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Friend BD, Schiller GJ. Beyond steroids: A systematic review and proposed solutions to managing acute graft-versus-host disease in adolescents and young adults. Blood Rev 2021; 52:100886. [PMID: 34509319 DOI: 10.1016/j.blre.2021.100886] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 08/18/2021] [Accepted: 08/26/2021] [Indexed: 12/11/2022]
Abstract
The outcomes of allogeneic hematopoietic cell transplantation (HCT) in adolescents and young adults (AYAs) with hematologic malignancies have been shown to be poorer when compared to results in children, due to a combination of higher relapse rates and greater treatment-related mortality (TRM). Although differences in relapse risk have been studied extensively, toxicity has been examined and reported less often. In this systematic review, we summarize recently published studies that have examined the differences in rates of TRM and acute graft-versus-host disease (GVHD) in AYAs and children with hematologic malignancies, and attempt to explain why these disparities exist and how they impact outcomes. In addition, we present best practices for management of steroid-refractory GVHD that are likely to improve survival in this patient population. Further, we propose the development of personalized, risk-based approaches for the prevention and treatment of GVHD that incorporate novel platforms and interventions. We believe this individualized approach is likely to reduce toxicity and greatly improve outcomes for this vulnerable population.
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Affiliation(s)
- Brian D Friend
- Department of Pediatrics, Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital, 1102 Bates Ave, Suite 1630, Houston, TX 77030, USA.
| | - Gary J Schiller
- Department of Medicine, Division of Hematology-Oncology, University of California Los Angeles, 10833 Le Conte Ave, 42-121 CHS, Los Angeles, CA 90095, USA.
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2
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Antirelapse effect of pretransplant exposure to rabbit antithymocyte globulin. Blood Adv 2020; 3:1394-1405. [PMID: 31043372 DOI: 10.1182/bloodadvances.2018030247] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 03/24/2019] [Indexed: 01/15/2023] Open
Abstract
It remains unknown why rabbit antithymocyte globulin (ATG; Thymoglobulin) has not affected relapse after hematopoietic cell transplantation (HCT) in randomized studies. We hypothesized that high pre-HCT ATG area under the curve (AUC) would be associated with a low incidence of relapse, whereas high post-HCT AUC would be associated with a high incidence of relapse. We measured serum levels of ATG capable of binding to mononuclear cells (MNCs), lymphocytes, T cells, CD4 T cells, or CD33 cells. We estimated pre- and post-HCT AUCs in 152 adult recipients of myeloablative conditioning and blood stem cells. High pre-HCT AUCs of MNC- and CD33 cell-binding ATG were associated with a low incidence of relapse and high relapse-free survival (RFS). There was a trend toward an association of high post-HCT AUC of lymphocyte-binding ATG with a high incidence of relapse and low RFS. High pre-HCT AUCs were also associated with faster engraftment and had no impact on graft-versus-host disease (GVHD) or fatal infections. High post-HCT AUCs were associated with a low risk of GVHD, seemed associated with an increased risk of fatal infections, and had no impact on engraftment. In conclusion, pre-HCT AUC seems to have a positive, whereas post-HCT AUC seems to have a negative, impact on relapse.
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Risk factors for acute GVHD and survival after hematopoietic cell transplantation. Blood 2011; 119:296-307. [PMID: 22010102 DOI: 10.1182/blood-2011-06-364265] [Citation(s) in RCA: 481] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Risk factors for acute GVHD (AGVHD), overall survival, and transplant-related mortality were evaluated in adults receiving allogeneic hematopoietic cell transplants (1999-2005) from HLA-identical sibling donors (SDs; n = 3191) or unrelated donors (URDs; n = 2370) and reported to the Center for International Blood and Marrow Transplant Research, Minneapolis, MN. To understand the impact of transplant regimen on AGVHD risk, 6 treatment categories were evaluated: (1) myeloablative conditioning (MA) with total body irradiation (TBI) + PBSCs, (2) MA + TBI + BM, (3) MA + nonTBI + PBSCs, (4) MA + nonTBI + BM, (5) reduced intensity conditioning (RIC) + PBSCs, and (6) RIC + BM. The cumulative incidences of grades B-D AGVHD were 39% (95% confidence interval [CI], 37%-41%) in the SD cohort and 59% (95% CI, 57%-61%) in the URD cohort. Patients receiving SD transplants with MA + nonTBI + BM and RIC + PBSCs had significantly lower risks of grades B-D AGVHD than patients in other treatment categories. Those receiving URD transplants with MA + TBI + BM, MA + nonTBI + BM, RIC + BM, or RIC + PBSCs had lower risks of grades B-D AGVHD than those in other treatment categories. The 5-year probabilities of survival were 46% (95% CI, 44%-49%) with SD transplants and 33% (95% CI, 31%-35%) with URD transplants. Conditioning intensity, TBI and graft source have a combined effect on risk of AGVHD that must be considered in deciding on a treatment strategy for individual patients.
