - Paul B Koller
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope Medical Center, City of Hope, Duarte, California
| | - Monzr M Al Malki
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope Medical Center, City of Hope, Duarte, California
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17
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Luo XH, Zhu Y, Chen YT, Shui LP, Liu L. CMV Infection and CMV-Specific Immune Reconstitution Following Haploidentical Stem Cell Transplantation: An Update. Front Immunol 2021; 12:732826. [PMID: 34777342 PMCID: PMC8580860 DOI: 10.3389/fimmu.2021.732826] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 09/14/2021] [Indexed: 02/05/2023] Open
Abstract
Haploidentical stem cell transplantation (haploSCT) has advanced to a common procedure for treating patients with hematological malignancies and immunodeficiency diseases. However, cure is seriously hampered by cytomegalovirus (CMV) infections and delayed immune reconstitution for the majority of haploidentical transplant recipients compared to HLA-matched stem cell transplantation. Three major approaches, including in vivo T-cell depletion (TCD) using antithymocyte globulin for haploSCT (in vivo TCD-haploSCT), ex vivo TCD using CD34 + positive selection for haploSCT (ex vivo TCD-haploSCT), and T-cell replete haploSCT using posttransplant cyclophosphamide (PTCy-haploSCT), are currently used worldwide. We provide an update on CMV infection and CMV-specific immune recovery in this fast-evolving field. The progress made in cellular immunotherapy of CMV infection after haploSCT is also addressed. Groundwork has been prepared for the creation of personalized avenues to enhance immune reconstitution and decrease the incidence of CMV infection after haploSCT.
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Affiliation(s)
- Xiao-Hua Luo
- Department of Hematology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yan Zhu
- Department of Hematology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Yu-Ting Chen
- Department of Hematology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Li-Ping Shui
- Department of Hematology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Lin Liu
- Department of Hematology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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18
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Romero S, Balaguer-Roselló A, Montoro J, Beneit P, Martínez A, Ruiz C, Andreu R, Guerreiro M, Arnao M, Montava A, Vicente AI, Jarque I, Sanz J. Addition of chemotherapy to nivolumab after PD-1 inhibitor failure as bridge to allogeneic stem cell transplantation in classical Hodgkin's lymphoma: report on three cases and literature review. Ther Adv Hematol 2021; 12:20406207211038181. [PMID: 34434538 PMCID: PMC8381419 DOI: 10.1177/20406207211038181] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 07/19/2021] [Indexed: 11/16/2022] Open
Abstract
The poor prognosis of refractory or relapsed (R/R) classical Hodgkin's lymphoma (cHL) after autologous stem cell transplantation has improved greatly due to the introduction of brentuximab vedotin and PD-1 inhibitors. However, the duration of response achieved with these novel agents is too short. The information about the management of patients after anti-PD-1 therapy failure is very limited in cHL, although chemotherapy alone or combined with PD-1 inhibitors has shown encouraging results. We report three cases of heavily pretreated cHL, refractory to nivolumab monotherapy, successfully rescued with the addition of chemotherapy to nivolumab, as a bridge to allogeneic stem cell transplantation (allo-SCT). All three patients presented poor clinical features such as three to four previous lines including brentuximab vedotin and autologous stem cell transplantation, refractoriness to the last line of therapy previous to nivolumab, and rapid disease progression. Notwithstanding these characteristics and nivolumab failure, they achieved a complete response after the addition of chemotherapy, were consolidated with allo-SCT, and still remain in complete response. There are few studies concerning the combination of PD-1 inhibitors and chemotherapy after nivolumab failure, including one retrospective study and one phase II trial with nivolumab plus bendamustine. Therefore, only few patients are consolidated with allo-SCT. However, there are several ongoing trials investigating new combinations of chemotherapy and PD-1 inhibitors in R/R cHL, as well as in first line. All these data suggest that anti-PD-1 therapy may reprogram the immune system, activating and inhibiting effector and immunosuppressive cells, respectively, leading to overtake of chemorefractoriness. Allo-SCT can increase the immune-related events of patients treated with anti-PD-1 previously, consistent on acute graft-versus-host disease, sinusoidal obstruction syndrome, and noninfectious febrile syndrome. In conclusion, the combination of PD-1 inhibitor and chemotherapy may be a feasible therapy after anti-PD-1 treatment failure as a bridge to allo-SCT.
