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Gherman RF, Ewald S, Ihorst G, Strüßmann T, Zeiser R, Wäsch R, Bertz H, Stolz D, Duyster J, Finke J, Marks R, Engelhardt M, Duque-Afonso J. Identification of clinical factors impacting outcome in patients undergoing autologous hematopoietic cell transplantation after BEAM and TEAM conditioning. Eur J Haematol 2024; 112:350-359. [PMID: 37823328 DOI: 10.1111/ejh.14118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 09/29/2023] [Accepted: 09/30/2023] [Indexed: 10/13/2023]
Abstract
Organ dysfunction, including pulmonary function impairment, plays a key role in the choice of conditioning chemotherapy before autologous hematopoietic stem cell transplantation (auto-HSCT). Replacement of BCNU/carmustine as part of BEAM (BCNU/carmustine, etoposide, cytarabine, and melphalan) conditioning protocol by thiotepa (TEAM) reduces pulmonary toxicity while maintaining efficacy. We retrospectively analyzed the association of clinical characteristics, comorbidities, and organ function with outcomes after conditioning with BEAM or TEAM. Three hundred ninety-six patients undergoing auto-HSCT (n = 333 with BEAM; n = 63 with TEAM) at our institution between 2008 and 2021 were included in this study. In the multivariate analysis, CO-diffusion capacity corrected for hemoglobin (DLCOcSB) ≤ 60% of predicted, progressive disease (PD) before auto-HSCT, Karnofsky performance score (KPS) ≤ 80%, HCT-CI score ≥ 4, and cardiac disease before auto-HSCT were associated with decreased overall survival (OS) in patients treated with BEAM. In contrast, only PD before auto-HSCT was identified in patients treated with TEAM. Patients conditioned with BEAM and DLCOcSB ≤ 60% had higher non-relapse mortality, including pulmonary cause of death. In summary, we have identified clinical and pulmonary risk factors associated with worse outcomes in patients conditioned with BEAM compared to TEAM. Our data suggest TEAM conditioning as a valid alternative for patients with comorbidities, including pulmonary dysfunction and/or poorer performance scores, before auto-HSCT.
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Affiliation(s)
- Radu-Florian Gherman
- Department of Hematology/Oncology/Stem Cell Transplantation, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - Sophie Ewald
- Department of Hematology/Oncology/Stem Cell Transplantation, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - Gabriele Ihorst
- Clinical Trials Unit, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - Tim Strüßmann
- Department of Hematology/Oncology/Stem Cell Transplantation, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - Robert Zeiser
- Department of Hematology/Oncology/Stem Cell Transplantation, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - Ralph Wäsch
- Department of Hematology/Oncology/Stem Cell Transplantation, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - Hartmut Bertz
- Department of Hematology/Oncology/Stem Cell Transplantation, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - Daiana Stolz
- Department of Pneumology, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - Justus Duyster
- Department of Hematology/Oncology/Stem Cell Transplantation, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - Jürgen Finke
- Department of Hematology/Oncology/Stem Cell Transplantation, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - Reinhard Marks
- Department of Hematology/Oncology/Stem Cell Transplantation, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - Monika Engelhardt
- Department of Hematology/Oncology/Stem Cell Transplantation, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - Jesús Duque-Afonso
- Department of Hematology/Oncology/Stem Cell Transplantation, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
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Benefits of plerixafor for mobilization of peripheral blood stem cells prior to autologous transplantation: a dual-center retrospective cohort study. Cytotherapy 2023:S1465-3249(23)00057-9. [PMID: 36914555 DOI: 10.1016/j.jcyt.2023.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 02/04/2023] [Accepted: 02/13/2023] [Indexed: 03/14/2023]
Abstract
BACKGROUND AIMS Before autologous stem cell transplantation (ASCT), hematopoietic stem cells must be stimulated to move from the bone marrow to the peripheral blood for harvesting. Plerixafor, a C-X-C chemokine receptor type 4 antagonist, is used to increase stem cell harvests. However, the effects of plerixafor on post-ASCT outcomes remain unclear. METHODS In a dual-center retrospective cohort study of 43 Japanese patients who received ASCT, the authors compared transplantation outcomes in patients who underwent stem cell mobilization with granulocyte colony-stimulating factor with (n = 25) or without (n = 18) plerixafor. RESULTS The number of days to neutrophil and platelet engraftment was significantly shorter with plerixafor than without plerixafor, as assessed by univariate (neutrophil, P = 0.004, platelet, P = 0.002), subgroup, propensity score matching and inverse probability weighting analyses. Although the cumulative incidence of fever was comparable with or without plerixafor (P = 0.31), that of sepsis was significantly lower with plerixafor than without (P < 0.01). Thus, the present data indicate that plerixafor leads to earlier neutrophil and platelet engraftment and a reduction of infectious risk. CONCLUSIONS The authors conclude that plerixafor may be safe to use and that it reduces the risk of infection in patients with a low CD34+ cell count the day before apheresis.