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Salmasian H, Rohanizadegan M, Banihosseini S, Rahimi Darabad R, Rabbani‐Anari M, Shakiba A, Ferrara JL. Corticosteroid regimens for treatment of acute and chronic graft versus host disease (GvHD) after allogenic stem cell transplantation. Cochrane Database Syst Rev 2010; 2010:CD005565. [PMID: 20091579 PMCID: PMC7388928 DOI: 10.1002/14651858.cd005565.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Corticosteroids are commonly used in treatment of acute and chronic graft-versus-host disease (GvHD). Nevertheless, there has been no systematic analysis of effects of their use on the patients' survival and quality of life. OBJECTIVES To compare the effect of corticosteroids in treatment of patients with GvHD and to compare the effect of different regimens of corticosteroids. SEARCH STRATEGY We searched MEDLINE (up to July 2008), EMBASE (up to July 2008) and the Cochrane Controlled Trials Register (up to July 2008) to identify relevant studies. All of the references were assessed in order to identify additional trials. SELECTION CRITERIA Randomized controlled trials of any language were included in the study as long as they met any of the predefined comparisons of interest. The primary outcome in question was the overall survival of the patients. Due to lack of evidence, inclusion criteria was revised during the process of the review to include studies comparing different dosage of corticosteroids. DATA COLLECTION AND ANALYSIS All derived citations and abstracts were screened by two independent review authors for relevance. For the potentially relevant trials, the full text was obtained and reviewed by two review authors independently. Two review authors completed data extraction independently. After revising the inclusion criteria, this process was retried to ensure all relevant evidence is included in the review. MAIN RESULTS No studies met the original inclusion criteria but two studies (four articles) met the revised inclusion criteria. As they addressed different clinical questions, meta-analysis was not performed. The outcomes of one study were in favor of efficacy of corticosteroids in inducing an earlier remission of acute GvHD, while the other study reported that early corticosteroid therapy of acute GvHD could not prevent progression of the disease to higher grades, although it was accompanied by a slightly better prognosis in the patients who responded by the fifth day of treatment. AUTHORS' CONCLUSIONS There is no certain study regarding appropriate use, dose and length of therapy for acute GvHD. Further studies are needed to define the appropriate use of steroids and whether other agents are appropriate as frontline therapy.
