1
|
Rovó A, Gras L, Piepenbroek B, Kröger N, Reinhardt HC, Radujkovic A, Blaise D, Kobbe G, Niityvuopio R, Platzbecker U, Sockel K, Hunault-Berger M, Cornelissen JJ, Forcade E, Bourhis JH, Chalandon Y, Kinsella F, Nguyen-Quoc S, Maertens J, Elmaagacli A, Mordini N, Hayden P, Raj K, Drozd-Sokolowska J, de Wreede LC, McLornan DP, Robin M, Yakoub-Agha I, Onida F. Outcomes of CMML patients undergoing allo-HCT are significantly worse compared to MDS-a study of the CMWP of the EBMT. Am J Hematol 2024; 99:203-215. [PMID: 38009469 DOI: 10.1002/ajh.27150] [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: 08/06/2023] [Revised: 10/16/2023] [Accepted: 10/25/2023] [Indexed: 11/29/2023]
Abstract
Although CMML since long has been separated from MDS, many studies continue to evaluate the outcomes of both diseases after hematopoietic cell transplantation (allo-HCT) together. Data evaluating outcomes of a large CMML cohort after allo-HCT compared to MDS are limited. We aim to compare outcomes of CMML to MDS patients who underwent allo-HCT between 2010 and 2018. Patients ≥18 years with CMML and MDS undergoing allo-HCT reported to the EBMT registry were analyzed. Progression to AML before allo-HCT was an exclusion criterion. Overall survival (OS), progression/relapse-free survival (PFS), relapse incidence (including progression) (REL), and non-relapse mortality (NRM) were evaluated in univariable and multivariable (MVA) Cox proportional hazard models including interaction terms between disease and confounders. In total, 10832 patients who underwent allo-HCT were included in the study, there were a total of 1466 CMML, and 9366 MDS. The median age at time of allo-HCT in CMML (median 60.5, IQR 54.3-65.2 years) was significantly higher than in the MDS cohort (median 58.8, IQR 50.2-64.5 years; p < .001). A significantly higher percentage of CMML patients were male (69.4%) compared to MDS (61.2%; p < .001). There were no clinically meaningful differences in the distribution of Karnofsky score, Sorror HCT-CI score at allo-HCT, and donor type, between the CMML and MDS patients. RIC platforms were utilized in 63.9% of CMML allo-HCT, and in 61.4% of MDS patients (p = .08). In univariable analyses, we found that OS, PFS, and REL were significantly worse in CMML when compared with MDS (all p < .0001), whereas no significant difference was observed in NRM (p = .77). In multivariable analyses, the HR comparing MDS versus CMML for OS was 0.81 (95% CI, 0.74-0.88, p < .001), PFS 0.76 (95% CI 0.70-0.82, p < .001), relapse 0.66 (95% CI 0.59-0.74, p < .001), and NRM 0.87 (95% CI 0.78-0.98, p = .02), respectively. The association between baseline variables and outcome was found to be similar in MDS and CMML (all interaction p > .05) except for a decreasing trend over time of the risk of relapse in CMML (HR allo-HCT per year later 0.94, 95% CI 0.90-0.98), whereas no such trend was observed in MDS (HR 1.00, 95% CI 0.98-1.02). The poor outcome observed for CMML could be related to variables not measured in this study or to factors inherent to the disease itself. This study demonstrates that outcomes of CMML patients after allo-HCT are significantly worse compared to MDS. The results of this study may contribute to future recommendations for allo-HCT in CMML patients.
Collapse
Affiliation(s)
- Alicia Rovó
- Department of Hematology and Central Hematology Laboratory, University Hospital of Bern, Bern, Switzerland
| | - Luuk Gras
- EBMT Statistical Unit, Leiden, Netherlands
| | | | | | - H Christian Reinhardt
- Department of Hematology and Stem Cell Transplantation, University Hospital Essen, Essen, Germany
| | | | - Didier Blaise
- Programme de Transplantation&Therapie Cellulaire, Marseille, France
| | - Guido Kobbe
- Heinrich Heine Universitaet, Duesseldorf, Germany
| | | | | | - Katja Sockel
- Medical Clinic and Policlinic I, University Hospital Dresden, Dresden, Germany
| | | | - J J Cornelissen
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | | | | | - Yves Chalandon
- Département d'Oncologie, Service d'Hématologie, Hôpitaux Universitaire de Genève and Faculty of Medicine of Geneva, University of Geneva, Geneva, Switzerland
| | | | | | | | | | | | - Patrick Hayden
- St. James's Hospital, Trinity College Dublin, Dublin, Ireland
| | - Kavita Raj
- Department of Stem Cell Transplantation, University College Hospital London, London, UK
| | | | | | - Donal P McLornan
- Department of Stem Cell Transplantation, University College Hospital London, London, UK
| | | | | | - Francesco Onida
- ASST Fatebenefratelli-Sacco-University of Milan, Milano, Italy
| |
Collapse
|
2
|
Robin M, Itzykson R. Contemporary treatment approaches to CMML - Is allogeneic HCT the only cure? Best Pract Res Clin Haematol 2020; 33:101138. [PMID: 32460980 DOI: 10.1016/j.beha.2019.101138] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Accepted: 12/22/2019] [Indexed: 11/18/2022]
Abstract
Chronic Myelomonocytic Leukemias are frequently diagnosed in older adults. Their prognosis is heterogeneous, but several prognostic factors can identify patients with an expected survival of a few years only, including among younger patients eligible for allogeneic stem cell transplantation. Based on the retrospective data available, we discuss how to identify CMML patients for whom curative therapy must be envisaged. We emphasize that, although transplantation remains the only path to cure in CMML, it can be envisaged in only a minority of patients. Despite increased donor availability, its potential remains limited by significant rates of mortality caused both by the procedure and by post-transplantation relapses. We review the options available to bridge patients to transplant, the management of transplantation itself (choice of donor, graft source and condition regimen), and finally the potential for post-transplantation interventions. Our review underscores the need for further prospective studies of allogeneic stem cell transplantation in CMML.
Collapse
Affiliation(s)
- Marie Robin
- Département D'Hématologie Immunologie, Service Hématologie-Greffe, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, F-75010, Paris, France.
| | - Raphael Itzykson
- Département D'Hématologie Immunologie, Service Hématologie-Greffe, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, F-75010, Paris, France; Université de Paris, Génomes, Biologie Cellulaire et Thérapeutique U944, INSERM, CNRS, F-75010, Paris, France.
| |
Collapse
|
3
|
Abstract
Immunotherapy is distinct from traditional chemotherapy in that it acts on immune cells rather than cancer cells themselves. Monoclonal antibodies targeting immune checkpoints on T cells - CTLA-4 and PD-1 - and PD-L1 on the cells of immune microenvironment are now approved for clinical use in several solid tumors and hematological malignancies. This article provides a general overview of the use of checkpoint inhibitors in hematologic malignancies with a special focus in acute myeloid leukemia.
Collapse
Affiliation(s)
- Arnab Ghosh
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Pere Barba
- Hematology Department, Vall d'Hebron University Hospital-Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| |
Collapse
|
4
|
Biology-Driven Approaches to Prevent and Treat Relapse of Myeloid Neoplasia after Allogeneic Hematopoietic Stem Cell Transplantation. Biol Blood Marrow Transplant 2019; 25:e128-e140. [DOI: 10.1016/j.bbmt.2019.01.016] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 01/08/2019] [Indexed: 12/22/2022]
|
5
|
Mechanisms of immune escape after allogeneic hematopoietic cell transplantation. Blood 2018; 133:1290-1297. [PMID: 30578254 DOI: 10.1182/blood-2018-10-846824] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 12/15/2018] [Indexed: 02/04/2023] Open
Abstract
Relapse of the original disease is a major cause of death after allogeneic hematopoietic cell transplantation for acute leukemias. There is growing evidence that relapses may be explained not only by resistance to chemotherapy but also by the escape of tumor cells from the control of the allogeneic immune response. Mechanisms of immune evasion can involve abrogation of leukemia cell recognition due to loss of HLA genes, immunosuppression by immune-checkpoint ligand expression, production of anti-inflammatory factors, release of metabolically active enzymes, loss of proinflammatory cytokine production, and acquisition of novel driver mutations that promote leukemia outgrowth. These mechanisms, and therapeutic targeting of immune escape, will be discussed. We divide the evidence in support of immune-escape mechanisms into animal studies, human laboratory studies, and human clinical experience. A better understanding of the molecular pathways connected to immune escape and relapse may help to improve our therapeutic armamentarium against acute myeloid leukemia relapse.