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Nawas MT, Schetelig J, Damm F, Levine RL, Perales MA, Giralt SA, VanDenBrink MR, Arcila ME, Zehir A, Papaemmanuil E, Klussmeier A, Schmidt AH, Maiwald S, Bolton KL, Tamari R. The clinical implications of clonal hematopoiesis in hematopoietic cell transplantation. Blood Rev 2021; 46:100744. [PMID: 32896435 PMCID: PMC8278242 DOI: 10.1016/j.blre.2020.100744] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 07/22/2020] [Accepted: 08/13/2020] [Indexed: 12/22/2022]
Abstract
Clonal hematopoiesis (CH) describes somatic mutations in hematopoietic stem and progenitor cells resulting in clonal expansion in individuals with no overt hematologic disease. Since CH increases in an age-related manner, understanding its role in hematopoietic cell transplantation (HCT) has become increasingly relevant to an aging transplant population. Multiple factors distinguish post-transplant hematopoiesis from unperturbed, steady-state hematopoiesis, including the influence of immunosuppressants, cytotoxic reagents, and marked proliferative stress, all of which may enhance or diminish the opportunity for clonal expansion. We reviewed the available clinical evidence on the consequences of CH at time of transplant in patients undergoing autologous HCT, and the impact of donor and recipient CH on allogeneic HCT outcomes. In the absence of evidence-based guidelines, we share our suggestions for managing donors and recipients found to have CH. Large-scale studies are needed to guide an evidence-based, uniform approach for the management of CH in the setting of HCT.
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Affiliation(s)
- Mariam T Nawas
- Department of Medicine, Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, USA.
| | - Johannes Schetelig
- DKMS, Dresden, Tübingen, Germany; Department of Internal Medicine, University Hospital Carl Gustav Carus, TU Dresden, Germany.
| | - Frederik Damm
- Department of Hematology, Oncology and Tumor Immunology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany; Berlin Institute of Health, Berlin, Germany.
| | - Ross L Levine
- Department of Medicine, Adult Leukemia Service, Memorial Sloan Kettering Cancer Center, USA.
| | - Miguel-Angel Perales
- Department of Medicine, Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, USA; Department of Medicine, Weill Cornell Medical College, USA.
| | - Sergio A Giralt
- Department of Medicine, Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, USA; Department of Medicine, Weill Cornell Medical College, USA.
| | - Marcel R VanDenBrink
- Department of Medicine, Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, USA; Department of Medicine, Weill Cornell Medical College, USA.
| | - Maria E Arcila
- Department of Pathology, Memorial Sloan Kettering Cancer Center, USA.
| | - Ahmet Zehir
- Department of Pathology, Memorial Sloan Kettering Cancer Center, USA.
| | - Elli Papaemmanuil
- Department of Epidemiology-Biostatistics, Center for Computational Oncology, Memorial Sloan Kettering Cancer Center, USA.
| | | | | | | | - Kelly L Bolton
- Department of Medicine, Adult Leukemia Service, Memorial Sloan Kettering Cancer Center, USA.
| | - Roni Tamari
- Department of Medicine, Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, USA; Department of Medicine, Weill Cornell Medical College, USA.
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Wiebach H, Gezer D, Brummendorf TH, Crysandt M, Wilop S. Tolerability of high dose chemotherapy and autologous stem cell transplantation in elderly patients with multiple myeloma: A single-center retrospective analysis. Curr Res Transl Med 2020; 68:139-144. [PMID: 32381471 DOI: 10.1016/j.retram.2020.04.001] [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: 01/07/2020] [Revised: 03/28/2020] [Accepted: 04/09/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE OF THE STUDY In the past years, high dose chemotherapy (HDT) with autologous stem cell transplantation (ASCT)has more extensively been performed in elderly patients with multiple myeloma (MM). Several studies found a similar survival benefit compared to younger patients. The objective of our retrospective study is to analyse the tolerability of HDT + ASCT in elderly patients. PATIENTS AND METHODS We compared 26 ASCT performed in MM patients ≥65 years to 127 ASCT in patients <65 years by evaluating treatment-tolerability, length of hospital stay and number of transfusions. RESULTS There was no significant difference in the duration of hospitalisation (16 days (range 14-47) in the elderly vs. 17 days (range 14-71) days, P = 0.0903), median time of cytopenia (neutrophils<500/μl: 5 days (range 4-24) vs. 6 days (range 3-28) days, P = 0.1091; platelets<30 000/μl: 6 days (range 3-36) vs. 7 days (range 0-53) days, P = 0.274) or incidence of, or degree of complications between the two age-groups. Immediate and day 100 treatment related mortality (TRM) was comparable in both groups (3.85% vs. 1.58%, P = 0.4304). CONCLUSION our findings support the concept that HDT + ASCT can be safely administered as first-line option for well-selected patients≥65 years.