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Affiliation(s)
- Hojjat Salmasian
- Tehran University of Medical SciencesStudents' Scientific Research CenterBaradaran Soleimani Ave., QeytariehTehranIran1938833911
| | - Mersedeh Rohanizadegan
- Tehran University of Medical SciencesStudents' Scientific Research CenterBaradaran Soleimani Ave., QeytariehTehranIran1938833911
| | - Setareh Banihosseini
- Tehran University of Medical SciencesSystematic Review Study GroupPoorsina St., 16 Azar St., Enghelab AveTehranIran14155‐6537
| | - Raheleh Rahimi Darabad
- Tehran University of Medical SciencesFaculty of Pharmacy and PHarmaceutical Sciences Research CenterNo 18 Laleh St Ashrafi Estfahani AveTehranIran
| | - Mahtab Rabbani‐Anari
- Tehran University of Medical SciencesStudents' Scientific Research CenterBaradaran Soleimani Ave., QeytariehTehranIran1938833911
| | - Alia Shakiba
- Tehran University of Medical SciencesStudents' Scientific Research CenterBaradaran Soleimani Ave., QeytariehTehranIran1938833911
| | - James L.M. Ferrara
- University of University of MichiganUniversity of Michigan Blood and Marrow Transplant ProgramCancer Center Rm 6308Ann ArborMichiganUSA48109‐0942
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Hahn T, McCarthy PL, Zhang MJ, Wang D, Arora M, Frangoul H, Gale RP, Hale GA, Horan J, Isola L, Maziarz RT, van Rood JJ, Gupta V, Halter J, Reddy V, Tiberghien P, Litzow M, Anasetti C, Pavletic S, Ringdén O. Risk factors for acute graft-versus-host disease after human leukocyte antigen-identical sibling transplants for adults with leukemia. J Clin Oncol 2008; 26:5728-34. [PMID: 18981462 PMCID: PMC2645611 DOI: 10.1200/jco.2008.17.6545] [Citation(s) in RCA: 136] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2008] [Accepted: 07/22/2008] [Indexed: 12/13/2022] Open
Abstract
PURPOSE Acute graft-versus-host disease (GVHD) causes substantial morbidity and mortality after human leukocyte antigen (HLA)-identical sibling transplants. No large registry studies of acute GVHD risk factors have been reported in two decades. Risk factors may have changed in this interval as transplant-related techniques have evolved. PATIENTS AND METHODS Acute GVHD risk factors were analyzed in 1,960 adults after HLA-identical sibling myeloablative transplant for acute myeloid leukemia (AML), acute lymphocytic leukemia (ALL), or chronic myeloid leukemia (CML) reported by 226 centers worldwide to the Center for International Blood and Marrow Transplant Research from 1995 to 2002. Outcome was measured as time from transplant to onset of grade 2 to 4 acute GVHD, with death without acute GVHD as a competing risk. RESULTS Cumulative incidence of grade 2 to 4 acute GVHD was 35% (95% CI, 33% to 37%). In multivariable analyses, factors significantly associated with grade 2 to 4 acute GVHD were cyclophosphamide + total-body irradiation versus busulfan + cyclophosphamide (relative risk [RR] = 1.4; P < .0001), blood cell versus bone marrow grafts in patients age 18 to 39 years (RR = 1.43; P = .0023), recipient age 40 and older versus age 18 to 39 years receiving bone marrow grafts (RR = 1.44; P = .0005), CML versus AML/ALL (RR = 1.35; P = .0003), white/Black versus Asian/Hispanic race (RR = 1.54; P = .0003), Karnofsky performance score less than 90 versus 90 to 100 (RR = 1.27; P = .014), and recipient/donor cytomegalovirus-seronegative versus either positive (RR = 1.20; P = .04). Stratification by disease showed the same significant predictors of grade 2 to 4 acute GVHD for CML; however, KPS and cytomegalovirus serostatus were not significant predictors for AML/ALL. CONCLUSION This analysis confirmed several previously reported risk factors for grade 2 to 4 acute GVHD. However, several new factors were identified whereas others are no longer significant. These new data may facilitate individualized risk estimates and raise several interesting biologic questions.
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MESH Headings
- Acute Disease
- Adolescent
- Adult
- Bone Marrow Transplantation/adverse effects
- Canada
- Europe
- Female
- Graft vs Host Disease/etiology
- Graft vs Host Disease/mortality
- HLA Antigens/analysis
- Histocompatibility Testing
- Humans
- Leukemia/immunology
- Leukemia/surgery
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/immunology
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/surgery
- Leukemia, Myeloid, Acute/immunology
- Leukemia, Myeloid, Acute/surgery
- Living Donors
- Male
- Peripheral Blood Stem Cell Transplantation/adverse effects
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/immunology
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/surgery
- Reproducibility of Results
- Retrospective Studies
- Risk Assessment
- Risk Factors
- Severity of Illness Index
- Siblings
- Time Factors
- Treatment Outcome
- United States
- Young Adult
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Affiliation(s)
- Theresa Hahn
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, NY 14263, USA.