Collapse
|
6
|
Alsuliman T, Kitel C, Dulery R, Guillaume T, Larosa F, Cornillon J, Labussière-Wallet H, Médiavilla C, Belaiche S, Delage J, Alain S, Yakoub-Agha I. Cytotect®CP as salvage therapy in patients with CMV infection following allogeneic hematopoietic cell transplantation: a multicenter retrospective study. Bone Marrow Transplant 2018; 53:1328-1335. [PMID: 29654288 DOI: 10.1038/s41409-018-0166-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Revised: 02/21/2018] [Accepted: 03/04/2018] [Indexed: 11/09/2022]
Abstract
Cytomegalovirus is one of the main contributing factors to high mortality rates in patients undergoing allogeneic hematopoietic cell transplantation (allo-HCT). The main factors of treatment failure are both drug resistance and intolerance. In some cases, Cytotect®CP CMV-hyperimmune globulin is used as salvage therapy. This study aims to investigate the safety and efficacy of Cytotect®CP as a salvage therapy in patients with CMV infection after allo-HCT. Twenty-three consecutive patients received Cytotect®CP for CMV infection after prior CMV therapy. At the time of Cytotect®CP introduction, 17 patients (74%) had developed acute GVHD and 15 patients (64%) were receiving steroid treatment; Cytotect®CP was used as monotherapy (n = 7) and in combination (n = 16). Overall, response was observed in 18 patients (78%) with a median time of 15 days (range: 3-51). Of the 18 responders, 4 experienced CMV reactivation, while 5 responders died within 100 days of beginning treatment. Of these 5 deaths, 4 were due to causes unrelated to CMV. Estimated 100-day OS from the introduction of Cytotect®CP was 69.6%. No statistically significant difference was observed in 100-day OS between responders and non-responders (73.7% vs 50.0%, p = 0.258). Cytotect®CP as salvage therapy is effective and well-tolerated. Given its safety profile, early treatment use should be considered.
Collapse
Affiliation(s)
- Tamim Alsuliman
- Maladies du sang, CHRU de Lille, 59037, Lille, France.,Service d'Hématologie, CH de Boulogne, 62321, Boulogne sur mer, France
| | | | - Rémy Dulery
- Service d'Hématologie, Hôpital Saint-Antoine, AP-HP, Université Pierre et Marie Curie (UPMC), 75012, Paris, France
| | - Thierry Guillaume
- Service d'Hématologie, CHU de Nantes, 44093, Nantes, Cedex 1, France
| | - Fabrice Larosa
- Service d'Hématologie, CHU de Besançon, 25030, Besançon, France
| | - Jérôme Cornillon
- Service d'Hématologie, IC Loire, 42270, Saint-Priest-en-Jarez, France
| | | | | | | | - Jeremy Delage
- Service d'Hématologie, CHU de Montpellier, 34295, Montpellier, cedex 5, France
| | - Sophie Alain
- National Reference Center for Herpes viruses, Inserm U1092, Université de Limoges, Laboratoire de Bactériologie-Virologie-Hygiène, CHU de Limoges, Limoges, France
| | - Ibrahim Yakoub-Agha
- Maladies du sang, CHRU de Lille, 59037, Lille, France. .,CHU de Lille, LIRIC, INSERM U995, université de Lille2, 59000, Lille, France.
| |
Collapse
|
7
|
Kobbe G, Schroeder T, Haas R, Germing U. The current and future role of stem cells in myelodysplastic syndrome therapies. Expert Rev Hematol 2018; 11:411-422. [DOI: 10.1080/17474086.2018.1452611] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Guido Kobbe
- Medical Faculty, Department of Hematology, Oncology and Clinical Immunology, Heinrich Heine University, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Thomas Schroeder
- Medical Faculty, Department of Hematology, Oncology and Clinical Immunology, Heinrich Heine University, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Rainer Haas
- Medical Faculty, Department of Hematology, Oncology and Clinical Immunology, Heinrich Heine University, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Ulrich Germing
- Medical Faculty, Department of Hematology, Oncology and Clinical Immunology, Heinrich Heine University, University Hospital Düsseldorf, Düsseldorf, Germany
| |
Collapse
|
8
|
Goldsmith SR, Slade M, DiPersio JF, Westervelt P, Schroeder MA, Gao F, Romee R. Donor-lymphocyte infusion following haploidentical hematopoietic cell transplantation with peripheral blood stem cell grafts and PTCy. Bone Marrow Transplant 2017; 52:1623-1628. [PMID: 29035393 DOI: 10.1038/bmt.2017.193] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 07/17/2017] [Accepted: 07/28/2017] [Indexed: 11/09/2022]
Abstract
Donor-lymphocyte infusion (DLI) for relapse following haploidentical hematopoietic cell transplantation (haploHCT) with post-transplant cyclophosphamide (PTCy) has been described in recipients of bone marrow grafts, but not recipients of G-CSF mobilized peripheral blood (PB) grafts. We retrospectively identified patients who underwent DLI following PB-haploHCT with PTCy for relapse, or loss of chimerism (LOC). Twelve patients (57%) received DLI for hematologic relapse/persistent disease, seven (33%) for extramedullary relapse and two (10%) for LOC. Sixteen (76%) received chemotherapy prior to DLI, which did not correlate with response. The most common first dose was 1 × 106 CD3+ cells/kg. Two patients developed grade I aGvHD post DLI, one had grade II and two had grade III. One developed mild skin cGvHD 1361 days post DLI. Pre-DLI aGvHD predicted post-DLI aGvHD (P=0.025). Six patients achieved CR after DLI for overt relapse, one achieved full donor chimerism after LOC. Patients with LOC or EM relapse had superior relapse-free survival following DLI (P=0.029). DLI following PB-haploHCT with PTCy is a viable salvage therapy for overt relapse or LOC without a substantial increase in GvHD, and donor lymphocytes may be collected simultaneously with graft collection to facilitate availability in patients at high risk of relapse.
Collapse
Affiliation(s)
- S R Goldsmith
- Bone Marrow Transplantation and Leukemia Program, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - M Slade
- Bone Marrow Transplantation and Leukemia Program, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - J F DiPersio
- Bone Marrow Transplantation and Leukemia Program, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - P Westervelt
- Bone Marrow Transplantation and Leukemia Program, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - M A Schroeder
- Bone Marrow Transplantation and Leukemia Program, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - F Gao
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - R Romee
- Bone Marrow Transplantation and Leukemia Program, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| |
Collapse
|
9
|
Esensten JH, Bluestone JA, Lim WA. Engineering Therapeutic T Cells: From Synthetic Biology to Clinical Trials. ANNUAL REVIEW OF PATHOLOGY 2017; 12:305-330. [PMID: 27959633 PMCID: PMC5557092 DOI: 10.1146/annurev-pathol-052016-100304] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Engineered T cells are currently in clinical trials to treat patients with cancer, solid organ transplants, and autoimmune diseases. However, the field is still in its infancy. The design, and manufacturing, of T cell therapies is not standardized and is performed mostly in academic settings by competing groups. Reliable methods to define dose and pharmacokinetics of T cell therapies need to be developed. As of mid-2016, there are no US Food and Drug Administration (FDA)-approved T cell therapeutics on the market, and FDA regulations are only slowly adapting to the new technologies. Further development of engineered T cell therapies requires advances in immunology, synthetic biology, manufacturing processes, and government regulation. In this review, we outline some of these challenges and discuss the contributions that pathologists can make to this emerging field.