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Affiliation(s)
- H Wiebach
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Medical Faculty, RWTH Aachen University, Aachen, Germany.
| | - D Gezer
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Medical Faculty, RWTH Aachen University, Aachen, Germany.
| | - T H Brummendorf
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Medical Faculty, RWTH Aachen University, Aachen, Germany.
| | - M Crysandt
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Medical Faculty, RWTH Aachen University, Aachen, Germany.
| | - S Wilop
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Medical Faculty, RWTH Aachen University, Aachen, Germany; MVZ West GmbH Wuerselen, Hematology - Oncology, Wuerselen, Germany.
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Hematopoietic Cell Transplant (HCT) in the Elderly: Myths, Controversies and Unknowns. Drugs Aging 2019; 35:1055-1064. [PMID: 30302674 DOI: 10.1007/s40266-018-0596-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The incidence of most hematological malignancies increases with age. Despite the higher incidence of hematological malignancies in the elderly, the geriatric population is poorly represented in the early oncology clinical trials that established the current standards of care. Hematopoietic cell transplant (HCT), either upfront or at relapse, provides a potentially life-prolonging, often curative option for many patients with hematological malignancies and is considered the standard of care, at least for younger patients. Historically, the concern that older adults undergoing HCT may experience higher morbidity and transplant-related complications has limited the use of this potentially curative option to younger adults, particularly in allogeneic (allo-) HCT. There is growing evidence to support the feasibility, tolerability, and relatively similar effectiveness of both autologous and allo-HCT in the geriatric population. In the allo-HCT setting, nonmyeloablative/reduced-intensity conditioning (NMA/RIC) has expanded the spectrum of patients that can be considered for this approach. Overall survival is largely affected by disease stage, performance status, and comorbidities rather than by chronological age per se. Comprehensive geriatric assessment (CGA) is a promising tool that can uncover frequently undocumented vulnerabilities in an elderly transplant-eligible patient. Serial study of CGA throughout the peri-HCT period may help predict the short- and long-term impact of HCT on an older adult's functional status and quality of life. Further research is needed to evaluate whether early intervention to improve such vulnerabilities can improve survival and quality of life of these older patients.
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Melphalan dose in myeloma patients ≥65 years of age undergoing high-dose therapy and autologous stem cell transplantation: a multicentric observational registry study. Bone Marrow Transplant 2018; 54:1029-1037. [PMID: 30390061 DOI: 10.1038/s41409-018-0379-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 09/24/2018] [Accepted: 10/14/2018] [Indexed: 11/09/2022]
Abstract
The optimal melphalan dose prior to autologous stem cell transplantation (ASCT) is not known for elderly multiple myeloma (MM) patients. We analyzed data of all MM patients ≥65 years (n = 388) enrolled in the observational Swiss Blood Stem Cell Transplantation Registry. The median age was 67 years (65-77). Single ASCT was performed in 344 (88.7%) patients, with 259 patients (75.3%) receiving a melphalan dose of 200 mg/m2 (MEL200), and 85 patients (24.7%) receiving lower doses (MELlow) (median 140 mg/m2, range 70-180 mg/m2). MEL200 patients were slightly younger, and had a better renal function, but did not differ with regards to ISS stage, cytogenetic risk, remission status, and KPS. Overall mortality at day 100 was 1.5% without differences between the MEL groups (p = 0.621). Median progression-free survival (PFS) in the MEL200 and the MELlow group was 27.7 and 22.1 months, respectively (p = 0.294). Median overall survival (OS) in the MEL200 and in MELlow group was 91.2 and 61.2 months (p = 0.015). However, multivariate analysis showed no significant association of the melphalan dose and OS (HR 0.734; CI95% 0.264-2.038; p = 0.553). In conclusion, our data reveal no significant differences in safety and PFS for elderly myeloma patients treated with MEL200 or with lower MEL doses.
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7
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Autologous hematopoietic stem cell transplant is safe for elderly lymphoma patients. Hematol Oncol Stem Cell Ther 2018; 12:124-125. [PMID: 30075096 DOI: 10.1016/j.hemonc.2018.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 06/13/2018] [Accepted: 07/12/2018] [Indexed: 10/28/2022] Open
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Abstract
Multiple myeloma (MM) is a plasma cell neoplasm that affects elderly individuals with two-thirds of patients over 65 years at diagnosis. However, data available are derived from clinical trials conducted in younger patients. Fewer studies investigated treatment options in the elderly. This review summarizes the clinical outcomes and toxicities associated with therapeutic regimens in older patients including doublet, triplet and high dose therapyin newly diagnosed patients and relapsed patients with MM. We highlight the importance of an approach tailored to individuals, incorporates the geriatric frailty assessment, considers comorbiditiess and commits to early recognition and management of toxicities ranging from myelosuppression to polypharmacy. To date, no trial has prospectively investigated a tailored treatment paradigm in older patients based on frailty and/or comorbidities. As the population ages, the proportion of MM patients with advanced age will grow. Studies are indicated to determine optimal treatment approaches in this increasingly heterogeneous geriatric population.