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Affiliation(s)
- Samuel Romero
- Hematology Department, Hospital Universitari i
Politècnic La Fe, Avda. Fernando Abril Martorell, 106, 46026 Valencia,
Spain
- Instituto de Investigación Sanitaria La Fe
(IIS-La Fe), Valencia, Spain
| | - Aitana Balaguer-Roselló
- Hematology Department, Hospital Universitari i
Politècnic La Fe, Valencia, Spain
- Instituto de Investigación Sanitaria La Fe
(IIS-La Fe), Valencia, Spain
| | - Juan Montoro
- Hematology Department, Hospital Universitari i
Politècnic La Fe, Valencia, Spain
- Instituto de Investigación Sanitaria La Fe
(IIS-La Fe), Valencia, Spain
| | - Paola Beneit
- Hematology Department, Hospital Universitario
San Juan de Alicante, Spain
| | - Amelia Martínez
- Hematology Department, Hospital Universitario
de Torrevieja, Spain
| | - Cristina Ruiz
- Nuclear Medicine Department, Hospital
Universitari i Politècnic La Fe, Valencia, Spain
| | - Rafael Andreu
- Hematology Department, Hospital Universitari i
Politècnic La Fe, Valencia, Spain
| | - Manuel Guerreiro
- Hematology Department, Hospital Universitari i
Politècnic La Fe, Valencia, Spain
- Instituto de Investigación Sanitaria La Fe
(IIS-La Fe), Valencia, Spain
| | - Mario Arnao
- Hematology Department, Hospital Universitari i
Politècnic La Fe, Valencia, Spain
| | - Alberto Montava
- Hematology Department, Hospital Universitari i
Politècnic La Fe, Valencia, Spain
| | - Ana I. Vicente
- Hematology Department, Hospital Universitari i
Politècnic La Fe, Valencia, Spain
| | - Isidro Jarque
- Hematology Department, Hospital Universitari i
Politècnic La Fe, Valencia, Spain
- CIBERONC, Instituto Carlos III, Madrid,
Spain
| | - Jaime Sanz
- Hematology Department, Hospital Universitari i
Politècnic La Fe, Valencia, Spain
- CIBERONC, Instituto Carlos III, Madrid,
Spain
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19
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Greco R, Lorentino F, Albanese S, Lupo Stanghellini MT, Giglio F, Piemontese S, Clerici D, Lazzari L, Marcatti M, Mastaglio S, Xue E, Farina F, Pavesi F, Assanelli A, Carrabba MG, Marktel S, Vago L, Bonini C, Corti C, Bernardi M, Ciceri F, Peccatori J. Posttransplantation Cyclophosphamide- and Sirolimus-Based Graft-Versus-Host-Disease Prophylaxis in Allogeneic Stem Cell Transplant. Transplant Cell Ther 2021; 27:776.e1-776.e13. [PMID: 34087452 DOI: 10.1016/j.jtct.2021.05.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 05/20/2021] [Accepted: 05/24/2021] [Indexed: 12/11/2022]
Abstract
Post-transplantation cyclophosphamide (PTCy) has emerged as a promising graft-versus-host-disease (GVHD) prophylaxis in the setting of allogeneic hematopoietic stem cell transplantation (HSCT) from haploidentical donors and more recently in matched donor transplants. Herein, we describe our real-life experience on 249 adult patients undergoing allogeneic HSCT, from HLA-matched related (MRD), HLA-matched unrelated (MUD), or mismatched related donors (MMRD). Patients received unmanipulated peripheral blood stem cells (PBSCs), using a GVHD prophylaxis with PTCy and sirolimus. Mycophenolate mofetil was added in MUD or MMRD. In the HLA-matched donor group (MRD, n = 48, MUD, n = 50), the cumulative incidence of grades II-IV and III-IV acute GvHD was 23% and 9% at 100 days, respectively. The cumulative incidence of chronic GvHD was 25% at 2 years, severe only for 5% of the patients. The cumulative incidences of relapse and transplant-related mortality (TRM) were 31% and 9% at 2 years, respectively. The 2-year overall survival (OS) was 72% and progression-free survival (PFS) 60%; the composite endpoint of GvHD/relapse-free survival (GRFS) was 52% at 2 years. In the haploidentical donor group (n = 151), we documented a cumulative incidence of grades II-IV and III-IV acute GVHD of 35% and 20% at 100 days, respectively, and a cumulative incidence of chronic GvHD of 39% at 2 years. We observed severe chronic GVHD in 15% of the patients. The cumulative incidence of relapse and TRM was 32% and 25% at 2 years, respectively. The 2-year OS was 48%, whereas PFS was 43%; GRFS was 28% at 2 years. However, more patients in the haploidentical group presented high/very high disease risk index (DRI) and higher HCT-comorbidity index. In patients classified in the low-intermediate DRI, 2-year GRFS was 53% in MRD, 65% in MUD, and 46% in haploidentical HSCT (P = .33). Sirolimus-PTCy platform deserves further investigation as an alternative to calcineurin-inhibitor-based GVHD prophylaxis for all donor sources. In patients presenting a low-intermediate DRI, this strategy translates in relevant survival independently from the transplant source.
