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Mulder RL, Bresters D, Van den Hof M, Koot BGP, Castellino SM, Loke YKK, Post PN, Postma A, Szőnyi LP, Levitt GA, Bardi E, Skinner R, van Dalen EC. Hepatic late adverse effects after antineoplastic treatment for childhood cancer. Cochrane Database Syst Rev 2019; 4:CD008205. [PMID: 30985922 PMCID: PMC6463806 DOI: 10.1002/14651858.cd008205.pub3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Survival rates have greatly improved as a result of more effective treatments for childhood cancer. Unfortunately, the improved prognosis has been accompanied by the occurrence of late, treatment-related complications. Liver complications are common during and soon after treatment for childhood cancer. However, among long-term childhood cancer survivors, the risk of hepatic late adverse effects is largely unknown. To make informed decisions about future cancer treatment and follow-up policies, it is important to know the risk of, and associated risk factors for, hepatic late adverse effects. This review is an update of a previously published Cochrane review. OBJECTIVES To evaluate all the existing evidence on the association between antineoplastic treatment (that is, chemotherapy, radiotherapy involving the liver, surgery involving the liver and BMT) for childhood cancer and hepatic late adverse effects. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2018, Issue 1), MEDLINE (1966 to January 2018) and Embase (1980 to January 2018). In addition, we searched reference lists of relevant articles and scanned the conference proceedings of the International Society of Paediatric Oncology (SIOP) (from 2005 to 2017) and American Society of Pediatric Hematology/Oncology (ASPHO) (from 2013 to 2018) electronically. SELECTION CRITERIA All studies, except case reports, case series, and studies including fewer than 10 patients that examined the association between antineoplastic treatment for childhood cancer (aged 18 years or less at diagnosis) and hepatic late adverse effects (one year or more after the end of treatment). DATA COLLECTION AND ANALYSIS Two review authors independently performed the study selection and 'risk of bias' assessment. The 'risk of bias' assessment was based on earlier checklists for observational studies. For the original version of the review, two review authors independently performed data extraction. For the update of the review, the data extraction was performed by one reviewer and checked by another reviewer. MAIN RESULTS Thirteen new studies were identified for the update of this review. In total, we included 33 cohort studies including 7876 participants investigating hepatic late adverse effects after antineoplastic treatment (especially chemotherapy and radiotherapy) for different types of childhood cancer, both haematological and solid malignancies. All studies had methodological limitations. The prevalence of hepatic late adverse effects, all defined in a biochemical way, varied widely, between 0% and 84.2%. Selecting studies where the outcome of hepatic late adverse effects was well-defined as alanine aminotransferase (ALT) above the upper limit of normal, indicating cellular liver injury, resulted in eight studies. In this subgroup, the prevalence of hepatic late adverse effects ranged from 5.8% to 52.8%, with median follow-up durations varying from three to 23 years since cancer diagnosis in studies that reported the median follow-up duration. A more stringent selection process using the outcome definition of ALT as above twice the upper limit of normal, resulted in five studies, with a prevalence ranging from 0.9% to 44.8%. One study investigated biliary tract injury, defined as gamma-glutamyltransferase (γGT) above the upper limit of normal and above twice the upper limit of normal and reported a prevalence of 5.3% and 0.9%, respectively. Three studies investigated disturbance in biliary function, defined as bilirubin above the upper limit of normal and reported prevalences ranging from 0% to 8.7%. Two studies showed that treatment with radiotherapy involving the liver (especially after a high percentage of the liver irradiated), higher BMI, and longer follow-up time or older age at evaluation increased the risk of cellular liver injury in multivariable analyses. In addition, there was some suggestion that busulfan, thioguanine, hepatic surgery, chronic viral hepatitis C, metabolic syndrome, use of statins, non-Hispanic white ethnicity, and higher alcohol intake (> 14 units per week) increase the risk of cellular liver injury in multivariable analyses. Chronic viral hepatitis was shown to increase the risk of cellular liver injury in six univariable analyses as well. Moreover, one study showed that treatment with radiotherapy involving the liver, higher BMI, higher alcohol intake (> 14 units per week), longer follow-up time, and older age at cancer diagnosis increased the risk of biliary tract injury in a multivariable analysis. AUTHORS' CONCLUSIONS The prevalence of hepatic late adverse effects among studies with an adequate outcome definition varied considerably from 1% to 53%. Evidence suggests that radiotherapy involving the liver, higher BMI, chronic viral hepatitis and longer follow-up time or older age at follow-up increase the risk of hepatic late adverse effects. In addition, there may be a suggestion that busulfan, thioguanine, hepatic surgery, higher alcohol intake (>14 units per week), metabolic syndrome, use of statins, non-Hispanic white ethnicity, and older age at cancer diagnosis increase the risk of hepatic late adverse effects. High-quality studies are needed to evaluate the effects of different therapy doses, time trends, and associated risk factors after antineoplastic treatment for childhood cancer.