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Affiliation(s)
- Evan Diamond
- a Division of Hematologic Oncology, Department of Medicine , Memorial Sloan Kettering Cancer Center , New York , NY , USA
| | - Oscar B Lahoud
- a Division of Hematologic Oncology, Department of Medicine , Memorial Sloan Kettering Cancer Center , New York , NY , USA
| | - Heather Landau
- a Division of Hematologic Oncology, Department of Medicine , Memorial Sloan Kettering Cancer Center , New York , NY , USA
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9
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Garderet L, Beohou E, Caillot D, Stoppa AM, Touzeau C, Chretien ML, Karlin L, Moreau P, Fontan J, Blaise D, Polge E, Gueye MS, Ikhlef S, Marjanovic Z, Labopin M, Mohty M. Upfront autologous stem cell transplantation for newly diagnosed elderly multiple myeloma patients: a prospective multicenter study. Haematologica 2016; 101:1390-1397. [PMID: 27612987 DOI: 10.3324/haematol.2016.150334] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 09/06/2016] [Indexed: 11/09/2022] Open
Abstract
The feasibility and efficacy of high-dose melphalan followed by autologous hematopoietic stem cell transplantation in newly diagnosed elderly patients with multiple myeloma was analyzed prospectively. Fifty-six multiple myeloma patients, aged 65 years or over, from 6 French centers were studied. The induction therapy was bortezomib-based in combination with dexamethasone and either thalidomide, cyclophosphamide or lenalidomide, for 4-6 cycles. Peripheral blood stem cells were collected after high-dose cyclophosphamide plus G-CSF or G-CSF alone, with plerixafor if needed. The conditioning regimen consisted of melphalan at 140 mg/m2 in 18 patients (36%) and 200 mg/m2 in 32 (64%). Three months post autologous hematopoietic stem cell transplantation, a 2-month consolidation phase with either lenalidomide plus dexamethasone or bortezomib-based combination therapy was allowed, but maintenance treatment was not given. All but 6 patients underwent autologous hematopoietic stem cell transplantation and 3 had tandem transplantations. The treatment-related mortality was 0% at 100 days post transplantation. Sixty-eight percent received consolidation therapy following transplantation. The best response achieved was 40% complete response, 36% very good partial response, and 18% partial response. After a median follow up of 21 months (range 6-31), the estimated progression-free and overall survival rates at two years were 76% [95%CI: (61.6-94.1)] and 88% [95%CI: (76.7-100)], respectively. The higher dose of melphalan (200 mg/m2) afforded superior progression-free and overall survival rates. This prospective study provides evidence for the safety and efficacy of autologous hematopoietic stem cell transplantation as a first-line treatment approach in elderly multiple myeloma patients. (clinicaltrials.gov identifier: 01671826).
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Affiliation(s)
- Laurent Garderet
- INSERM, UMR_S 938, Proliferation and Differentiation of Stem Cells, AP-HP, Hôpital Saint Antoine, Département d'Hématologie et de Thérapie Cellulaire, F-75012, Paris, Université Pierre et Marie Curie-Paris 6, Paris, France
| | | | | | - Anne Marie Stoppa
- Department of Hematology, Institut Paoli Calmettes, Marseille, Paris, France
| | - Cyrille Touzeau
- Department of hematology, University Hospital Hotel Dieu, Nantes, Paris, France
| | | | - Lionel Karlin
- Department of Hematology, CHU Lyon Sud, Pierre Bénite, Paris, France
| | - Philippe Moreau
- Department of hematology, University Hospital Hotel Dieu, Nantes, Paris, France
| | - Jean Fontan
- Department of Hematology, CHU Besançon, Paris, France
| | - Didier Blaise
- Department of Hematology, Institut Paoli Calmettes, Marseille, Paris, France
| | | | - Mor Seny Gueye
- Hôpital Saint Antoine, Département d'Hématologie et de Thérapie Cellulaire, F-75012, Paris, France
| | - Souhila Ikhlef
- Hôpital Saint Antoine, Département d'Hématologie et de Thérapie Cellulaire, F-75012, Paris, France
| | - Zora Marjanovic
- Hôpital Saint Antoine, Département d'Hématologie et de Thérapie Cellulaire, F-75012, Paris, France
| | | | - Mohamad Mohty
- INSERM, UMR_S 938, Proliferation and Differentiation of Stem Cells, AP-HP, Hôpital Saint Antoine, Département d'Hématologie et de Thérapie Cellulaire, F-75012, Paris, Université Pierre et Marie Curie-Paris 6, Paris, France
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10
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Wildes TM, Stirewalt DL, Medeiros B, Hurria A. Hematopoietic stem cell transplantation for hematologic malignancies in older adults: geriatric principles in the transplant clinic. J Natl Compr Canc Netw 2014; 12:128-36. [PMID: 24453296 DOI: 10.6004/jnccn.2014.0010] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Hematopoietic cell transplantation (HCT) provides a life-prolonging or potentially curative treatment option for patients with hematologic malignancies. Given the high transplant-related morbidity, these treatment strategies were initially restricted to younger patients, but are increasingly being used in older adults. The incidence of most hematologic malignancies increases with age; with the aging of the population, the number of potential older candidates for HCT increases. Autologous