Collapse
Affiliation(s)
- Jonathan H Esensten
- Department of Laboratory Medicine, University of California, San Francisco, California 94143;
| | - Jeffrey A Bluestone
- Diabetes Center and Department of Medicine, University of California, San Francisco, California 94143;
| | - Wendell A Lim
- Department of Cellular and Molecular Pharmacology, University of California, San Francisco 94158-2517;
| |
Collapse
|
10
|
Allogeneic hematopoietic stem cell transplantation for MDS and CMML: recommendations from an international expert panel. Blood 2017; 129:1753-1762. [PMID: 28096091 DOI: 10.1182/blood-2016-06-724500] [Citation(s) in RCA: 238] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Accepted: 01/04/2017] [Indexed: 01/19/2023] Open
Abstract
An international expert panel, active within the European Society for Blood and Marrow Transplantation, European LeukemiaNet, Blood and Marrow Transplant Clinical Trial Group, and the International Myelodysplastic Syndromes Foundation developed recommendations for allogeneic hematopoietic stem cell transplantation (HSCT) in myelodysplastic syndromes (MDS) and chronic myelomonocytic leukemia (CMML). Disease risks scored according to the revised International Prognostic Scoring System (IPSS-R) and presence of comorbidity graded according to the HCT Comorbidity Index (HCT-CI) were recognized as relevant clinical variables for HSCT eligibility. Fit patients with higher-risk IPSS-R and those with lower-risk IPSS-R with poor-risk genetic features, profound cytopenias, and high transfusion burden are candidates for HSCT. Patients with a very high MDS transplantation risk score, based on combination of advanced age, high HCT-CI, very poor-risk cytogenetic and molecular features, and high IPSS-R score have a low chance of cure with standard HSCT and consideration should be given to treating these patients in investigational studies. Cytoreductive therapy prior to HSCT is advised for patients with ≥10% bone marrow myeloblasts. Evidence from prospective randomized clinical trials does not provide support for specific recommendations on the optimal high intensity conditioning regimen. For patients with contraindications to high-intensity preparative regimens, reduced intensity conditioning should be considered. Optimal timing of HSCT requires careful evaluation of the available effective nontransplant strategies. Prophylactic donor lymphocyte infusion (DLI) strategies are recommended in patients at high risk of relapse after HSCT. Immune modulation by DLI strategies or second HSCT is advised if relapse occurs beyond 6 months after HSCT.
Collapse
|
11
|
Contribution of Revised International Prognostic Scoring System Cytogenetics to Predict Outcome After Allogeneic Stem Cell Transplantation for Myelodysplastic Syndromes: A Study From the French Society of Bone Marrow Transplantation and Cellular Therapy. Transplantation 2015; 99:1672-80. [PMID: 25769079 DOI: 10.1097/tp.0000000000000649] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The prognosis of myelodysplastic syndromes (MDS) after allogeneic stem cell transplantation is critically determined by cytogenetic abnormalities, as previously defined by International Prognostic Scoring System (IPSS) cytogenetics. It has been shown that a new cytogenetic classification, included in the IPSS-R (cytogenetic-IPSS-R [C-IPSS-R]), can better predict the outcome of untreated MDS patients. METHODS In this study, we assessed the impact of the IPSS-R cytogenetic score (C-IPSS-R) on the outcome of 367 MDS patients transplanted from HLA-identical siblings or HLA allele-matched unrelated donors. RESULTS According to the C-IPSS-R, 178 patients (48%) fell in the good risk, 102 (28%) in the intermediate risk, 77 (21%) in the poor risk, and 10 (3%) in the very poor risk group. In multivariate analysis, after a median follow-up of 4 years, the poor and very poor-risk categories correlated with shorter overall survival (OS) (4-year OS, 32%; hazard ratio [HR], 1.59; P = 0.009 and OS, 10%; HR, 3.18; P = 0.002, respectively) and higher cumulative incidence of relapse (CIR) (CIR, 52%; HR, 1.82; P = 0.004 and CIR, 60%; HR, 2.44; P = 0.060, respectively). CONCLUSIONS Overall, the C-IPSS-R changed the IPSS cytogenetic risk only in 8% of cases but identified a new risk group, the very poor C-IPSS-R category, with dismal outcome after allogeneic stem cell transplantation (10% 4-year OS, 60% 4-year CIR). Posttransplantation maintenance therapy should be investigated in prospective trials for patients with high-risk C-IPSS-R karyotypes.
Collapse
|
12
|
Guièze R, Damaj G, Pereira B, Robin M, Chevallier P, Michallet M, Vigouroux S, Beguin Y, Blaise D, El Cheikh J, Roos-Weil D, Thiebaut A, Rohrlich PS, Huynh A, Cornillon J, Contentin N, Suarez F, Lioure B, Mohty M, Maillard N, Clement L, François S, Guillerm G, Yakoub-Agha I. Management of Myelodysplastic Syndrome Relapsing after Allogeneic Hematopoietic Stem Cell Transplantation: A Study by the French Society of Bone Marrow Transplantation and Cell Therapies. Biol Blood Marrow Transplant 2015; 22:240-247. [PMID: 26256942 DOI: 10.1016/j.bbmt.2015.07.037] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 07/30/2015] [Indexed: 11/27/2022]
Abstract
To find out prognostic factors and to investigate different therapeutic approaches, we report on 147 consecutive patients who relapsed after allogeneic hematopoietic stem cell transplantation (allo-HSCT) for myelodysplastic syndrome (MDS). Sixty-two patients underwent immunotherapy (IT group, second allo-HSCT or donor lymphocyte infusion), 39 received cytoreductive treatment alone (CRT group) and 46 were managed with palliative/supportive cares (PSC group). Two-year rates of overall survival (OS) were 32%, 6%, and 2% in the IT, CRT, and PSC groups, respectively (P < .001). In multivariate analysis, 4 factors adversely influenced 2-year rates of OS: history of acute graft-versus-host disease (hazard ratio [HR], 1.83; 95% confidence interval [CI], 1.26 to 2.67; P = .002), relapse within 6 months (HR, 2.69; 95% CI, .82 to 3.98; P < .001), progression to acute myeloid leukemia (HR, 2.59; 95% CI, 1.75 to 3.83; P < .001), and platelet count < 50 G/L at relapse (HR, 1.68; 95% CI, 1.15 to 2.44; P = .007). A prognostic score based on those factors discriminated 2 risk groups with median OSs of 13.2 versus 2.4 months, respectively (P < .001). When propensity score, prognostic score, and treatment strategy were included in Cox model, immunotherapy was found to be an independent factor that favorably impacts OS (HR, .40; 95% CI, .26 to .63; P < .001). In conclusion, immunotherapy should be considered when possible for MDS patients relapsing after allo-HSCT.
Collapse
Affiliation(s)
- Romain Guièze
- CHU de Clermont-Ferrand, Hôpital Estaing, Service d'Hématologie Clinique Adulte, and Université Clermont 1, Clermont-Ferrand, France
| | - Gandhi Damaj
- CHU et Université Basse Normandie, Service d'Hématologie, Caen, France
| | - Bruno Pereira
- Biostatistics Unit, Direction de la Recherche Clinique, Clermont-Ferrand, France
| | - Marie Robin
- Hématologie Greffe de moelle, AP-HP, Hôpital Saint-Louis, Université Paris 7, Paris, France
| | | | | | - Stéphane Vigouroux
- Service d'Hématologie Clinique et Thérapie Cellulaire, CHU, Bordeaux, France
| | - Yves Beguin
- Hematology, CHU and University of Liège, Liège, Belgium
| | - Didier Blaise
- Unité de Transplantation et de Thérapie Cellulaire, Institut Paoli-Calmettes, Marseille, France
| | - Jean El Cheikh
- Unité de Transplantation et de Thérapie Cellulaire, Institut Paoli-Calmettes, Marseille, France
| | - Damien Roos-Weil
- Hématologie, Hôpital Pitié-Salpétrière, AP-HP, Université Pierre et Marie Curie Paris 6, Paris, France
| | - Anne Thiebaut
- Hématologie, CHU et UMR 5525 CNRS-UJF, Grenoble, France
| | | | - Anne Huynh
- Service d'Hématologie, CHU, Toulouse, France
| | - Jérôme Cornillon
- Service d'Hématologie, Institut de Cancérologie de la Loire, Saint-Etienne, France
| | | | - Felipe Suarez
- Service d'Hématologie, APHP, Hôpital Necker Enfants-Malades, Université Paris 5, Paris, France
| | - Bruno Lioure
- Service d'Hématologie, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Mohamad Mohty
- Service d'Hématologie, AP-HP, Hôpital Saint-Antoine, Université Paris 6, Paris, France
| | | | | | | | | | - Ibrahim Yakoub-Agha
- Hématologie, CHRU de lille, Inserm U995, and Université Lille 2, Lille, France.
| |
Collapse
|
13
|
Benton CB, Nazha A, Pemmaraju N, Garcia-Manero G. Chronic myelomonocytic leukemia: Forefront of the field in 2015. Crit Rev Oncol Hematol 2015; 95:222-42. [PMID: 25869097 PMCID: PMC4859155 DOI: 10.1016/j.critrevonc.2015.03.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 01/27/2015] [Accepted: 03/05/2015] [Indexed: 12/22/2022] Open
Abstract
Chronic myelomonocytic leukemia (CMML) includes components of both myelodysplastic syndrome and myeloproliferative neoplasms and is associated with a characteristic peripheral monocytosis. CMML is caused by the proliferation of an abnormal hematopoietic stem cell clone and may be influenced by microenvironmental changes. The disease is rare and has undergone revisions in its classification. We review the recent classification strategies as well as diagnostic criteria, focusing on CMML's genetic alterations and unique pathophysiology. We also discuss the latest molecular characterization of the disease, including how molecular factors affect current prognostic models. Finally, we focus on available treatment strategies, with a special emphasis on experimental and forthcoming therapies.