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Affiliation(s)
- Raffaella Greco
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesca Lorentino
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy; PhD Program in Public Health, Department of Medicine and Surgery, University of Milano-Bicocca, Italy
| | - Serena Albanese
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy; University Vita-Salute San Raffaele, Milan, Italy
| | | | - Fabio Giglio
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Simona Piemontese
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Daniela Clerici
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Lorenzo Lazzari
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy; University Vita-Salute San Raffaele, Milan, Italy
| | - Magda Marcatti
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sara Mastaglio
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Elisabetta Xue
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesca Farina
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesca Pavesi
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Andrea Assanelli
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Matteo G Carrabba
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sarah Marktel
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luca Vago
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy; Unit of Immunogenetics, Leukemia Genomics and Immunobiology, San Raffaele Scientific Institute, Milano, Italy
| | - Chiara Bonini
- University Vita-Salute San Raffaele, Milan, Italy; Experimental Hematology Unit, San Raffaele Scientific Institute, Milano, Italy
| | - Consuelo Corti
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Bernardi
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fabio Ciceri
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy; University Vita-Salute San Raffaele, Milan, Italy.
| | - Jacopo Peccatori
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
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20
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A phase 2 trial of GVHD prophylaxis with PTCy, sirolimus, and MMF after peripheral blood haploidentical transplantation. Blood Adv 2021; 5:1154-1163. [PMID: 33635333 DOI: 10.1182/bloodadvances.2020003779] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 01/13/2021] [Indexed: 12/14/2022] Open
Abstract
The introduction of posttransplant cyclophosphamide (PTCy) made performing allogeneic hematopoietic cell transplantation (HCT) from HLA haplotype-incompatible donors possible. In a setting of PTCy and tacrolimus/mycophenolate mofetil (MMF) as a graft-versus-host disease (GVHD) prophylaxis, a peripheral blood (PB) graft source as compared with bone marrow reduces the relapse rate but increases acute GVHD (aGVHD) and chronic GVHD (cGVHD). This phase 2 trial assessed sirolimus and MMF efficacy following PTCy as a GVHD prophylaxis after PB haploidentical HCT (haplo-HCT). With 32 evaluable patients (≥18 years) enrolled, this study had 90% power to demonstrate a reduction in 100-day grade II-IV aGVHD to 20% from the historical benchmark of 40% after haplo-HCT using PTCy/tacrolimus/MMF. At a median follow-up of 16.1 months, the primary end point of the trial was met with a day-100 grade II-IV aGVHD cumulative incidence of 18.8% (95% confidence interval [CI], 7.5% to 34.0%). There were no graft-failure events and the 1-year probability of National Institutes of Health (NIH) moderate/severe cGVHD was 18.8% (95% CI, 7.4% to 34.0%), nonrelapse mortality was 18.8% (95% CI, 7.4% to 34.0%), relapse was 22.2% (95% CI, 9.6% to 38.2%), disease-free survival was 59.0% (95% CI, 44.1% to 79.0%), GVHD-free relapse-free survival was 49.6% (95% CI, 34.9% to 70.5%), and overall survival was 71.7% (95% CI, 57.7% to 89.2%) for the entire cohort. These data demonstrate that GVHD prophylaxis with sirolimus/MMF following PTCy effectively prevents grade II-IV aGVHD after PB haplo-HCT, warranting prospective comparison of sirolimus vs tacrolimus in combination with MMF following PTCy as GVHD prophylaxis after PB HCT. This trial was registered at www.clinicaltrials.gov as #NCT03018223.