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6
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Quellmann S, Schwarzer G, Hübel K, Greb A, Engert A, Bohlius J. Corticosteroids for preventing graft-versus-host disease after allogeneic myeloablative stem cell transplantation. Cochrane Database Syst Rev 2008:CD004885. [PMID: 18646116 DOI: 10.1002/14651858.cd004885.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Despite ongoing progress, acute and chronic GvHD still represent major drawbacks in the context of allogeneic myeloablative haematopoietic stem cell transplantation (HSCT) due to their high morbidity and mortality. Corticosteroids are used as first-line treatment of acute and chronic GvHD. However, their role for preventing GvHD is unclear as the published study results are controversial. OBJECTIVES To determine the effectiveness of corticosteroids used for the prophylaxis of GvHD in adults following allogeneic myeloablative HSCT. in improving overall survival, disease-free survival, relapse incidence, non-relapse mortality, acute GvHD grade I to IV, II to IV and III to IV, chronic GvHD, incidence of infectious complications, other adverse effects and cause of deaths. SEARCH STRATEGY We searched the Cochrane Haematological Malignancies Group trials register, CENTRAL (The Cochrane Library Issue 2, 2004), MEDLINE (January 1999 to February 2006), EMBASE (January 1999 to 2004), LILACS covering publications until 2004, as well as handsearched conference proceedings, including citations until 2005. SELECTION CRITERIA Randomised controlled trials (RCT) comparing the addition of corticosteroids to a GvHD prophylaxis regimen in adult patients having undergone allogeneic myeloablative HSCT were included into the review. All types and stages of the underlying disease as well as all types of possible HLA-matching were considered. DATA COLLECTION AND ANALYSIS Trial eligibility and quality assessment, data extraction and analysis were done in duplicate. MAIN RESULTS Five RCTs involving 604 people were included. The pooled results revealed that the addition of corticosteroids reduces statistically significant the risk for acute GvHD grade I to IV (HR 0.58; 95% CI 0.45 to 0.76) and II to IV (HR 0.69; 95% CI 0.51 to 0.92). No evidence was found that it has any clinical relevance on overall survival (HR 0.99; 95% CI 0.79 to 1.25) or disease-free survival (HR 0.95; 95% CI 0.74 to 1.23). As well, no statistically significant influence was found for acute GvHD grade III to IV (HR 0.78; 95% CI 0.52 to 1.15), chronic GvHD (HR 1.21;95% CI 0.89 to 1.65]), relapse incidence (HR 0.82; 95% CI 0.57 to 1.18) or non-relapse mortality (HR 0.88;95% CI 0.61 to 1.26). No clear evidence was found that the rate of infectious complications (under the concomitant use of antiviral or antibacterial medication or both) increases with the addition of corticosteroids. With respect to the other outcomes no significant differences could be detected. AUTHORS' CONCLUSIONS The addition of corticosteroids reduces the incidences of acute GvHD grade I to IV and II to IV. This reduction, however, did not show any effect on overall survival and disease-free survival. Further randomised controlled studies are needed to evaluate if the timing of steroid administration has a significant influence on the outcome; data on quality of life should be assessed systematically.
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Affiliation(s)
- Susanne Quellmann
- Cochrane Haematological Malignancies Group - Department of Internal Medicine 1, University Hospital of Cologne, Kerpener Str. 62, Cologne, Germany, 50924.
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7
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Achievement of Target Cyclosporine Concentrations as a Predictor of Severe Acute Graft Versus Host Disease in Children Undergoing Hematopoietic Stem Cell Transplantation and Receiving Cyclosporine and Methotrexate Prophylaxis. Ther Drug Monit 2007; 29:750-7. [DOI: 10.1097/ftd.0b013e31815c12ca] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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8
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9
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Hayashi T, Morishita E, Ontachi Y, Yamazaki M, Asakura H, Yoshida T, Nakao S. Effects of sarpogrelate hydrochloride in a patient with chronic graft-versus-host disease: a case report. Am J Hematol 2006; 81:121-3. [PMID: 16432874 DOI: 10.1002/ajh.20511] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Chronic graft-versus-host disease (cGVHD) is a frequent complication of allogenic bone marrow transplantation. Even with aggressive treatment, cGVHD is associated with a significant degree of morbidity and mortality. cGVHD resembles autoimmune disorder, particularly systemic sclerosis (SSc). Sarpogrelate hydrochloride (SH) is an antagonist of the 5-hydroxytryptamine2A (5HT2A) receptor and has been reported to be effective in the treatment of systemic sclerosis (SSc) patients with Raynaud phenomenon. We used SH to treat a cGVHD patient, and we measured plasma PDGF and total TGF-beta levels. After SH treatment, his plasma PDGF and total TGF-beta levels decreased, and he noticed improvement in his skin pigmentation. In the present case, SH may have improved the skin lesion by inhibiting the synthesis of PDGF and TGF-beta.