Collapse
Affiliation(s)
- Christopher B Benton
- Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Aziz Nazha
- Leukemia Program, Department of Hematologic Oncology and Blood Disorders, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Naveen Pemmaraju
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Guillermo Garcia-Manero
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| |
Collapse
|
14
|
Symeonidis A, van Biezen A, de Wreede L, Piciocchi A, Finke J, Beelen D, Bornhäuser M, Cornelissen J, Volin L, Mufti G, Chalandon Y, Ganser A, Bruno B, Niederwieser D, Kobbe G, Schwerdtfeger R, de Witte T, Robin M, Kröger N. Achievement of complete remission predicts outcome of allogeneic haematopoietic stem cell transplantation in patients with chronic myelomonocytic leukaemia. A study of the Chronic Malignancies Working Party of the European Group for Blood and Marrow Trans. Br J Haematol 2015. [DOI: 10.1111/bjh.13576] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Argiris Symeonidis
- Haematology Division; Department of Internal Medicine; University of Patras Medical School; Patras Greece
| | - Anja van Biezen
- Department of Medical Statistics & Bioinformatics; Leiden University Medical Centre; Leiden the Netherlands
| | - Liesbeth de Wreede
- Department of Medical Statistics & Bioinformatics; Leiden University Medical Centre; Leiden the Netherlands
| | | | - Juergen Finke
- Department of Medicine, Haematology, Oncology; University of Freiburg; Freiburg Germany
| | - Dietrich Beelen
- Department of Bone Marrow Transplantation; University Hospital; Essen Germany
| | - Martin Bornhäuser
- Medizinische Klinik und Poliklinik I; Universitätsklinikum Technische Universität Dresden; Dresden Germany
| | - Jan Cornelissen
- Erasmus MC-Daniel den Hoed Cancer Centre; Rotterdam the Netherlands
| | - Liisa Volin
- Stem Cell Transplantation Unit; Comprehensive Cancer Centre; Helsinki University Hospital; Helsinki Finland
| | - Ghulam Mufti
- Department of Haematological Medicine; GKT School of Medicine; London UK
| | - Yves Chalandon
- Département des Spécialités de Médecine Service d'Hématologie; Hôpitaux Universitaires de Genève, and Faculty of Medicine; University of Geneva; Geneva Switzerland
| | - Arnold Ganser
- Department of Haematology; Haemostasis and Oncology and Stem Cell Transplantation; Hannover Medical School; Hannover Germany
| | - Benedetto Bruno
- Division of Haematology; Città della Salute e della Scienza di Torino; Torino Italy
- Department of Molecular Biotechnology and Health Sciences; University of Torino; Torino Italy
| | - Dietger Niederwieser
- Division of Haematology, Oncology and Haemostasiology; University of Leipzig; Leipzig Germany
| | - Guido Kobbe
- Department for Haematology, Oncology and Clinical Immunology; University Hospital Dusseldorf; Heinrich Heine University; Dusseldorf Germany
| | | | - Theo de Witte
- Department of Tumourimmunology; Radboud University Medical Centre; Nijmegen the Netherlands
| | - Marie Robin
- Department of Haematology and BMT; Hopital Saint Louis; Paris France
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation; University Medical Centre Hamburg; Hamburg Germany
| | | |
Collapse
|
15
|
Infusion of donor lymphocytes expressing the herpes simplex virus thymidine kinase suicide gene for recurrent hematologic malignancies after allogeneic hematopoietic stem cell transplantation. Int J Hematol 2015; 102:101-10. [PMID: 25948083 DOI: 10.1007/s12185-015-1801-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Revised: 04/11/2015] [Accepted: 04/14/2015] [Indexed: 10/23/2022]
Abstract
The infusion of donor lymphocytes expressing the herpes simplex virus thymidine kinase suicide gene (TK-cells) is a promising strategy for the treatment of hematologic malignancies relapsing after allogeneic hematopoietic stem cell transplantation. Here we report the results of a phase I clinical trial designed to examine the feasibility, safety, and efficacy of donor lymphocyte infusion (DLI) of TK-cells. Three patients (two with malignant lymphomas, one with acute myeloid leukemia) were enrolled in the trial and received a single DLI of 1 × 10(7) or 5 × 10(7) TK-cells/kg. No local or systemic toxicity related to the gene-transfer procedure was observed. Two patients achieved stable disease. No patient had severe graft-versus-host disease requiring systemic steroid and/or ganciclovir administration. TK-cells were detected in the peripheral blood of all three patients by PCR, but did not persist longer than 28 days. Analysis of cytotoxic T lymphocyte activity detected no immune response against TK-cells by the recipient's own T cells. Flow cytometric analysis showed low proliferative activity and cytotoxic function of TK-cells. In conclusion, DLI of TK-cells was safely performed in all three patients. Our analysis suggests the probable cause of rapid disappearance of TK-cells to be insufficient in vivo expansion of TK-cells in these patients.
Collapse
|
16
|
Antithymocyte globulin before allogeneic stem cell transplantation for progressive myelodysplastic syndrome: a study from the French Society of Bone Marrow Transplantation and Cellular Therapy. Biol Blood Marrow Transplant 2014; 20:646-54. [PMID: 24462982 DOI: 10.1016/j.bbmt.2014.01.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 01/17/2014] [Indexed: 12/19/2022]
Abstract
We investigated the impact of rabbit antithymocyte globulins (ATG) on patient outcomes after allogeneic stem cell transplantation (allo-SCT) for progressive myelodysplastic syndrome (MDS). Of the 242 consecutive patients who underwent allo-SCT for progressive MDS between October 1999 and December 2009, 93 received ATG (ATG group) at the median dose of 5 mg/kg, whereas 149 patients did not (no-ATG group). Donors were sibling (n = 153) or HLA-matched unrelated (n = 89). Patients received blood (n = 90) or marrow (n = 152) grafts after either myeloablative (n = 109) or reduced-intensity (n = 133) conditioning. Three-year overall and event-free survival, nonrelapse mortality, relapse, and chronic graft-versus-host disease (GVHD) development were not significantly different between the 2 groups. In contrast, acute grade II to IV GVHD occurred more often in the no-ATG group (55% of the patients) than in the ATG group (27%, P < .0001). Similar results were observed with acute grade III to IV GVHD (28% and 14% in the no-ATG group and ATG group, respectively; P = .009). In multivariate analysis, after adjustment with propensity score, the absence of ATG was the strongest parameter associated with an increased risk of acute grade II to IV GVHD (hazard ratio, 2.13; 95% confidence interval, 1.35 to 3.37; P = .001]. ATG had no impact on overall and event-free survival or cumulative incidence of the relapse. In conclusion, the addition of ATG to allo-SCT conditioning did not increase the incidence of relapse of patients with progressive MDS. The incidence of acute GVHD was decreased without compromising outcomes.
Collapse
|
17
|
Rager A, Porter DL. Cellular therapy following allogeneic stem-cell transplantation. Ther Adv Hematol 2013; 2:409-28. [PMID: 23556106 DOI: 10.1177/2040620711412416] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Allogeneic hematopoietic stem-cell transplantation (HSCT) is the most effective approach for many patients with hematologic malignancies. Unfortunately, relapse remains the most common cause of death after allogeneic HSCT, and the prognosis of relapsed disease is poor for most patients. Induction of a graft-versus-leukemia (GVL), or graft-versus-tumor, effect through the use of donor leukocyte infusion (DLI), or donor lymphocyte infusion, has been remarkably successful for relapsed chronic myelogenous leukemia. Unfortunately, response to DLI in other hematologic malignancies is much less common and depends on many factors including histology, pace and extent of relapse, and time from HSCT to relapse. Furthermore, graft-versus-host disease (GVHD) is common after DLI and often limits successful immunotherapy. Ultimately, manipulations to minimize GVHD while preserving or enhancing GVL are necessary to improve outcomes for relapse after allogeneic HSCT.