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21
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Hernani R, Piñana JL, Pérez A, Quintero A, Montoro J, Hernández‐Boluda JC, Carretero C, Balaguer‐Roselló A, Guerreiro M, Lorenzo I, Aguilar C, Giménez E, Navarro D, Sanz MA, Sanz J, Solano C. Sirolimus versus cyclosporine in haploidentical stem cell transplantation with posttransplant cyclophosphamide and mycophenolate mofetil as graft‐versus‐host disease prophylaxis. EJHAEM 2021; 2:236-248. [PMID: 35845283 PMCID: PMC9175741 DOI: 10.1002/jha2.183] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 02/28/2021] [Accepted: 03/02/2021] [Indexed: 11/12/2022]
Abstract
Sirolimus has emerged as an alternative to calcineurin inhibitors‐based (CNI) graft‐versus‐host disease (GVHD) prophylaxis. This retrospective study compares the outcome of 133 consecutive adult patients with haematological malignancies undergoing haploidentical stem cell transplantation with posttransplant cyclophosphamide (PTCy) and mycophenolate mofetil (MMF), combined with cyclosporine A (PTCy–CsA–MMF, n = 67) or sirolimus (PTCy–Sir–MMF, n = 66) as GVHD prophylaxis strategy. The median follow‐up was 48 (range 22–83) and 13 (range 3–33) months, respectively. PTCy–CsA–MMF was associated in multivariate analyses with a higher risk of acute kidney injury (HR 2.1, 95% CI, 1.21–3.57, p = .008) and thrombotic microangiopathy (HR 12.5, 95% CI, 1.66–93.5, p = .014), whereas PTCy–Sir–MMF was associated with a higher risk of hepatic sinusoidal obstruction syndrome (SOS) (HR 10.8, 95% CI, 1.52–77, p = .018), especially late‐onset forms, which totally resolved and none of the patients needed discontinuation of sirolimus. Two SOS‐related deaths were detected, both in the PTCy–CsA–MMF subgroup. Both GVHD prophylaxis strategies were otherwise comparable in terms of engraftment, GVHD incidence and survival.
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Affiliation(s)
- Rafael Hernani
- Department of Haematology Hospital Clínico Universitario Institute for Research INCLIVA Valencia Spain
| | - José Luis Piñana
- Department of Haematology Hospital Universitari i Politècnic La Fe Valencia Spain
- CIBERONC Instituto Carlos III Madrid Spain
| | - Ariadna Pérez
- Department of Haematology Hospital Clínico Universitario Institute for Research INCLIVA Valencia Spain
| | - Abdiel Quintero
- Department of Haematology Hospital Universitari i Politècnic La Fe Valencia Spain
| | - Juan Montoro
- Department of Haematology Hospital Universitari i Politècnic La Fe Valencia Spain
| | - Juan C. Hernández‐Boluda
- Department of Haematology Hospital Clínico Universitario Institute for Research INCLIVA Valencia Spain
- Department of Medicine University of Valencia Valencia Spain
| | - Carlos Carretero
- Department of Haematology Hospital Clínico Universitario Institute for Research INCLIVA Valencia Spain
| | | | - Manuel Guerreiro
- Department of Haematology Hospital Universitari i Politècnic La Fe Valencia Spain
| | - Ignacio Lorenzo
- Department of Haematology Hospital Universitari i Politècnic La Fe Valencia Spain
| | - Cristóbal Aguilar
- Department of Haematology Hospital Universitari i Politècnic La Fe Valencia Spain
| | - Estela Giménez
- Microbiology Service Hospital Clínico Universitario Institute for Research INCLIVA Valencia Spain
| | - David Navarro
- Microbiology Service Hospital Clínico Universitario Institute for Research INCLIVA Valencia Spain
- Department of Microbiology University of Valencia Valencia Spain
| | - Miguel A. Sanz
- Department of Haematology Hospital Universitari i Politècnic La Fe Valencia Spain
- Department of Medicine University of Valencia Valencia Spain
- CIBERONC Instituto Carlos III Madrid Spain
| | - Jaime Sanz
- Department of Haematology Hospital Universitari i Politècnic La Fe Valencia Spain