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Affiliation(s)
- Renée L Mulder
- Princess Máxima Center for Pediatric OncologyHeidelberglaan 25UtrechtNetherlands3584 CS
- Emma Children's Hospital, Amsterdam UMC, University of AmsterdamDepartment of Paediatric OncologyP.O. Box 22660AmsterdamNetherlands1100 DD
| | - Dorine Bresters
- Princess Máxima Center for Pediatric OncologyHeidelberglaan 25UtrechtNetherlands3584 CS
- Leiden University Medical CenterWillem Alexander Children's HospitalPO Box 9600LeidenNetherlands2300 RC
| | - Malon Van den Hof
- Emma Children's Hospital, Amsterdam UMC, University of AmsterdamDepartment of Paediatric OncologyP.O. Box 22660AmsterdamNetherlands1100 DD
| | - Bart GP Koot
- Emma Children's Hospital, Amsterdam UMC, University of AmsterdamDepartment of Paediatric Gastroenterology and NutritionP.O. Box 22660AmsterdamNetherlands1100 DD
| | - Sharon M Castellino
- Emory School of MedicineDepartment of Pediatrics, Division Hematology/OncologyAtlanta, GAUSA
| | | | - Piet N Post
- Dutch Institute for Healthcare Improvement CBOPO Box 20064UtrechtNetherlands3502 LB
| | - Aleida Postma
- University Medical Center Groningen and University of Groningen, Beatrix Children's HospitalDepartment of Paediatric OncologyPostbus 30.000GroningenNetherlands9700 RB
| | - László P Szőnyi
- King Feisal Specialist HospitalOrgan Transplant CentreRiyadhSaudi Arabia11211
| | - Gill A Levitt
- Great Ormond Street Hospital for Children NHS Foundation TrustOncologyGt Ormond StLondonUK
| | - Edit Bardi
- Kepler UniversitätsklinikumMed Campus IV26‐30 KrankenhausstraßeLinzAustria4020
| | - Roderick Skinner
- Great North Children’s HospitalDepartment of Paediatric and Adolescent Haematology / OncologyQueen Victoria RoadNewcastle upon TyneUKNE1 4LP
| | - Elvira C van Dalen
- Princess Máxima Center for Pediatric OncologyHeidelberglaan 25UtrechtNetherlands3584 CS
- Emma Children's Hospital, Amsterdam UMC, University of AmsterdamDepartment of Paediatric OncologyP.O. Box 22660AmsterdamNetherlands1100 DD
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Mulder RL, van Dalen EC, Van den Hof M, Leclercq E, Bresters D, Koot BGP, Castellino SM, Loke Y, Post PN, Caron HN, Postma A, Kremer LCM. Hepatic late adverse effects after antineoplastic treatment for childhood cancer. Cochrane Database Syst Rev 2011; 2011:CD008205. [PMID: 21735424 PMCID: PMC6464972 DOI: 10.1002/14651858.cd008205.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Survival rates have greatly improved as a result of more effective treatments for childhood cancer. Unfortunately the improved prognosis has resulted in the occurrence of late, treatment-related complications. Liver complications are common during and soon after treatment for childhood cancer. However, among long-term childhood cancer survivors the risk of hepatic late adverse effects is largely unknown. To make informed decisions about future cancer treatment and follow-up policies it is important to know the risk of, and associated risk factors for, hepatic late adverse effects. OBJECTIVES To evaluate the existing evidence on the association between antineoplastic treatment for childhood cancer and hepatic late adverse effects. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, Issue 2), MEDLINE (1966 to June 2009) and EMBASE (1980 to June 2009). In addition, we searched reference lists of relevant articles and conference proceedings. SELECTION CRITERIA All studies except case reports, case series and studies including less than 10 patients that examined the association between antineoplastic treatment for childhood cancer (aged 18 years or less at diagnosis) and hepatic late adverse effects (one year or more after the end of treatment). DATA COLLECTION AND ANALYSIS Two review authors independently performed the study selection, risk of bias assessment and data extraction. MAIN RESULTS We identified 20 cohort studies investigating hepatic late adverse effects after antineoplastic treatment for childhood cancer. All