Collapse
|
18
|
Hamilton BK, Vereb G, Copelan EA. Sustained disease-free survival achieved with withdrawal of immunosuppression after rapid relapse of myelodysplastic syndrome following myeloablative allogeneic hematopoietic transplantation: a case report. J Med Case Rep 2013; 7:18. [PMID: 23316877 PMCID: PMC3562165 DOI: 10.1186/1752-1947-7-18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Accepted: 12/01/2012] [Indexed: 11/10/2022] Open
Abstract
UNLABELLED INTRODUCTION Relapse after allogeneic hematopoietic stem cell transplantation in patients with myelodysplasia is a challenging problem with limited treatment options. Attempts to induce a graft-versus-leukemia effect have been used with limited success. In patients with myelodysplasia, sustained complete remissions have generally been limited to patients with long-term remission after transplant and those with low numbers of marrow blasts. CASE PRESENTATION We report the case of a 41-year-old Caucasian woman with relapsed myelodysplastic syndrome and a high blast percentage six months after undergoing an allogeneic transplant who achieved a sustained complete remission after withdrawal of immunosuppression alone. CONCLUSION This case highlights the importance of a reasonable period of observation after withdrawing immunosuppression to induce graft-versus-leukemia, and the potential effectiveness of that approach.
Collapse
Affiliation(s)
- Betty K Hamilton
- Bone Marrow Transplant Program, Department of Hematologic Oncology and Blood Disorders, Cleveland Clinic Taussig Cancer Institute, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
| | | | | |
Collapse
|
19
|
van Gelder M, de Wreede LC, Schetelig J, van Biezen A, Volin L, Maertens J, Robin M, Petersen E, de Witte T, Kröger N. Monosomal karyotype predicts poor survival after allogeneic stem cell transplantation in chromosome 7 abnormal myelodysplastic syndrome and secondary acute myeloid leukemia. Leukemia 2012; 27:879-88. [DOI: 10.1038/leu.2012.297] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
|
20
|
Abstract
Abstract
Allogeneic hematopoietic stem cell transplantation (SCT) is well accepted as a curative treatment approach for younger patients with myelodysplastic syndrome (MDS) and has become one of the most frequent indications for allogeneic SCT as reported to the Center for International Blood and Marrow Transplant Research. However, MDS patients are usually elderly with a median age of approximately 75 years at diagnosis. Large register studies have confirmed the feasibility of the procedure in elderly MDS patients; and in the register of the European Group for Blood and Marrow Transplantation, one-third of the allogeneic transplant procedures for MDS were performed in 2010 in patients older than 60 years. Despite its curative potential, its role in the treatment of elderly MDS patients is less defined. Because of the inherent complications of the transplantation leading to treatment-related mortality and the risk of relapse, a careful calculation of the benefit for each patient is mandatory, taking into account comorbidities, disease status, donor selection, and effective nontransplant therapies. Prospective multicenter studies are needed to define optimal intensity of the conditioning regimen, timing of transplantation within a treatment algorithm, including drug-based therapies, and posttransplant strategies to reduce the risk of relapse.
Collapse
|
21
|
Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndrome: Current Status. Arch Immunol Ther Exp (Warsz) 2011; 60:31-41. [DOI: 10.1007/s00005-011-0152-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Accepted: 10/28/2011] [Indexed: 01/06/2023]
|
22
|
Abstract
Cancer immunotherapy consists of approaches that modify the host immune system, and/or the utilization of components of the immune system, as cancer treatment. During the past 25 years, 17 immunologic products have received regulatory approval based on anticancer activity as single agents and/or in combination with chemotherapy. These include the nonspecific immune stimulants BCG and levamisole; the cytokines interferon-α and interleukin-2; the monoclonal antibodies rituximab, ofatumumab, alemtuzumab, trastuzumab, bevacizumab, cetuximab, and panitumumab; the radiolabeled antibodies Y-90 ibritumomab tiuxetan and I-131 tositumomab; the immunotoxins denileukin diftitox and gemtuzumab ozogamicin; nonmyeloablative allogeneic transplants with donor lymphocyte infusions; and the anti-prostate cancer cell-based therapy sipuleucel-T. All but two of these products are still regularly used to treat various B- and T-cell malignancies, and numerous solid tumors, including breast, lung, colorectal, prostate, melanoma, kidney, glioblastoma, bladder, and head and neck. Positive randomized trials have recently been reported for idiotype vaccines in lymphoma and a peptide vaccine in melanoma. The anti-CTLA-4 monoclonal antibody ipilumumab, which blocks regulatory T-cells, is expected to receive regulatory approval in the near future, based on a randomized trial in melanoma. As the fourth modality of cancer treatment, biotherapy/immunotherapy is an increasingly important component of the anticancer armamentarium.
Collapse
Affiliation(s)
- Robert O Dillman
- Hoag Cancer Institute of Hoag Hospital , Newport Beach, California 92658, USA.
| |
Collapse
|
23
|
Bacher U, Haferlach T, Schnittger S, Kreipe H, Kröger N. Recent advances in diagnosis, molecular pathology and therapy of chronic myelomonocytic leukaemia. Br J Haematol 2011; 153:149-67. [DOI: 10.1111/j.1365-2141.2011.08631.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
24
|
Abstract
Hematopoietic stem cell transplantation (HSCT) offers potentially curative therapy for patients with myelodysplastic syndromes (MDS). However, as the majority of patients with MDS are in the seventh or eighth decade of life, conventional transplant regimens have been used only infrequently, and only with the development of reduced-intensity conditioning has transplantation been applied more broadly to older patients. Dependent upon disease status at the time of transplantation, 30% to 70% of patients can be expected to be cured of their disease and survive long term. However, posttransplant relapse and graft-versus-host disease (GVHD) remain problems and further investigations are needed.
Collapse
Affiliation(s)
- Matthias Bartenstein
- Clinical Research Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue N., Seattle, WA 98109-1024, USA
| | | |
Collapse
|
25
|
Gineikiene E, Stoskus M, Griskevicius L. Recent advances in quantitative chimerism analysis. Expert Rev Mol Diagn 2010; 9:817-32. [PMID: 19895227 DOI: 10.1586/erm.09.66] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Quantitative chimerism analysis is a diagnostic tool used to monitor engraftment kinetics after allogeneic stem cell transplantation. It reflects the proportion of recipient and donor genotypes and is based on the identification of genetic markers characteristic to a given transplant pair. Currently, PCR amplification of short tandem repeats and single-nucleotide polymorphism-specific quantitative real-time PCR are the most widely used techniques for this purpose. In this review, we will address advances as well as technology-specific imperfections, of both techniques that have emerged over the recent years. We will discuss new principles that may simplify assay design, and improve its robustness and reliability. A better chimerism assay could then guide clinical interventions and may, eventually, improve the outcome of allogeneic stem cell transplantation.
Collapse
Affiliation(s)
- Egle Gineikiene
- Department of Molecular and Regenerative Medicine, Hematology, Oncology and Transfusion Medicine Center, Vilnius University Hospital Santariskiu Clinics, Santariskiu 2, LT-08661, Vilnius, Lithuania.
| | | | | |
Collapse
|
26
|
Czibere A, Bruns I, Kröger N, Platzbecker U, Lind J, Zohren F, Fenk R, Germing U, Schröder T, Gräf T, Haas R, Kobbe G. 5-Azacytidine for the treatment of patients with acute myeloid leukemia or myelodysplastic syndrome who relapse after allo-SCT: a retrospective analysis. Bone Marrow Transplant 2009; 45:872-6. [DOI: 10.1038/bmt.2009.266] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|
27
|
Abstract
Allogeneic transplantation of hematopoietic cells is an effective treatment of leukemia, even in advanced stages. Allogeneic lymphocytes produce a strong graft-versus-leukemia (GVL) effect, but the beneficial effect is limited by graft-versus-host disease (GVHD). Depletion of T cells abrogates GVHD and GVL effects. Delayed transfusion of donor lymphocytes into chimeras after T cell-depleted stem cell transplantation produces a GVL effect without necessarily producing GVHD. Chimerism and tolerance provide a platform for immunotherapy using donor lymphocytes. The allogeneic GVL effects vary from one disease to another, the stage of the disease, donor histocompatibility, the degree of chimerism, and additional treatment. Immunosuppressive therapy before donor lymphocyte transfusions may augment the effect as well as concomitant cytokine treatment. Possible target antigens are histocompatibility antigens and tumor-associated antigens. Immune escape of tumor cells and changes in the reactivity of T cells are to be considered. Durable responses may be the result of the elimination of leukemia stem cells or the establishment of a durable immune control on their progeny. Recently, we have learned from adoptive immunotherapy of viral diseases and HLA-haploidentical stem cell transplantation that T-cell memory may be essential for the effective treatment of leukemia and other malignancies.