- Department of Medicine University of Valencia Valencia Spain
- CIBERONC Instituto Carlos III Madrid Spain
| | - Carlos Solano
- Department of Haematology Hospital Clínico Universitario Institute for Research INCLIVA Valencia Spain
- Department of Medicine University of Valencia Valencia Spain
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22
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Zhang B, Chen L, Zhou J, Zu Y, Gui R, Li Z, Wang J, Yu F, Zhang Y, Zhao H, Ji Z, Song Y. Ruxolitinib early administration reduces acute GVHD after alternative donor hematopoietic stem cell transplantation in acute leukemia. Sci Rep 2021; 11:8501. [PMID: 33875780 PMCID: PMC8055912 DOI: 10.1038/s41598-021-88080-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 04/08/2021] [Indexed: 12/25/2022] Open
Abstract
This study aimed to observe the safety and clinical efficacy of early application of ruxolitinib to prevent acute graft-versus-host disease (aGVHD) after alternative donor transplantation in acute leukemia. There were 57 patients undergoing allo-HSCT at the Affiliated Cancer Hospital of Zhengzhou University from July 2017 to October 2019. They were divided into control(16 patients) and ruxolitinib (41 patients) groups. For aGVHD prophylaxis, the control group received post-transplantation cyclophosphamide, antithymocyte globulin-Fresenius, cyclosporine A, and mycophenolate mofetil, while in the ruxolitinib group, ruxolitinib 5 mg/d in adults or 0.07–0.1 mg/(kg d) in children was administered from the day of neutrophil engraftment to 100 days post-transplantation based on control group. We found 55 patients had successful reconstitution of hematopoiesis; No significant difference was found in cGVHD, hemorrhagic cystitis, pulmonary infection, intestinal infection, Epstein-Barr virus infection, cytomegalovirus infection, relapse, death, and nonrelapse mortality. The incidences of aGVHD (50 vs. 22%, P = 0.046) and grade II–IV aGVHD (42.9 vs. 12.2%, P = 0.013) were significantly higher in the control group than in the ruxolitinib group. No significant differences were observed in overall survival (P = 0.514), disease-free survival (P = 0.691), and cumulative platelet transfusion within 100 days post-transplantation between two groups. This suggests early application of ruxolitinib can reduce the incidence and severity of aGVHD and patients are well tolerated.
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Affiliation(s)
- Binglei Zhang
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, 450000, Henan, China.,Henan Academy of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, 450000, Henan, China.,School of Basic Medical Sciences, Zhengzhou University, Zhengzhou, 450000, Henan, China.,Academy of Medical Sciences, Zhengzhou University, Zhengzhou, 450000, Henan, China
| | - Lingyun Chen
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, 450000, Henan, China
| | - Jian Zhou
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, 450000, Henan, China.
| | - Yingling Zu
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, 450000, Henan, China
| | - Ruirui Gui
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, 450000, Henan, China
| | - Zhen Li
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, 450000, Henan, China
| | - Juan Wang
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, 450000, Henan, China
| | - Fengkuan Yu
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, 450000, Henan, China
| | - Yanli Zhang
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, 450000, Henan, China
| | - Huifang Zhao
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, 450000, Henan, China
| | - Zhenyu Ji
- Henan Academy of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, 450000, Henan, China.
| | - Yongping Song
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, 450000, Henan, China.