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Affiliation(s)
- Tomoe Hayashi
- Cellular Transplantation Biology, Kanazawa University Graduate School of Medicine, Kanazawa, Japan.
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10
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Santos ES, Masri M, Safah H. Revisiting the role of hematopoietic stem cell transplantation in chronic lymphocytic leukemia. Expert Rev Anticancer Ther 2005; 5:875-91. [PMID: 16221057 DOI: 10.1586/14737140.5.5.875] [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: 11/08/2022]
Abstract
Since the advent of hematopoietic stem cell transplantation more than 40 years ago, numerous methods of transplantation have been developed, modified and improved upon. Although hematopoietic stem cell transplantation has been used in a variety of malignant diseases since then, its use in the treatment of chronic lymphocytic leukemia has recently started to gain interest. Patients with chronic lymphocytic leukemia are generally elderly, and because of its relatively benign course, they were not considered suitable candidates for hematopoietic stem cell transplantation. Nonetheless, there have been marked improvements in transplantation techniques, including better conditioning regimens that have decreased treatment-related morbidity and mortality. In this article, the authors review the most recent data on hematopoietic stem cell transplantation in chronic lymphocytic leukemia as well as the change in risk stratification based on newer prognostic factors and its impact on treatment decisions in chronic lymphocytic leukemia.
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Affiliation(s)
- Edgardo S Santos
- Division of Hematology-Oncology, Tulane University Health Sciences Center, New Orleans VA Medical Center, New Orleans, LA 70112, USA.
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11
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Abstract
Although myeloablative conditioning can cytoreduce or debulk malignancies, the curative antitumor effects of allogeneic hematopoietic stem cell transplantation (HCT) are mostly mediated by transplanted donor immune cells. A heightened awareness and appreciation of the immune-mediated anticancer effects that occur after allogeneic transplantation has led to the increasing use of reduced-intensity stem cell transplantation (RIST) approaches to treat advanced malignancies. The graft-versus-leukemia effects that occur against hematologic cancers after RIST have recently attracted oncologists to explore the therapeutic potential of allogeneic HCT for treatment-refractory solid tumors. Delayed tumor regression after RIST in a subset of patients with metastatic renal cell, breast, ovarian, pancreatic, and colon carcinoma has recently been reported, confirming the existence of a graft-versus-tumor effect in solid tumors. Advanced disease states, rapidly growing tumors, and accrual of patients with extremely short survival are factors that have been identified to limit the efficacy of allogeneic immunotherapy. This review discusses results of allogeneic HCT for solid tumors and the development of newer transplant strategies to optimize the potential of the graft-versus-tumor effect.