Collapse
|
28
|
Porter DL, Hexner EO, Cooley S, Miller JS. Cellular adoptive immunotherapy after autologous and allogeneic hematopoietic stem cell transplantation. Cancer Treat Res 2009; 144:497-537. [PMID: 19779876 DOI: 10.1007/978-0-387-78580-6_20] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Affiliation(s)
- David L Porter
- Division of Hematology-Oncology, University of Pennsylvania Medical Center, 16 Penn Tower, 3400 Spruce St, Philadelphia, PA, USA.
| | | | | | | |
Collapse
|
29
|
Sprangers B, Van Wijmeersch B, Luyckx A, Sagaert X, De Somer L, Rutgeerts O, Lenaerts C, Landuyt W, Boeckx N, Dubois B, De Wolf-Peeters C, Waer M, Billiau AD. Allogeneic bone marrow transplantation and donor lymphocyte infusion in a mouse model of irradiation-induced myelodysplastic/myeloproliferation syndrome (MD/MPS): evidence for a graft-versus-MD/MPS effect. Leukemia 2008; 23:340-9. [PMID: 18987665 DOI: 10.1038/leu.2008.298] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The role of graft-versus-malignancy reactivity in the effects of allogeneic hematopoietic stem cell transplantation and donor lymphocyte infusion (DLI) for myelodysplastic syndromes is as yet not well established. Clinical data are limited and animal models are scarce. Here, we report on the effects of allogeneic bone marrow transplantation (alloBMT) and DLI in a novel model of irradiation-induced murine myelodysplastic/myeloproliferation syndrome (MD/MPS). Total body irradiation with 8.5 Gy in SJL/J mice gave rise to a lethal wasting syndrome in 60% of mice, characterized by 1 degrees normocellular bone marrow with dysplastic features in erythroid, myeloid and megakaryocytic cell lineages, 2 degrees lymphosplenomegaly with spleens harboring a prominent extramedullary hematopoiesis with erythroid, myeloid and megakaryocytic lineages exhibiting dysplastic features, and foci of dysplastic hematomyelopoiesis in the liver, 3 degrees peripheral thrombocytopenia and 4 degrees evidence of disseminated infection or leukemic transformation in selected animals. This clinicopathological picture was consistent with a murine form of MD/MPS. Syngeneic or allogeneic (BALB/c) T cell-depleted BMT could not prevent the occurrence of lethal MD/MPS. In contrast, DLI at weeks 2-4 after BMT led to restoration of the dysbalanced hematomyelopoiesis. However, severe DLI-induced acute graft-versus-host disease occurred, precluding a survival advantage. We present evidence of the existence of a post-alloBMT DLI-induced graft-versus-MD/MPS effect in murine irradiation-induced MD/MPS.
Collapse
Affiliation(s)
- B Sprangers
- Laboratory of Experimental Transplantation, University of Leuven, Leuven, Belgium
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
30
|
Donor lymphocyte infusions: the long and winding road: how should it be traveled? Bone Marrow Transplant 2008; 42:569-79. [PMID: 18711351 DOI: 10.1038/bmt.2008.259] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Donor lymphocyte infusions (DLI) often are used after allo-SCT to augment the graft-versus-tumor effect. Timing of infusion varies according to indication, for example to treat tumor recurrence, as a planned strategy to prevent disease relapse in the setting of T-cell-depleted grafts or non-myeloablative conditioning regimens, or as a method to convert mixed to full donor chimerism. The optimal strategy of timing, use of cytotoxic conditioning, cell dose and cell product composition, and so on, for DLI administration remains unclear. Despite varied techniques, DLI may lead to 3-year disease-free survivals (DFS) in excess of 60% for all CML patients and approach 90% in patients with only molecular or cytogenetic relapse. Other hematologic malignancies appear much less responsive, as less than 50% of patients respond and provide, at best, 3-year DFS rates of 20-50%. Multiple myeloma patients have overall response rates of 40-45% after DLI, suggesting benefit in relapsed disease, but limited experiences for diseases such as Hodgkin's lymphoma, myelodysplasia and ALL preclude recommendations for use of DLI at this time. Regardless of the indication, treatment-related mortality after DLI is 5-20% and more than one-third of patients will develop acute and/or chronic GVHD after DLI. The risks of these complications appear related, in part, to donor source, cell dose and therapy prior to DLI. Although there are no definitive answers, the information gleaned from published literature suggests that DLI should be administered early after relapse or as a prophylactic strategy in patients receiving T-cell-depleted grafts, and patients with bulky or aggressive disease may benefit from disease reduction prior to DLI.
Collapse
|
31
|
Castro-Malaspina H, Jabubowski AA, Papadopoulos EB, Boulad F, Young JW, Kernan NA, Perales MA, Small TN, Hsu K, Chiu M, Heller G, Collins NH, Jhanwar SC, van den Brink M, Nimer SD, O'Reilly RJ. Transplantation in remission improves the disease-free survival of patients with advanced myelodysplastic syndromes treated with myeloablative T cell-depleted stem cell transplants from HLA-identical siblings. Biol Blood Marrow Transplant 2008; 14:458-68. [PMID: 18342789 DOI: 10.1016/j.bbmt.2008.02.006] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2007] [Accepted: 02/06/2008] [Indexed: 11/28/2022]
Abstract
From 1985 to 2004, 49 patients with advanced myelodysplastic syndromes (MDS) (> or =5% blasts) or acute myeloid leukemia (AML) transformed from MDS underwent T cell depleted bone marrow or peripheral blood hematopoietic stem cell transplantation (HSCT) from HLA-identical siblings following conditioning with a myeloablative regimen that included total body irradiation (44 patients) or busulfan (5 patients). Thirty-six patients received chemotherapy (3 low dose and 33 induction doses) before conditioning, and 13 patients did not receive any chemotherapy. Prior to transplantation, 22 of the 36 treated patients were in hematologic remission; 4 were in a second refractory cytopenia phase (26 responders); 8 had failed to achieve remission; and 2 of the responders had progression or relapse of their MDS (10 failures). No post-transplantation pharmacologic prophylaxis for graft-versus-host disease (GVHD) was given. The median age was 48 yrs (range 13-61). Forty-five of the 49 patients engrafted; 2 had primary graft failure; and 2 died before engraftment. Only 3 patients developed acute GVHD (aGVHD) (grades I and III) and 1 chronic GVHD (cGVHD). At 3 yrs post-transplantation, the overall survival (OS) was 54% in the responders; 31% in the untreated group; and 0% in the failure group (P=.0004). The disease free survival (DFS) was 50%, 15% and 0% in each group respectively (P=.0008). In multivariate analysis, disease status before cytoreduction remained highly correlated with DFS (P<.001). The cumulative incidence (CI) of relapse at 2-yrs post-transplantation for the responders was 23%; for the untreated group was 38%; and for the failures was 50%. The CI of non-relapse mortality at 2-yrs post-transplantation, for the responders was 23%; for the untreated group was 38%; and for the failures was 40%. All survivors achieved a Karnofsky Performance Status (KPS) of > or =90. These results indicate that patients with advanced MDS who achieve and remain in remission or a second refractory cytopenia phase with chemotherapy before conditioning can achieve successful long-term remissions following a myeloablative T cell depleted allogeneic HSCT.