studies had methodological limitations. The prevalence of hepatic late adverse effects varied widely, between 0% and 84.2%. Selecting studies where the outcome of hepatic late adverse effects was well defined as alanine aminotransferase (ALT) above the upper limit of normal resulted in five studies. In this subgroup the prevalence of hepatic late adverse effects ranged from 8.0% to 52.8%, with follow-up durations varying from one to 27 years after the end of treatment. A more stringent selection process using the outcome definition of ALT as above twice the upper limit of normal resulted in three studies, with a prevalence ranging from 7.9% to 44.8%. Chronic viral hepatitis was identified as a risk factor for hepatic late adverse effects in univariate analyses. It is unclear which specific antineoplastic treatments increase the risk of hepatic late adverse effects AUTHORS' CONCLUSIONS The prevalence of hepatic late adverse effects ranged from 7.9% to 52.8% when selecting studies with an adequate outcome definition. It has not been established which childhood cancer treatments result in hepatic late adverse effects. There is a suggestion that chronic viral hepatitis increases the risk of hepatic late adverse effects. More well-designed studies are needed to reliably evaluate the prevalence of, and risk factors for, hepatic late adverse effects after antineoplastic treatment for childhood cancer.
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Affiliation(s)
- Renée L Mulder
- Emma Children's Hospital/Academic Medical CenterDepartment of Paediatric OncologyP.O. Box 22660AmsterdamNetherlands1100 DD
| | - Elvira C van Dalen
- Emma Children's Hospital/Academic Medical CenterDepartment of Paediatric OncologyP.O. Box 22660AmsterdamNetherlands1100 DD
| | - Malon Van den Hof
- Emma Children's Hospital/Academic Medical CenterDepartment of Paediatric OncologyP.O. Box 22660AmsterdamNetherlands1100 DD
| | - Edith Leclercq
- Emma Children's Hospital/Academic Medical CenterDepartment of Paediatric OncologyP.O. Box 22660AmsterdamNetherlands1100 DD
| | - Dorine Bresters
- Leiden University Medical CenterDepartment of Paediatric Immunology, Haemato‐Oncology, Bone Marrow Transplantation and Auto‐immune Diseases, Willem‐Alexander Kinder‐ en JeugdcentrumPO Box 9600LeidenNetherlands2300 RC
| | - Bart GP Koot
- Emma Children's Hospital / Academic Medical CenterDepartment of Paediatric Gastroenterology and NutritionP.O. Box 22660AmsterdamNetherlands1100 DD
| | - Sharon M Castellino
- Wake Forest University School of MedicinePediatrics section Hematology/OncologyMedical Center blvd.Winston‐Salem, NCUSA27157
| | - Yoon Loke
- University of East AngliaSchool of MedicineNorwichUKNR4 7TJ
| | - Piet N Post
- Dutch Institute for Healthcare Improvement CBOPO Box 20064UtrechtNetherlands3502 LB
| | - Huib N Caron
- Emma Children's Hospital/Academic Medical CenterDepartment of Paediatric OncologyP.O. Box 22660AmsterdamNetherlands1100 DD
| | - Aleida Postma
- University Medical Center Groningen and University of Groningen, Beatrix Children's HospitalDepartment of Paediatric OncologyPostbus 30.000GroningenNetherlands9700 RB
| | - Leontien CM Kremer
- Emma Children's Hospital/Academic Medical CenterDepartment of Paediatric OncologyP.O. Box 22660AmsterdamNetherlands1100 DD
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Comparative analysis of outcomes of allogeneic peripheral blood stem cell transplantation from related and unrelated donors. Ann Hematol 2010; 89:813-20. [DOI: 10.1007/s00277-010-0913-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2009] [Accepted: 01/22/2010] [Indexed: 10/19/2022]
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Diaz MA, Gonzalez-Vicent M, Gonzalez ME, Verdeguer A, Martinez A, Perez-Hurtado M, Badell I, de la Rubia J, Bargay J, de Arriba F, Diez JL, Caballero D, Madero L, Brunet S. Long-term outcome of allogeneic PBSC transplantation in pediatric patients with hematological malignancies: a report of the Spanish Working Party for Blood and Marrow Transplantation in Children (GETMON) and the Spanish Group for Allogeneic Peripheral Blood Transplantation (GETH). Bone Marrow Transplant 2006; 36:781-5. [PMID: 16151427 DOI: 10.1038/sj.bmt.1705135] [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: 11/08/2022]