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23
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Riddell P, Vasudevan-Nampoothiri R, Ma J, Singer LG, Lipton JH, Juvet SC. Lung transplantation for late-onset non-infectious chronic pulmonary complications of allogenic hematopoietic stem cell transplant. Respir Res 2021; 22:101. [PMID: 33827576 PMCID: PMC8025894 DOI: 10.1186/s12931-021-01699-8] [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: 01/29/2021] [Accepted: 03/29/2021] [Indexed: 11/12/2022] Open
Abstract
Background Late onset non-infectious pulmonary complications (LONIPCs) following allogenic hematopoietic stem cell transplantation (allo-HSCT) confer a significant mortality risk. Lung transplantation (LTx) has the potential to provide survival benefit but the impact of prior allo-HSCT on post-LTx outcomes is not well studied.
Methods This retrospective, single-centre cohort study assessed the post-LTx outcomes of adults with LONIPCs of allo-HSCT. Outcomes of LTx for LONIPCs were compared to propensity-score matched LTx controls (n = 38, non-HSCT) and recipients of re-LTx (n = 70) for chronic lung allograft dysfunction (CLAD).
Results Nineteen patients underwent DLTx for LONIPCs of allo-HSCT between 2003 and 2019. Post-LTx survival was 50% at 5-years. Survival to 1-year post-LTx was similar to matched controls (p = 0.473). Survival, conditional on 1-year survival, was lower in the allo-HSCT cohort (p = 0.034). An increased risk of death due to infection was identified in the allo-HSCT cohort compared to matched controls (p = 0.003). Compared to re-LTx recipients, the allo-HSCT cohort had superior survival to 1-year post-LTx (p = 0.034) but conditional 1-year survival was similar (p = 0.145).
Conclusion This study identifies an increased risk of post-LTx mortality in recipients with previous allo-HSCT, associated with infection. It supports the hypothesis that allo-HSCT LTx recipients are relatively more immunosuppressed than patients undergoing LTx for other indications. Optimisation of post-LTx immunosuppressive and antimicrobial strategies to account for this finding should be considered.
Supplementary Information The online version contains supplementary material available at 10.1186/s12931-021-01699-8.
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Affiliation(s)
- Peter Riddell
- Ajmera Transplant Centre and Toronto Lung Transplant Program, Toronto General Hospital, Toronto, Canada
| | - Ram Vasudevan-Nampoothiri
- Hans Messner Allogenic Blood and Marrow Transplant Program, Princess Margaret Cancer Centre, Toronto, Canada
| | - Jin Ma
- Biostatistics Research Unit, University Health Network, University of Toronto, Toronto, Canada
| | - Lianne G Singer
- Ajmera Transplant Centre and Toronto Lung Transplant Program, Toronto General Hospital, Toronto, Canada
| | - Jeff H Lipton
- Hans Messner Allogenic Blood and Marrow Transplant Program, Princess Margaret Cancer Centre, Toronto, Canada
| | - Stephen C Juvet
- Ajmera Transplant Centre and Toronto Lung Transplant Program, Toronto General Hospital, Toronto, Canada.