HCT (auto-HCT) in older patients may confer a slightly increased risk of specific toxicities (such as cardiac toxicities and mucositis) and have modestly lower effectiveness (in the case of lymphoma). However, auto-HCT remains a feasible, safe, and effective therapy for selected older adults with multiple myeloma and lymphoma. Similarly, allogeneic transplant (allo-HCT) is a potential therapeutic option for selected older adults, although fewer data exist on allo-HCT in older patients. Based on currently available data, age alone is not the best predictor of toxicity and outcomes; rather, the comorbidities and functional status of the older patient are likely better predictors of toxicity than chronologic age in both the autologous and allogeneic setting. A comprehensive geriatric assessment (CGA) in older adults being considered for either an auto-HCT or allo-HCT may identify additional problems or geriatric syndromes, which may not be detected during the standard pretransplant evaluation. Further research is needed to establish the utility of CGA in predicting toxicity and to evaluate the quality of survival in older adults undergoing HCT.
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Affiliation(s)
- Tanya M Wildes
- From aWashington University School of Medicine, St. Louis, Missouri; bFred Hutchinson Cancer Research Center, Seattle, Washington; cStanford University School of Medicine, Stanford, California; and dCity of Hope Comprehensive Cancer Center, Duarte, California
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11
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Quach H, Prince HM, Spencer A. Managing multiple myeloma in the elderly: are we making progress? Expert Rev Hematol 2014; 4:301-15. [DOI: 10.1586/ehm.11.18] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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12
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Ninan MJ, Morrison VA. Therapeutic approaches to non-Hodgkin’s lymphoma in the elderly patient. Expert Rev Hematol 2014; 2:173-82. [DOI: 10.1586/ehm.09.7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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13
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Furness A, Pettengell R. Pixantrone for the treatment of adult patients with multiply relapsed or refractory aggressive non-Hodgkin B-cell lymphoma. Int J Hematol Oncol 2013. [DOI: 10.2217/ijh.13.39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY There is a clear need for efficacious, well-tolerated therapies in patients with multiply relapsed or refractory aggressive B-cell non-Hodgkin lymphoma. Pixantrone is a novel aza-anthracenedione manufactured by Cell Therapeutics Incorporated. Structurally related to anthracyclines and anthracenediones but engineered to minimize cardiotoxicity whilst maintaining efficacy, pixantrone has shown promise in Phase II and III clinical trials as a single agent and in combination. While further prospective studies are required to establish pixantrone as a standard salvage therapy, it has already received approval in the EU as monotherapy for adult patients with multiply relapsed or refractory aggressive B-cell non-Hodgkin lymphoma. Here we review the pharmacology, preclinical and clinical development of this novel agent and consider potential future utility.
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Affiliation(s)
- Andrew Furness
- Department of Haemato-Oncology, St George‘s Hospital, University of London, London, SW11 0RE, UK
| | - Ruth Pettengell
- Department of Haemato-Oncology, St George‘s Hospital, University of London, London, SW11 0RE, UK
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14
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Predictors of non-compliance in autologous hematopoietic SCT patients undergoing out-patient transplants. Bone Marrow Transplant 2011; 47:556-61. [PMID: 21691260 DOI: 10.1038/bmt.2011.129] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Non-compliance has received significant attention in medicine, yet few studies have examined its correlates in autologous hematopoietic SCT (AHSCT) patients. This study examined predictors of non-compliance in a sample of 151 AHSCT patients treated in an outpatient setting. Before AHSCT, participants completed a validated measure of mood and retrospective chart reviews were conducted to assess non-compliance during AHSCT, defined as refusal of oral hygiene, prescribed exercise programs, oral nutrition and/or prescribed medications. We found 121 patients (80%) were non-compliant with an aspect of the AHSCT regimen on 1 or more days; mean percentage of non-compliant days was 16.6 (s.d. 15.6). Men were more likely than women to be non-compliant (P<0.05); as were participants with an elevated depression score (P<0.05). Stepwise regression models identified significant predictors of non-compliance: gender, depression, global distress and nausea and vomiting severity (P-values all <0.01). Further analysis revealed that the interaction of the psychological variables with gender was a more robust predictor of non-compliance (P<0.001). For outpatient AHSCT, our findings suggest the need to broaden conceptualizations of risk factors for non-compliance and the importance of assessing patient barriers to compliance to ensure optimal treatment outcome.