Abstract
We analyzed the clinical outcome in 90 children undergoing allogeneic PBSC transplantation from HLA-identical relative for leukemia. GvHD prophylaxis was CsA+ methotrexate in 50 and CsA+/-steroids in 40. Median CD34+ cells infused were 6 x 10(6)/kg (range, 1.4-32). Median follow-up was 60 months (range, 6-115). CI of transplant-related mortality (TRM) was 18.4+/-4%. On multivariate analysis, high Lansky score (>80) at transplantation was associated with lower TRM (HR, 0.9; P<0.0002). Relapse incidence (RI) was 33.6+/-6%. On multivariate analysis, high Lansky score at transplantation and cGvHD were associated with lower RI (HR, 0.04; P<0.0005 and HR, 0.23; P<0.03, respectively). Disease-free survival (DFS) was 57.8+/-5%. Disease status at transplantation (HR, 0.33; P<0.02), steroid treatment at day +90 (HR, 5.61; P<0.005) and cGvHD (HR, 0.23; P<0.005) had a significant impact on DFS in multivariate analysis. CI of cGvHD was 63.7+/-7%. Patients with cGvHD had better DFS (65+/-5%) because of lower RI (15.7+/-6%) and similar TRM (27.4+/-4%). These data suggest acceptable long-term outcomes after allogeneic PBSC transplantation in children despite the high incidence of cGvHD. These patients had a lower risk of relapse and a better DFS.
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Affiliation(s)
- M A Diaz
- Department of Pediatrics, Division of Pediatric Hematology Oncology, Hospital Infantil Niño Jesus, Madrid, Spain.
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Lassaletta A, Ramírez M, Montero JM, González-Vicent M, Balas A, Madero L, Díaz MA. Full donor chimerism by day 30 after allogeneic peripheral blood progenitor cell transplantation is associated with a low risk of relapse in pediatric patients with hematological malignancies. Leukemia 2005; 19:504-6. [PMID: 15729381 DOI: 10.1038/sj.leu.2403692] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
MESH Headings
- Acute Disease
- Adolescent
- Child
- Child, Preschool
- Female
- Hematopoietic Stem Cell Transplantation
- Humans
- Infant
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/epidemiology
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/therapy
- Leukemia, Myeloid/epidemiology
- Leukemia, Myeloid/therapy
- Male
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/epidemiology
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/therapy
- Recurrence
- Retrospective Studies
- Risk Factors
- Transplantation Chimera
- Transplantation, Homologous
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Affiliation(s)
- A Lassaletta
- Servicio de Oncohematología y Trasplante Hematopoyético, Hospital Infantil 'Niño Jesús', Madrid, Spain
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6
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Abstract
The ability to cure increasing numbers of individuals for malignant and non-malignant diseases with the use of stem cell transplantation has resulted in a growing number of long-term survivors with unique medical issues. Chronic graft versus host disease (GvHD) continues to be a significant problem in the allogeneic stem cell transplant setting and, as we continue to use alternative stem cell sources and attempt to modulate the immune system to increase an anti-tumour effect, we will probably see rising numbers of patients with this complication. The capacity to treat this problem and improve both the immediate quality of life as well as long-term effects is imperative and requires the ability of haematologists/oncologists to identify chronic GvHD and its multi-organ system presentations. We describe the risk factors for developing chronic GvHD, its presentation and the current treatment options for both initial therapy and secondary treatment.