Collapse
Affiliation(s)
- Hugo Castro-Malaspina
- The Allogeneic Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
32
|
Skinner R, Velangi M, Bown N. Donor lymphocyte infusions for post-transplant relapse of refractory anemia with excess blasts and monosomy 7. Pediatr Blood Cancer 2008; 50:670-2. [PMID: 17253642 DOI: 10.1002/pbc.21146] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
An 8-year-old male relapsed with refractory anemia with excess blasts (RAEB) and monosomy 7 and mixed chimerism (MC) 21 months after HLA-matched unrelated donor bone marrow transplant (BMT). He received three donor lymphocyte infusions (DLI) using an escalating dose schedule. He developed grade II acute graft-versus-host disease (GVHD) 9 days after the third DLI, but continued to deteriorate for 2 months with decreasing marrow cellularity but persisting blasts, MC, and monosomy 7, before exhibiting a delayed but complete response which has persisted for 5 years. This case suggests that DLI and graft-versus-myelodysplasia (GVMDS) may be beneficial in post-transplant relapse of pediatric myelodysplasia.
Collapse
MESH Headings
- Anemia, Refractory, with Excess of Blasts/drug therapy
- Anemia, Refractory, with Excess of Blasts/genetics
- Anemia, Refractory, with Excess of Blasts/surgery
- Anemia, Refractory, with Excess of Blasts/therapy
- Antineoplastic Combined Chemotherapy Protocols/administration & dosage
- Bone Marrow Transplantation
- Child
- Chromosomes, Human, Pair 7/genetics
- Combined Modality Therapy
- Humans
- Lymphocyte Transfusion
- Male
- Monosomy
- Recurrence
- Remission Induction
- Tissue Donors
- Transplantation Conditioning
Collapse
Affiliation(s)
- R Skinner
- Department of Paediatric and Adolescent Oncology, and Children's BMT Unit, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom.
| | | | | |
Collapse
|
33
|
Warlick ED, O'Donnell PV, Borowitz M, Grupka N, Decloe L, Garrett-Mayer E, Borrello I, Brodsky R, Fuchs E, Huff CA, Luznik L, Matsui W, Ambinder R, Jones RJ, Smith BD. Myeloablative allogeneic bone marrow transplant using T cell depleted allografts followed by post-transplant GM-CSF in high-risk myelodysplastic syndromes. Leuk Res 2008; 32:1439-47. [PMID: 18261793 DOI: 10.1016/j.leukres.2007.12.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2007] [Revised: 12/26/2007] [Accepted: 12/29/2007] [Indexed: 01/11/2023]
Abstract
Allogeneic blood and marrow transplantation (alloBMT) remains the only curative treatment for patients with myelodysplastic syndromes (MDS), but its application has been limited by the older age range of patients with this disease. T cell depletion decreases transplant-related toxicity related to graft-versus-host disease (GVHD), but does not improve overall survival because of increased risk for relapse and graft failure. Myeloid growth factors have been used to speed engraftment following alloBMT, but data suggest that they may also have anti-tumor properties. We treated 43 patients (median age 56) with MDS/AML with high-risk features using a myeloablative T cell depleted alloBMT followed by prolonged systemic GM-CSF. The current event-free survival at 1 and 3 years was 47% and 34%, respectively with a median follow-up of 22.8 months in surviving patients. The toxicities compared favorably with those seen using reduced intensity conditioning regimens and included grade III/IV GVHD (10%), graft failure (9%), and cumulative treatment-related mortality (28%). The cumulative incidence of relapse remained high at 38%; however, 3/10 patients receiving donor lymphocyte infusions achieved durable complete remissions. These results suggest that it is possible to maintain treatment intensity while minimizing toxicity in older, high-risk MDS patients.
Collapse
Affiliation(s)
- Erica D Warlick
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, United States
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
34
|
Epigenetic Modulation and Other Options to Improve Outcome of Stem Cell Transplantation in MDS. Hematology 2008:60-7. [DOI: 10.1182/asheducation-2008.1.60] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
AbstractAllogeneic stem cell transplantation can cure patients with myelodysplastic syndromes. However, more than 50% of the patients who underwent allogeneic stem cell transplantation have failed to benefit from this treatment approach either due to treatment-related mortality or to relapse. The introduction of toxicity or dose-reduced conditioning has significantly reduced the treatment-related mortality but did not affect the risk of relapse. New effective drugs, such as hypomethylating agents, histone-deacetylase inhibitors or lenalidomide, can be used alone or in combination to improve the pretransplant remission status before allogeneic stem cell transplantation or after transplantation to prevent relapse as maintenance or consolidation therapy. This review will focus on these new possibilities and give some perspectives as to how the results of allogeneic stem cell transplantation can be further improved
Collapse
|
35
|
Campregher PV, Gooley T, Scott BL, Moravec C, Sandmaier B, Martin PJ, Deeg HJ, Warren EH, Flowers MED. Results of donor lymphocyte infusions for relapsed myelodysplastic syndrome after hematopoietic cell transplantation. Bone Marrow Transplant 2007; 40:965-71. [PMID: 17846603 DOI: 10.1038/sj.bmt.1705840] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) represents a potentially curative approach for patients with myelodysplastic syndromes (MDSs). While a large proportion of HCT recipients become long-term disease-free survivors, recurrence of MDS remains the leading cause of mortality after HCT. The role of donor lymphocyte infusion (DLI) in patients with relapsed MDS after HCT is unclear. We report results among 16 patients treated with DLI for relapsed MDS after HCT at a single institution between March 1993 and February 2004. The cohort contained 10 men and 6 women with a median age of 49 (range, 22-67) years. CR with resolution of cytopenias and prior disease markers occurred in 3 of 14 patients who could be evaluated. Two patients survived without MDS for 68 and 65 months after DLI, respectively, but died with pneumonia. Grades II-IV acute GVHD and chronic GVHD occurred after DLI in 6 (43%) and 5 (36%) patients, respectively. All three responders developed grades III-IV acute GVHD and extensive chronic GVHD after DLI. Our results confirm prior reports that DLI can result in CR in some patients with recurrent MDS after transplant, but long-term survival is infrequent.
Collapse
Affiliation(s)
- P V Campregher
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, University of Washington School of Medicine, Seattle, WA 98109, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
36
|
Dazzi F, Fozza C. Disease relapse after haematopoietic stem cell transplantation: Risk factors and treatment. Best Pract Res Clin Haematol 2007; 20:311-27. [PMID: 17448964 DOI: 10.1016/j.beha.2006.10.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Disease relapse is the commonest cause of treatment failure after allogeneic haematopoietic stem-cell transplantation. Adoptive immunotherapy based on donor lymphocyte infusions (DLI) has a prominent role in the management of disease recurrence. Although the highest remission rates are achieved in chronic myeloid leukaemia (CML), encouraging results have also been reported in chronic lymphoproliferative disorders. However, the experience of DLI in CML is not necessarily applicable to the management of lymphoproliferative diseases because of the heterogeneity of the conditioning regimens used in chronic lymphoid malignancies. We will review the role of DLI for different disease types in the context of conventional and reduced-intensity conditioning regimens. The factors influencing response and graft-versus-host disease as well as the optimal cell dose will be discussed. Finally, we will describe the main avenues currently being explored to improve the selectivity and efficacy of DLI.
Collapse
Affiliation(s)
- F Dazzi
- Department of Haematology, Imperial College at Hammersmith Hospital, Du Cane Road, London W12 0NN, UK.
| | | |
Collapse
|
37
|
Abstract
Haematopoietic stem cell transplantation (HSCT) remains the only curative option for patients with myelodysplastic syndrome (MDS). Developing conditioning regimens with low toxicity, at the same time as preserving an effective graft versus tumour response, is pivotal to expanding the scope for allogeneic transplantation in older patients with MDS. With the introduction of reduced intensity conditioned regimens, transplant centres worldwide are able to offer allogeneic HSCT to a much larger cohort of patients. Graft versus host disease (GvHD) remains a significant cause of morbidity and mortality, however with the use of T-cell depletion, centres have been able to utilise volunteer unrelated donors with an increasing degree of HLA disparity. The graft versus dysplasia effect resulting from allogeneic HSCT and the infusion of donor leukocytes has led to a greater understanding of the immunological mechanisms that govern outcome following transplantation in MDS.