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15
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Bird JM, Owen RG, D'Sa S, Snowden JA, Pratt G, Ashcroft J, Yong K, Cook G, Feyler S, Davies F, Morgan G, Cavenagh J, Low E, Behrens J. Guidelines for the diagnosis and management of multiple myeloma 2011. Br J Haematol 2011; 154:32-75. [PMID: 21569004 DOI: 10.1111/j.1365-2141.2011.08573.x] [Citation(s) in RCA: 205] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Jennifer M Bird
- Bristol Haematology and Oncology Centre, University Hospitals Bristol NHS Foundation Trust, Bristol, UK.
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Jin K, Mao X, Xie L, Greenberg RB, Peng B, Moore A, Greenberg MB, Greenberg DA. Delayed transplantation of human neural precursor cells improves outcome from focal cerebral ischemia in aged rats. Aging Cell 2010; 9:1076-83. [PMID: 20883527 DOI: 10.1111/j.1474-9726.2010.00638.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Neural precursor cell (NPC) transplantation may have a role in restoring brain function after stroke, but how aging might affect the brain's receptivity to such transplants is unknown. We reported previously that transplantation of human embryonic stem cell (hESC)-derived NPCs together with biomaterial (Matrigel) scaffolding into the brains of young adult Sprague-Dawley rats 3 weeks after distal middle cerebral artery occlusion (MCAO) reduced infarct volume and improved neurobehavioral performance. In this study, we compared the effect of NPC and Matrigel transplants in young adult (3-month-old) and aged (24-month-old) Fisher 344 rats from the National Institute on Aging's aged rodent colony. Distal MCAO was induced by electrocoagulation, and hESC-derived NPCs were transplanted into the infarct cavity 3 weeks later. Aged rats developed larger infarcts, but infarct volume and performance on the cylinder and elevated body swing tests, measured 6-8 weeks post-transplant, were improved by transplantation. We conclude that advanced age does not preclude a beneficial response to NPC transplantation following experimental stroke.
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Affiliation(s)
- Kunlin Jin
- Buck Institute for Age Research, 8001 Redwood Boulevard, Novato, CA 94945, USA
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17
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Ohta M. Present status and perspectives regarding the therapeutic strategy for acute myeloid leukemia, non-Hodgkin's lymphoma and multiple myeloma in the elderly. Geriatr Gerontol Int 2009; 9:115-23. [DOI: 10.1111/j.1447-0594.2008.00498.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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18
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Changes in quality-of-life and psychosocial adjustment among multiple myeloma patients treated with high-dose melphalan and autologous stem cell transplantation. Biol Blood Marrow Transplant 2009; 15:12-20. [PMID: 19135938 DOI: 10.1016/j.bbmt.2008.09.023] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2008] [Accepted: 09/30/2008] [Indexed: 11/24/2022]
Abstract
High-dose melphalan and autologous hematopoietic stem cell transplantation (HSCT) is a standard treatment for myeloma, but very little is known about the psychosocial or quality-of-life difficulties that these patients encounter during treatment. Data regarding older patients is particularly scarce. Using a prospective design, this investigation evaluated 94 patients at stem cell collection and again after high-dose therapy and transplantation. Outcomes included quality-of-life (FACT-BMT) and psychosocial adjustment (ie, Brief Symptom Inventory, Impact of Events Scale, and Satisfaction with Life Scale). Findings were compared with age- and sex-adjusted population norms and with transplantation patient norms. At stem cell collection, physical deficits were common, with most patients scoring 1 standard deviation below population norms for physical well-being (70.2%) and functional well-being (57.5%), and many reporting at least moderate fatigue (94.7%) and pain (39.4%). Clinically meaningful levels of anxiety (39.4%), depression (40.4%), and cancer-related distress (37.0%) were evident in a notable proportion of patients. After transplantation, there was a worsening of transplant-related concerns (P < .05), depression (P < .05), and life-satisfaction (P < .001); however, pain improved (P < .01), and social functioning was well preserved. Overall, the declines in functioning after transplantation were less pronounced than anticipated. Older patients were not more compromised than younger ones; in multivariate analyses, they reported better overall quality of life (P < .01) and less depression (P < .05) before transplantation. Our findings emphasize the importance of early screening and intervention.