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Affiliation(s)
- Andreas Lundqvist
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland 20892-1652, USA
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12
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Neumann F, Graef T, Tapprich C, Vaupel M, Steidl U, Germing U, Fenk R, Hinke A, Haas R, Kobbe G. Cyclosporine A and Mycophenolate Mofetil vs Cyclosporine A and Methotrexate for graft-versus-host disease prophylaxis after stem cell transplantation from HLA-identical siblings. Bone Marrow Transplant 2005; 35:1089-93. [PMID: 15821769 DOI: 10.1038/sj.bmt.1704956] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The combination of Cyclosporin A (CSA) and Methotrexate (MTX) is considered to be the standard regimen for the prevention of graft-versus-host disease (GVHD) after stem cell transplantation (SCT) from HLA-identical siblings. Mycophenolate Mofetil (MMF) has been widely used for GVHD prophylaxis after nonmyeloablative SCT, but experience following myeloablative therapy is still limited. We retrospectively compared CSA/MTX and CSA/MMF in 93 patients (median age 35 years, range 17-59 years, male subjects 48, female subjects 45) with acute myeloid leukemia (n=33), myelodysplastic syndrome (MDS) (n=3), acute lymphoblastic leukemia (ALL) (n=20) or chronic myeloid leukemia (n=37) who received CSA/MMF (n=26) or CSA/MTX (n=67) as GVHD prophylaxis following high-dose therapy and allogeneic SCT from HLA-identical siblings. No statistically significant differences were found in overall survival, relapse rate, treatment-related mortality and acute or chronic GVHD. Time to myeloid recovery was significantly shorter in patients who received CSA/MMF. We conclude that the combination of CSA/MMF appears equivalent to CSA/MTX for GVHD prophylaxis in patients receiving conventional-intensity SCT from HLA-identical siblings.
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Affiliation(s)
- F Neumann
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine University, Duesseldorf, Germany, Moorenstrasse 5, Duesseldorf, Germany.
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13
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Kim JG, Sohn SK, Kim DH, Lee NY, Suh JS, Lee KS, Lee KB. Different efficacy of mycophenolate mofetil as salvage treatment for acute and chronic GVHD after allogeneic stem cell transplant. Eur J Haematol 2004; 73:56-61. [PMID: 15182339 DOI: 10.1111/j.1600-0609.2004.00247.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE The therapeutic options currently available for treating refractory graft-vs.-host disease (GVHD) are limited. Therefore, the present study evaluated the efficacy of mycophenolate mofetil (MMF) as a salvage treatment for acute and chronic GVHD in allograft patients. METHODS Twenty-six consecutive patients with refractory acute (13 patients) or chronic (13 patients) GVHD were enrolled. The first-line treatment for all patients with acute GVHD consisted of a combination of cyclosporine A (CyA) and steroids, while the first-line treatment for chronic GVHD was steroids with or without CyA according to the risk group. MMF was added at a dose of 1.5 or 2 g daily and the steroids were tapered in the refractory cases. RESULTS Four (30.8%) of 13 patients with refractory acute GVHD responded to MMF. When analyzing the overall results according to the type of acute GVHD, improvement was observed in four (30.8%) of 13 skin cases, four (44.4%) of nine liver cases, and two (22.9%) of nine gut cases. Ten (76.9%) of 13 patients with refractory chronic GVHD responded to MMF. The common side effects were gastrointestinal disturbance (26.9%) or infectious complications (23.1%). The estimated 2-yr survival rate for patients with acute GVHD and chronic GVHD was 33.3% and 53.9%, respectively. CONCLUSIONS MMF would appear to be effective and safe for treating refractory chronic GVHD, yet not as effective for treating refractory acute gut GVHD. Accordingly, a prospective randomized clinical trial is warranted to assess the impact of MMF in the treatment of refractory GVHD.
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Affiliation(s)
- Jong Gwang Kim
- Department of Hematology/Oncology, Kyungpook National University Hospital, Daegu, Korea
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14
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Baudard M, Vincent A, Moreau P, Kergueris MF, Harousseau JL, Milpied N. Mycophenolate mofetil for the treatment of acute and chronic GVHD is effective and well tolerated but induces a high risk of infectious complications: a series of 21 BM or PBSC transplant patients. Bone Marrow Transplant 2002; 30:287-95. [PMID: 12209350 DOI: 10.1038/sj.bmt.1703633] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2001] [Accepted: 10/04/2002] [Indexed: 11/08/2022]
Abstract
The use of mycophenolate mofetil (MMF) for prophylaxis of aGVHD and/or for treatment of acute or chronic GVHD is increasing. However, the benefit of MMF as an alternative to commonly used immunosuppressive agents still needs to be assessed. We ran a retrospective study on 21 consecutive patients (median age, 36 years; range, 20-63) with aGVHD or extensive cGVHD following related (17) or unrelated (4) matched donor SCT (BM, 16; PBSC, 5) who received MMF (2 g/day) because of intolerance to or failure of CsA-containing combinations. Four of the six patients with aGVHD responded, and the response rate was 69% in cGVHD patients. We observed neither significant differences in terms of response rate for skin, liver and bowel nor dissociated response in cases of multiple organ involvement (67% of the patients). Response was the same for lichenoid and sclerodermatous skin cGVHD subtypes. No adverse effects, except diarrhea (three patients), were observed. However, 22 opportunistic or serious viral or bacterial infections occurred in 10 patients. Analysis of trough plasma levels showed a trend for a higher mean MPA concentration in patients responding to MMF. Our study highlights the high risk of infectious complications induced by the administration of MMF, an otherwise efficient and well-tolerated treatment for GVHD.