Collapse
Affiliation(s)
- Wendy Ingram
- Department of Haematological Medicine, Kings College Hospital and Kings College London, Denmark Hill, London, SE5 9RS, UK.
| | | | | |
Collapse
|
38
|
Porter DL, Antin JH. Donor leukocyte infusions in myeloid malignancies: new strategies. Best Pract Res Clin Haematol 2006; 19:737-55. [PMID: 16997180 DOI: 10.1016/j.beha.2006.05.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Donor leukocyte infusion (DLI) provides direct and potent graft-versus-leukemia (GVL) activity to treat relapse after allogeneic stem-cell transplantation. DLI is dramatically effective for relapsed chronic myelogenous leukemia (CML), but has been less effective for relapse of other myeloid malignancies. Nevertheless, most recipients of DLI for relapsed CML, and many patients with relapsed acute myelogenous leukemia (AML) and myelodysplastic syndrome (MDS), will experience prolonged remissions and probable cure. Graft-versus-host disease remains the major complication of DLI. New strategies for GVL induction explore novel dosing regimens and both methods of enhancing GVL activity of donor T cells and of minimizing toxicity from graft-versus-host disease. Ultimately, the identification of the effector cells and target antigens for GVL induction will lead to the use of tumor-specific adoptive immunotherapy to both prevent and treat relapse with minimal toxicity. Although many issues remain unsettled, the potential to harness the graft-versus-leukemia activity of allogeneic donor cells provides a powerful new paradigm for the immunotherapy of cancer.
Collapse
Affiliation(s)
- David L Porter
- University of Pennsylvania Medical Center, 16 Penn Tower, 3400 Spruce St, Philadelphia, PA 19104, USA.
| | | |
Collapse
|
39
|
Duell T, Poleck-Dehlin B, Schmid C, Wunderlich B, Ledderose G, Mittermuller J, Kolb HJ, Schmetzer H. Clonal karyotype evolution involving ring chromosome 1 with myelodysplastic syndrome subtype RAEB-t progressing into acute leukemia. Acta Haematol 2006; 116:131-6. [PMID: 16914909 DOI: 10.1159/000093644] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2005] [Accepted: 09/10/2005] [Indexed: 11/19/2022]
Abstract
Karyotypic evolution is a well-known phenomenon in patients with malignant hematological disorders during disease progression. We describe a 50-year-old male patient who had originally presented with pancytopenia in October 1992. The diagnosis of a myelodysplastic syndrome (MDS) FAB subtype RAEB-t was established in April 1993 by histological bone marrow (BM) examination, and therapy with low-dose cytosine arabinoside was initiated. In a phase of partial hematological remission, cytogenetic assessment in August 1993 revealed a ring chromosome 1 in 13 of 21 metaphases beside BM cells with normal karyotypes [46,XY,r(1)(p35q31)/46,XY]. One month later, the patient progressed to an acute myeloid leukemia (AML), subtype M4 with 40% BM blasts and cytogenetic examination showed clonal evolution by the appearance of additional numerical aberrations in addition to the ring chromosome [46,XY,r(1),+8,-21/45,XY,r(1),+8,-21,-22/46, XY]. Intensive chemotherapy and radiotherapy was applied to induce remission in preparation for allogeneic bone marrow transplantation (BMT) from the patient's HLA-compatible son. After BMT, complete remission was clinically, hematologically and cytogenetically (normal male karyotype) confirmed. A complete hematopoietic chimerism was demonstrated. A relapse in January 1997 was successfully treated using donor lymphocyte infusion and donor peripheral blood stem cells (PB-SC) in combination with GM-CSF as immunostimulating agent in April 1997, and the patient's clinical condition remained stable as of January 2005. This is an interesting case of a patient with AML secondary to MDS. With the ring chromosome 1 we also describe a rare cytogenetic abnormality that predicted the poor prognosis of the patient, but the patient could be cured by adoptive immunotherapy and the application of donor's PB-SC. This case confirms the value of cytogenetic analysis in characterizing the malignant clone in hematological neoplasias, the importance of controlling the quality of an induced remission and of the detection of a progress of the disease.
Collapse
Affiliation(s)
- Thomas Duell
- Department of Medicine III, Klinikum Grosshadern, University of Munich, Munich, Germany
| | | | | | | | | | | | | | | |
Collapse
|
40
|
de Witte T, Oosterveld M, Muus P. Autologous and allogeneic stem cell transplantation for myelodysplastic syndrome. Blood Rev 2006; 21:49-59. [PMID: 16822600 DOI: 10.1016/j.blre.2006.03.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Allogeneic stem cell transplantation (alloSCT) is the treatment of choice in the majority of young patients with advanced stages MDS if they have a suitable donor. Since outcome of transplantation is superior for patients with a low blast percentage, this supports the use of chemotherapy prior to transplantation in patients with high blast marrow infiltration. The allogeneic transplant procedure continues to carry a high treatment-related risk, but results have improved progressively over the years. The transplantation results using phenotypically matched voluntary unrelated donors have improved impressingly, mainly due to significantly reduced transplantation-related mortality rate. The upper age limit for transplantation has moved to 65-70 years after the introduction of reduced intensity conditioning regimens (RIC). The place of RIC remains to be determined also in older patients in view of the associated higher relapse risk. For patients lacking a suitable donor the choice is ambiguous. Although the number of reports on autologous stem cell transplantation is still limited, the outcome seems similar to allogeneicSCT with donors other than HLA-identical siblings. Further development of accurate prognostic classification systems will allow a risk-adapted strategy for an individual patient.
Collapse
Affiliation(s)
- Theo de Witte
- Department of Hematology, University Medical Centre Radboud, Nijmegen, The Netherlands.
| | | | | |
Collapse
|
41
|
Tamura K, Kanazawa T, Suzuki M, Koitabashi M, Ogawa C, Morikawa A. Successful rapid discontinuation of immunosuppressive therapy at molecular relapse after allogeneic bone marrow transplantation in a pediatric patient with myelodysplastic syndrome. Am J Hematol 2006; 81:139-41. [PMID: 16432864 DOI: 10.1002/ajh.20498] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The success of allogeneic bone marrow transplantation (allo-BMT) in children with myelodysplastic syndrome (MDS) is mainly affected by relapse. The role of additional immunotherapy for pediatric patients with MDS relapsing after allo-BMT remains to be established. Because immunotherapy is generally more effective for patients who bear a low tumor burden, monitoring of minimal residual diseases (MRD) is essential for early diagnosis at molecular relapse. We report here that a patient with relapsed MDS after allo-BMT was successfully treated by the rapid discontinuation of immunosuppressive therapy at molecular relapse while monitoring Wilms tumor (WT1) gene expression levels. Quantitative analysis of WT1 gene expression appeared to be a useful tool to monitor MRD in the present case.
Collapse
Affiliation(s)
- Kazushi Tamura
- Department of Pediatrics and Developmental Medicine, Gunma University Graduate School, Maebashi, Japan.
| | | | | | | | | | | |
Collapse
|
42
|
Recent publications in hematological oncology. Hematol Oncol 2004; 22:73-84. [PMID: 15515243 DOI: 10.1002/hon.719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
|
43
|
Abstract
Abstract
The development of new therapeutic strategies for myelodysplastic syndromes (MDS) has gained new momentum fueled by improved characterization of the disease’s natural history and biology and by the recent US Food and Drug Administration (FDA) approval of the first agent with an indication for MDS. By integrating morphologic and cytogenetic features with greater discriminatory power, the World Health Organization (WHO) has refined the classification of these stem cell malignancies and enhanced its prognostic utility. Recognition that the malignant phenotype, which characterizes MDS, may arise from mechanistically diverse biological processes has raised new awareness that treatment strategies must be tailored to the pathobiology of the disease. Therapeutics targeting chromatin structure, angiogenesis and the microenvironment that nurtures the MDS phenotype have demonstrated remarkable activity and offer an opportunity to alter the natural history of the disease. This chapter provides an overview of recent developments in the characterization of MDS from the microscope to the laboratory and the translation of these findings into promising therapeutics.
In Section I, Dr. James Vardiman reviews the cytogenetic abnormalities that characterize MDS, their clinical and pathologic significance, and the application of the WHO classification. In Section II, Dr. Alan List reviews treatment goals driven by prognostic variables and biological features of the disease that have led to promising small molecule, selective therapeutics. In Section III, Dr. Jean-Pierre Issa provides an overview of epigenetic events regulating gene expression, which may be exploited therapeutically by chromatin remodeling agents. In Section IV, Dr. Theo DeWitte discusses new developments in hematopoietic stem cell transplantation, including reduced-intensity and myeloablative approaches.
Collapse
Affiliation(s)
- Alan F List
- H. Lee Moffitt Cancer Center and Research Institute, Malignant Hematology, Tampa, FL 33612-9497, USA
| | | | | | | |
Collapse
|