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Affiliation(s)
- Meghan A Higman
- The Sidney Kimmel Comprehensive Cancer at Johns Hopkins, Baltimore, MD, USA
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Lee KH, Choi SJ, Lee JH, Kim S, Seol M, Lee YS, Kim WK, Lee JS, Lee JH. Cyclosporine alone vs cyclosporine plus methotrexate for post-transplant immunosuppression after HLA-identical sibling bone marrow transplantation: a randomized prospective study. Bone Marrow Transplant 2004; 34:627-36. [PMID: 15300231 DOI: 10.1038/sj.bmt.1704624] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The role of methotrexate (MTX), given with cyclosporine (CS), after HLA-identical sibling bone marrow transplantation needs to be defined. In all, 80 patients with hematologic malignancies were enrolled in a prospective randomized trial. All were given BuCy conditioning. The 40 patients in the CS arm received CS 3 mg/kg/day intravenously, with subsequent oral dosing. Patients in the CS + MTX arm received, in addition to CS, MTX intravenously, 15 mg/m2 on day 1, and 10 mg/m2 on days 3, 6, and 11. Transplantation-related mortality was low in both groups of patients (13 vs 11% for CS vs CS + MTX groups, P = 0.94). The CS group had a significantly higher frequency of chronic graft-versus-host disease (56 vs 32%, P = 0.05). After a median follow-up of 22.1 months (5.1-47.8 months), three of 30 vs 10 of 28 patients with acute leukemia/myelodysplastic syndrome (MDS) in CS group vs CS + MTX group relapsed (P = 0.01) yielding better overall survival for patients with acute leukemia/MDS treated with CS (P = 0.02). After HLA-identical sibling bone marrow transplantation, immunosuppression with CS, with or without MTX, resulted in similarly low transplantation-related mortality. In acute leukemia/MDS, decreased relapse with patient survival prolongation was observed in the CS group.
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Affiliation(s)
- K-H Lee
- Sections of Hematology and Oncology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
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Diaz MA, Vicent MG, Gonzalez ME, Verdeguer A, de la Rubia J, Bargay J, de Arriba F, Diez JL, Caballero D, Madero L, Brunet S. Risk assessment and outcome of chronic graft-versus-host disease after allogeneic peripheral blood progenitor cell transplantation in pediatric patients. Bone Marrow Transplant 2004; 34:433-8. [PMID: 15273704 DOI: 10.1038/sj.bmt.1704589] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
We retrospectively evaluated the incidence, risk factors for chronic graft-versus-host disease (cGvHD) and outcome in 80 pediatric patients (36 male) (median age 13 years) who underwent allogeneic peripheral blood progenitor cell transplantation. Patients were grafted from an HLA-identical sibling after myeloablative conditioning (total body irradiation (TBI) based 52; non-TBI 28). GvHD prophylaxis used were: cyclosporin A (CsA)+ short methotrexate (MTX) in 52 and CsA+/-prednisone in 28. The median number of CD34+ cells infused were 5.8 x 10(6)/kg (range: 1.4-32.8). The median follow-up was 24 months (range: 3-94). In all, 28 patients had cGvHD (confidence interval (CI): 54.2+/-10%). Factors that were significant on univariate analysis were diagnosis (P=0.03) and GvHD prophylaxis administered (P=0.04). On multivariate analysis, only GvHD prophylaxis used was associated with a significant risk of cGvHD (hazard ratio (HR): 3.94; 95% CI: 1.41-10.91, P=0.009). The CI of cGvHD for patients receiving CsA+MTX was 40.9+/-12 vs 76.5+/-18% for patients who did not (P=0.03). The probability of relapse was 36+/-6% for all patients (12.5+/-8% for patients with cGvHD vs 47.9+/-8% without cGvHD). The probability of disease-free survival was better for patients with cGvHD (69.9+/-10 vs 37.9+/-7%; HR: 3.59, 95% CI: 1.47-5.56; P=0.001). Our data suggest that the GvHD prophylaxis used is the most relevant predictor of cGvHD. Patients with cGvHD had a lower risk of relapse and a better survival.
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Affiliation(s)
- M A Diaz
- Hospital Infantil 'Niño Jesus', Madrid, Spain.
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Sohn SK, Kim JG, Kim DH, Baek JH, Lee KB. Diverse clinical applications using advantages of allogeneic peripheral blood stem cell transplantation. Int J Hematol 2004; 79:457-61. [PMID: 15239395 DOI: 10.1532/ijh97.a10313] [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] [Indexed: 11/20/2022]
Abstract
The diverse clinical applications of allogeneic peripheral blood stem cells based on use of their advantages are summarized. It is apparent that more stem cells and T-lymphocytes can be harvested by mobilization treatment with cytokines from healthy donors in allogeneic peripheral blood stem cell transplantation (PBSCT) than in bone marrow transplantation. It is also clear that a stronger graft-versus-tumor effect can be induced with allogeneic PBSCT than with bone marrow transplantation. One merit of allogeneic PBSCT is that it allows clinicians to design diverse clinical applications. It would appear that allogeneic PBSCT may be preferable in special clinical settings, such as advanced hematological malignancies, situations requiring a strong graft-versus-tumor effect, nonmyeloablative stem cell transplantation, and situations requiring a megadose of stem cells. Cytokine-primed peripheral blood stem cells can also be used for adoptive immunotherapy, such as a nonprimed donor lymphocyte infusion.