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Autologous SCT with a dose-reduced BU and CY regimen in older patients with non-Hodgkin's lymphoma. Bone Marrow Transplant 2008; 43:37-42. [DOI: 10.1038/bmt.2008.298] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Jadu F, Lee L, Pharoah M, Reece D, Wang L. A retrospective study assessing the incidence, risk factors and comorbidities of pamidronate-related necrosis of the jaws in multiple myeloma patients. Ann Oncol 2007; 18:2015-9. [PMID: 17804475 DOI: 10.1093/annonc/mdm370] [Citation(s) in RCA: 123] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Bone necrosis of the jaws is a newly recognized complication associated with the use of bisphosphonates. The true incidence of this complication is unknown and the pathophysiology is controversial. The purpose of this study was to determine the incidence of jaw necrosis among a homogeneous population of multiple myeloma patients receiving the bisphosphonate pamidronate, to investigate risk factors and comorbidities that increase the risk and to characterize the radiographic changes on conventional dental radiographs in terms of type and frequency. MATERIALS AND METHODS The study was a retrospective review of medical and dental charts and databases in the medical oncology and dental departments at Princess Margaret Hospital, a tertiary cancer centre in Toronto. Two patient sample sizes were used, n = 655 for assessment of the incidence and n = 120 for analysis of the risk factors and comorbidities. RESULTS The incidence was estimated at 3.2% (95% confidence interval). The following risk factors were found to be statistically significant: longer duration of pamidronate therapy (P < 0.001), dental extractions (P < 0.001), cyclophosphamide therapy (P < 0.014), prednisone therapy (P < 0.014), erythropoietin therapy (P = 0.006), low hemoglobin levels (P < 0.001), renal dialysis (P < 0.016) and advanced age (P < 0.001). Radiographic changes produced by the necrotic bone were less evident than the clinically exposed bone.
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Affiliation(s)
- F Jadu
- Faculty of Dentistry, University of Toronto, Ontario, Canada.
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21
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Musto P, D'Auria F. Melphalan: old and new uses of a still master drug for multiple myeloma. Expert Opin Investig Drugs 2007; 16:1467-87. [PMID: 17714032 DOI: 10.1517/13543784.16.9.1467] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The treatment of multiple myeloma has seen significant changes from the initial use of melphalan to the introduction of stem cell transplantation and, most recently, to the era of novel targeted agents. Melphalan still remains as a reference drug for combination regimens, including emerging newer therapeutic options, either used at a standard dose for initial or salvage treatments in patients who are not eligible for more intensive therapies, or in conjunction with new molecules within high-dose chemotherapy programs. In this review, the authors analyze old and novel regimens, including melphalan for the treatment of newly diagnosed or relapsed/resistant patients with multiple myeloma in the clinical settings of standard chemotherapy, as well as autologous or allogeneic stem cell transplantation.
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Affiliation(s)
- Pellegrino Musto
- Unit of Hematology and Stem Cell Transplantation, CROB, Centro di Riferimento Oncologico di Basilicata, Strada Provinciale, Rionero in Vulture (Pz), Italy.
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22
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Keith MR, Levy RB. Transplant conditions determine the contribution of homeostatically expanded donor CD8 memory cells to host lymphoid reconstitution following syngeneic HCT. Exp Hematol 2007; 35:1303-15. [PMID: 17553613 DOI: 10.1016/j.exphem.2007.04.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2007] [Revised: 04/09/2007] [Accepted: 04/13/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To investigate the ability of donor CD8 memory (CD8 TM) cells to expand in recipients following syngeneic hematopoietic stem cell transplants (HCT). The influence of clinically important transplant parameters--conditioning level, delayed infusion and dose--on the homeostatic expansion and overall contribution of donor CD8 TM to host CD8 reconstitution was determined. MATERIALS AND METHODS Lymphopenia-induced CD8 TM homeostatic expansion was examined in a syngeneic murine HCT model. Antigen specific CD8 TM included both T-cell receptor transgenic and nontransgenic populations. An ex vivo technique using antigen, interleukin (IL)-2, and IL-15 was used to generate homogenous transgenic CD8 TM (i.e., central memory) and was adapted to enrich the heterogeneous nontransgenic CD8 population specific for a nonameric epitope. RESULTS Both transgenic and naturally occurring CD8 memory populations, derived in vivo or generated ex vivo, underwent a similar kinetic pattern of homeostatic expansion following transplantation into ablatively conditioned syngeneic recipients. Transplant parameters, i.e., lower conditioning, delayed infusion, and lower donor CD8 cell numbers shortened the period of expansion and lowered the steady-state numbers. CONCLUSIONS The pattern of CD8 TM expansion was dependent on conditioning levels, time of infusion, and dose. Transplantation of varying donor CD8 TM numbers demonstrated there was a maximal donor cell contribution to host CD8 reconstitution. The application of multiple well-defined memory CD8 populations supports the notion that these findings are characteristic of memory CD8 cells in general.