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Affiliation(s)
- M Baudard
- Service d'Hématologie, Centre Hospito-Universitaire Hôtel-Dieu, Nantes, France
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15
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Ancín I, Ferrá C, Gallardo D, Peris J, Berlanga J, Gonzalez JR, Virgili N, Grañena A. Do corticosteroids add any benefit to standard GVHD prophylaxis in allogeneic BMT? Bone Marrow Transplant 2001; 28:39-45. [PMID: 11498742 DOI: 10.1038/sj.bmt.1703085] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2000] [Accepted: 03/07/2001] [Indexed: 11/09/2022]
Abstract
In a retrospective study, we compared 15 patients who received cyclosporine (CsA), methotrexate (MTX) and prednisone (PDN) and 15 patients who received CsA-MTX for GVHD prophylaxis after allogeneic BMT (HLA-identical sibling (n = 22), related one HLA mismatch (n = 1), unrelated matched donors (n = 6), unrelated one HLA mismatch (n = 1)). The primary objectives of this study were to compare the incidence of GVHD and post-transplantation complications. Secondary objectives were to compare relapse rate, transplant-related mortality and overall survival. The incidence of acute GVHD grade III-IV was similar between the two groups (P = 0.66), as was the incidence of chronic GVHD (P = 0.67). Incidence of arterial hypertension was significantly higher in patients who received prophylactic PDN, (P = 0.03) and more insulin treatment was required in this group (P = 0.003). We observed no differences in the incidence of infections or upper digestive tract bleeding. Musculoskeletal complications appeared earlier in the group which received PDN. With a median follow-up of 4.4 years, patients in the CsA-MTX group had better overall survival, 46.7% vs 13.3% (P = 0.026). Relapse was a more frequent cause of death in the CsA-MTX group, whereas procedure-related mortality was more frequent in the CsA-MTX-PDN group (P = 0.013). These results suggest that prophylactic prednisone when combined with cyclosporine and methotrexate adds no benefit in acute or chronic GVHD prevention and may increase the morbidity of allogeneic transplantation. Corticosteroids may be reserved for GVHD treatment.
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Affiliation(s)
- I Ancín
- Department of Clinical Hematology, Hospital Duran i Reynals, Institut Català d'Oncologia, Spain.
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Esteve J, Villamor N, Colomer D, Cervantes F, Campo E, Carreras E, Montserrat E. Stem cell transplantation for chronic lymphocytic leukemia: different outcome after autologous and allogeneic transplantation and correlation with minimal residual disease status. Leukemia 2001; 15:445-51. [PMID: 11237069 DOI: 10.1038/sj.leu.2402036] [Citation(s) in RCA: 89] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The clinical outcome and its correlation with the status of minimal residual disease (MRD) was analyzed in 26 patients with chronic lymphocytic leukemia (CLL) undergoing stem cell transplantation. All patients having received autotransplant (n = 14) achieved CR which was MRD(-) in nine patients (64%) and MRD(+) in five. With a median follow-up of 26.5 months (range, 12-52), four of the five MRD(+) patients relapsed at 9, 15, 17 and 18 months after transplant, respectively. In contrast, only two patients of the nine MRD(-) patients have relapsed at 15 and 38 months (P = 0.02), and four became MRD(+) at 6, 12, 30, and 42 months after transplantation, respectively. Of the 12 patients that were allografted, three (25%) died in the early post-transplant period, one had resistant disease, and eight (67%) achieved CR. Among the latter, no evidence of MRD post-transplantation was observed in five cases, while a delayed clearance of MRD (up to 22 months after transplantation) was seen in two, and a persistent positivity of MRD after transplant was detectable in another patient until last follow-up (12 months). After a median follow-up of 43 months (range, 15-106), none of the responding patients had clinical or MRD relapse. These results show that in CLL the probability of achieving sustained MRD(-) CR is higher with allogeneic than with autologous transplants, and confirm the value of MRD assessment in the follow-up of patients transplanted for CLL.