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24
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Jiang JL, Gao WH, Wang LN, Wan M, Wang L, Hu J. Post-transplantation Cyclophosphamide, Tacrolimus and Low-Dose ATG as GVHD Prophylaxis for Allogeneic Peripheral Stem Cell Transplantation for Adult Patients With Lymphoid Malignancies: A Single Arm Phase II Study. Front Med (Lausanne) 2021; 8:630160. [PMID: 33816524 PMCID: PMC8012531 DOI: 10.3389/fmed.2021.630160] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 02/23/2021] [Indexed: 11/13/2022] Open
Abstract
The PT-Cy was considered as one of the mainstay protocol for graft verus host disease (GVHD) prophylaxis. Recent study demonstrated that PT-Cy combined with other immunosuppressants could further reduce the incidence of GVHD and improve the GVHD and relapse free survival (GRFS). In this prospective phase II study, we evaluated the effect of a new GVHD prophylaxis consist of PT-Cy combined with tacrolimus and low dose anti-thymoglobulin (ATG). A total of 23 patients were enrolled including 20 patients with acute lymphoblastic leukemia (ALL) and three patients with T cell lymphoma. The median age was 29 years (range, 16~58 years). Patients with HLA-matched related donor (MSD, n=7) received PT-Cy combined with tacrolimus, while patients with HLA matched unrelated (MUD, n = 2) or haplo-identical (Haplo, n = 14) donor received additional ATG at 2.5 mg/kg on day 15 or day 22 after engraftment of neutrophils. As to the acute GVHD (aGVHD), only three patients developed grade I (n = 1) or grade II (n = 2) aGVHD with 100-day incidence of all aGVHD and II-IV aGVHD at 13.0 ± 5.1% and 9.1 ± 6.1% respectively. Only two patients had mild and one had moderate chronic GVHD (cGVHD), with 1-year incidence of cGVHD and moderate/severe cGVHD at 15.2 ± 8.7% and 4.6 ± 4.4% respectively. A high incidence of CMV reactivation was documented (14/16 with MUD/Haplo donor and 2/7 with MSD) with only 1 CMV disease documented. There were two EBV reactivation without post-transplantation lymphoproliferative disease (PTLD) documented. With a median follow-up of 303 days (range, 75~700 days), three patients relapsed leading to 1-year cumulative incidence of relapse (CIR) at 12.8 ± 9.2%. Only one patient died of CMV pneumonia on day 91 with both 100-day and 1-year non-relapse mortality (NRM) at 4.6 ± 4.4%. The 1-year overall survival (OS), event-free survival (EFS) and GRFS were 95.5 ± 4.4%, 82.6 ± 9.5%, and 68.0 ± 11.3% respectively. Based on Simon's stage II design, our primary data showed that the PT-Cy+tacrolimus ± ATG protocol was promising in preventing aGVHD and cGVHD, which may translate into low NRM without increased CIR. Further clinical trial with large number of patients should be warranted. This trial was registered at www.clinicaltrials.gov as #NCT04118075.
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Affiliation(s)
- Jie-Ling Jiang
- Shanghai Institute of Hematology, Department of Hematology, Blood & Marrow Transplantation Center, Collaborative Innovation Center of Hematology, Rui Jin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wen-Hui Gao
- Shanghai Institute of Hematology, Department of Hematology, Blood & Marrow Transplantation Center, Collaborative Innovation Center of Hematology, Rui Jin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Li-Ning Wang
- Shanghai Institute of Hematology, Department of Hematology, Blood & Marrow Transplantation Center, Collaborative Innovation Center of Hematology, Rui Jin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ming Wan
- Shanghai Clinical Research Center (SCRC), Feng Lin International Centre, Shanghai, China
| | - Ling Wang
- Shanghai Institute of Hematology, Department of Hematology, Blood & Marrow Transplantation Center, Collaborative Innovation Center of Hematology, Rui Jin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiong Hu
- Shanghai Institute of Hematology, Department of Hematology, Blood & Marrow Transplantation Center, Collaborative Innovation Center of Hematology, Rui Jin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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25
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Hernández-Boluda JC, Pereira A, Alvarez-Larran A, Martín AA, Benzaquen A, Aguirre L, Mora E, González P, Mora J, Dorado N, Sampol A, García-Gutiérrez V, López-Godino O, Fox ML, Reguera JL, Pérez-Encinas M, Pascual MJ, Xicoy B, Parody R, González-Pinedo L, Español I, Avendaño A, Correa JG, Vallejo C, Jurado M, García-Cadenas I, Osorio S, Durán MA, Sánchez-Guijo F, Cervantes F, Piñana JL. Predicting Survival after Allogeneic Hematopoietic Cell Transplantation in Myelofibrosis: Performance of the Myelofibrosis Transplant Scoring System (MTSS) and Development of a New Prognostic Model. Biol Blood Marrow Transplant 2020; 26:2237-2244. [DOI: 10.1016/j.bbmt.2020.07.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/19/2020] [Accepted: 07/19/2020] [Indexed: 12/21/2022]
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PTCy and "The Story of the Three Bears". Bone Marrow Transplant 2020; 56:765-766. [PMID: 33214689 DOI: 10.1038/s41409-020-01123-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 10/22/2020] [Accepted: 10/30/2020] [Indexed: 11/09/2022]
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