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Abstract
One half of patients newly diagnosed with lymphoma are older than 60 years and a significant proportion of them older than 80 years. Older patients treated for lymphoma may not tolerate the high-dose therapies used in younger patients, usually because of the presence of concomitant diseases. Diffuse large B-cell lymphoma represents more than 60% of all lymphomas seen in older patients. Clinical presentation and prognostic parameters are identical to those described in young patients. However, response rate is usually lower in elderly patients compared with young patients, even if the patients are treated with the cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) regimen. Therefore, event-free and overall survival rates are shorter in elderly patients, even if disease-free survival rates are not really shorter than in young patients. Rituximab added to the CHOP regimen has recently been shown to dramatically improve the survival of these older patients without increasing the toxicity of the treatment. Patients older than 80 years may also be treated with rituximab plus CHOP, except for those having severe organ failure secondary to other diseases. Very few of these older patients may benefit from a salvage treatment after relapse.
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Affiliation(s)
- Catherine Thieblemont
- Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Service d'hématologie clinique, Pierre Bénite, France
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Gopal AK, Rajendran JG, Gooley TA, Pagel JM, Fisher DR, Petersdorf SH, Maloney DG, Eary JF, Appelbaum FR, Press OW. High-dose [131I]tositumomab (anti-CD20) radioimmunotherapy and autologous hematopoietic stem-cell transplantation for adults > or = 60 years old with relapsed or refractory B-cell lymphoma. J Clin Oncol 2007; 25:1396-402. [PMID: 17312330 DOI: 10.1200/jco.2006.09.1215] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The majority of patients with relapsed or refractory B-cell non-Hodgkin's lymphoma (NHL) are older than 60 years, yet they are often denied potentially curative high-dose therapy and autologous stem-cell transplantations (ASCT) because of the risk of excessive treatment-related morbidity and mortality. Myeloablative anti-CD20 radioimmunotherapy (RIT) can deliver curative radiation doses to tumor sites while limiting exposure to normal organs and may be particularly suited for older adults requiring high-dose therapy. PATIENTS AND METHODS Patients older than 60 years with relapsed B-cell NHL (B-NHL) received infusions of tositumomab anti-CD20 antibody labeled with 185 to 370 Mbq (5 to 10 mCi) [131I]-tracer for dosimetry purposes followed 10 days later by individualized therapeutic infusions of [131I]tositumomab (median, 19.4 Gbq [525 mCi]; range, 12.1 to 42.7 Gbq [328 to 1,154 mCi]) to deliver 25 to 27 Gy to the critical normal organ receiving the highest radiation dose. ASCT was performed approximately 2 weeks after therapy. RESULTS Twenty-four patients with a median age of 64 years (range, 60 to 76 years), who had received a median of four prior regimens (range, two to 14 regimens), were treated. Thirteen patients (54%) had chemotherapy-resistant disease. The estimated 3-year overall and progression-free survival rates were 59% and 51%, respectively, with a median follow-up of 2.9 years (range, 1 to 6 years). All patients experienced expected myeloablation with engraftment of platelets (> or = 20 K/microL) and neutrophils ( 500/microL), occurring at a median of 9 and 15 days after ASCT, respectively. There were no treatment-related deaths, and only two patients experienced grade 4 nonhematologic toxicity. CONCLUSION Myeloablative RIT and ASCT is a safe and effective therapeutic option for older adults with relapsed B-NHL.
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Affiliation(s)
- Ajay K Gopal
- Department of Medicine, Division of Medical Oncology, University of Washington, Seattle Cancer Care Alliance, Seattle, WA 98195, USA.
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Abstract
Multiple myeloma (MM), a plasma cell malignancy, is a disorder of the elderly with an increasing prevalence as the average life expectancy increases. Survival remains unacceptably low in elderly patients with MM, in whom the gold standard of treatment has been, until recently, oral melphalan and prednisolone, which induces a response rate of approximately 50% and overall survival of <3 years. In the last 15 years, traditional treatment paradigms for elderly patients with MM have been challenged not only as a result of the change in what we define as 'elderly' but also as a result of the reduced morbidity and treatment-related mortality associated with high-dose chemoradiotherapy (HDT) and autologous stem cell transplantation (ASCT), and the emergence of novel therapies including thalidomide, its immunomodulator drug derivative lenalidomide and the first-in-class proteasome inhibitor, bortezomib. In this review, we examine currently available data regarding the treatment of MM in the elderly population. Recent years have seen a paradigm shift in the standard of care of elderly patients with MM from oral melphalan and prednisolone to approaches including HDT with ASCT using intermediate-dose melphalan in selected elderly patients, and the evaluation of and incorporation of drugs such as thalidomide, bortezomib and lenalidomide. Importantly, we now have been able to change the traditional goal of palliation in the elderly group of patients to a more ambitious objective of achieving a complete response or a near complete response, in the hope that this will translate into improved progression-free survival, overall survival and quality of life.
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Affiliation(s)
- Hang Quach
- Peter MacCallum Cancer Centre and University of Melbourne, Melbourne, Victoria, Australia
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