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Affiliation(s)
- J Esteve
- Institute of Hematology and Oncology, Department of Hematology, University of Barcelona, Spain
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Goral J, Mathews HL, Nadler SG, Clancy J. Reduced levels of Hsp70 result in a therapeutic effect of 15-deoxyspergualin on acute graft-versus-host disease in (DA x LEW)F1 rats. Immunobiology 2000; 202:254-66. [PMID: 11045661 DOI: 10.1016/s0171-2985(00)80032-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We have shown previously that increased levels of hsp70, and antibodies reactive with hsp70 parallel the onset and severity of graft-versus-host disease (GVHD) in a parent --> (DA x LEW)F1 rat model. In this study we have assessed the effect of reducing the levels of the 70 kDa heat shock protein (hsp70), on the morbidity and mortality of acute GVHD in (DA x LEW)F1 rats. The reduction was accomplished by the administration of 15-deoxyspergualin (DSG), an immunosuppressive agent which binds to a constitutively expressed member of the 70 kDa heat shock protein family. DSG administered via three different protocols reduced GVHD-associated morbidity. One of the regimens, which consisted of intermittent DSG administration, also significantly reduced GVHD associated mortality. This DSG treatment reduced hsp70 levels in spleen and lymph nodes, inhibited anti-hsp70 antibody production, and diminished the serum levels of IL-2, IFN-gamma, TNF-alpha, and IL-10. IL-4 levels in the serum did not change during GVHD and were not effected by DSG. These results show that the mechanism of DSG immunosuppressive effect in rat GVHD may involve DSG's capacity to bind to hsp70, which in turn may lead to a decrease in levels of circulating anti-hsp70 antibodies, and reduced production of cytokines.
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Affiliation(s)
- J Goral
- Department of Cell Biology, Neurobiology and Anatomy, Stritch School of Medicine, Loyola University of Chicago, Maywood, Illinois 60153, USA
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Peters C, Minkov M, Gadner H, Klingebiel T, Vossen J, Locatelli F, Cornish J, Ortega J, Bekasi A, Souillet G, Stary J, Niethammer D. Statement of current majority practices in graft-versus-host disease prophylaxis and treatment in children. Bone Marrow Transplant 2000; 26:405-11. [PMID: 10982287 DOI: 10.1038/sj.bmt.1702524] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Great variations exist in the prophylaxis and treatment of GVHD in children undergoing allogeneic stem cell transplantation (SCT). The EBMT Working Party Paediatric Diseases (EBMT-WP PD) and the International BFM Study Group--Subcommittee Bone Marrow Transplantation (IBFM-SG), aimed at evaluating current local standards in the prevention and treatment of GVHD and steps which can be taken to achieve a uniform policy for the individual methods. Several conferences with their members assessed practices which are mainly applied or under investigation in children and identified where additional information is needed. For prevention of GVHD, the majority of the paediatric centres prefer CsA +/- MTX. Addition of folinic acid to MTX was considered for reduction of side-effects. During treatment of acute GVHD most centres administer prednisolone and whole blood level-adjusted CsA as medications of first choice. In cases of poor or no response to this therapy, additional immunosuppressive agents such as ATG, mycophenolate-mofetile and tacrolimus are being increasingly used. The treatment of chronic GVHD usually consists of various combinations of prednisolone and CsA. In severe cases, extracorporeal photopheresis, psoralene-UVA (PUVA) and thalidomide are administered.
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Affiliation(s)
- C Peters
- St Anna Children's Hospital, Vienna, Austria
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