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Affiliation(s)
- Sang Kyun Sohn
- Department of Hematology/Oncology, Kyungpook National University Hospital, Daegu, Korea.
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Sohn SK, Kim DH, Kim JG, Lee NY, Suh JS, Lee KS, Lee KB. Transplantation outcome in allogeneic PBSCT patients according to a new chronic GVHD grading system, including extensive skin involvement, thrombocytopenia, and progressive-type onset. Bone Marrow Transplant 2004; 34:63-8. [PMID: 15133486 DOI: 10.1038/sj.bmt.1704533] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Patients who had suffered chronic GVHD after an allogeneic PBSCT were evaluated using a new chronic GVHD grading system. The study included 36 consecutive adult patients with hematological diseases, who survived at least until day 90 following allogeneic PBSCT and who could be evaluated for chronic GVHD. Extensive skin involvement was observed in five patients, thrombocytopenia in 14, and progressive-type onset in 10, while grade 1 chronic GVHD appeared in 21 patients, grade 2 in 10, and grade 3 in five. There was a significant difference in the probability of relapse between the groups with grade 1 and 2+3 chronic GVHD (55.3 vs 16.4%, P=0.0211). The difference was particularly marked in patients with high-risk hematological malignancies (grade 1 vs grade 2+3, 75 vs 0%, P=0.0115). With a median follow-up of 12 months (range, 4-52 months), 22 (66.1%) patients were still alive. The estimated 2-year survival rate for the whole population was 57.6%, while that for the group with chronic GVHD grade 1 and grade 2+3 was 53.5 and 56.3%, respectively (P=0.4387). Accordingly, there was a significant difference in the probability of relapse between the groups with grade 1 and grade 2+3 chronic GVHD.
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Affiliation(s)
- S K Sohn
- Department of Hematology/Oncology, Kyungpook National University Hospital, Daegu, Korea
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11
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Sohn SK, Kim DH, Kim JG, Sung WJ, Baek JH, Lee NY, Won DI, Suh JS, Lee KS, Lee KB. Outcome of allogeneic peripheral blood stem cell transplantation using matched sibling donors in patients with high-risk hematological diseases. Eur J Haematol 2004; 72:430-6. [PMID: 15128422 DOI: 10.1111/j.1600-0609.2004.00249.x] [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] [Indexed: 11/29/2022]
Abstract
Although the use of peripheral blood stem cells instead of bone marrow is still a matter of debate in transplantation from HLA-identical sibling donors, allogeneic peripheral blood stem cell transplantation (PBSCT), with a stronger graft-versus-leukemia (GVL) effect, may be preferable as a source of stem cells, especially in the case of advanced hematologic diseases. As such, the current paper reports on the outcomes of 27 consecutive patients with high-risk hematologic diseases treated with allogeneic PBSCT. The median dose of CD34+, CD3+ cells, and MNC infused was 8.18 x 10(6)/kg (range: 2.78-14.93), 1.50 x 10(8)/kg (range: 0.06-4.25), and 7.17 x 10(8)/kg (range: 0.95-15.85), respectively. The median time taken for the ANC and platelets to reach 500 and 20,000 x 10(6)/microL was 15 (range: 9-25) and 16 d (range: 10-56), respectively. Three patients (11.1%) experienced transplant-related mortality within 90 d of transplantation, and 15 (62.5%) of 24 evaluated patients developed chronic graft-versus-host disease (GVHD; six limited, nine extensive). There was a significant difference in overall survival (OS) between the group with chronic GVHD and the group without chronic GVHD (P = 0.0253). The causes of death included relapse (six cases) and non-relapse mortality (infection: four cases, chronic GVHD-related death: three cases). The 4-yr OS rate and disease-free survival rate was 43.3 +/- 10.9% and 35.8 +/- 10.2%, respectively. Accordingly, chronic GVHD was found to have a positive role in patients with high-risk hematologic diseases that received allogeneic PBSCT.
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Affiliation(s)
- Sang Kyun Sohn
- Department of Hematology/Oncology and Stem Cell Transplantation Center, Kyungpook National University Hospital, Daegu, Korea
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12
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Cornelissen JJ, van der Holt B, Petersen EJ, Vindelov L, Russel CA, Höglund M, Maertens J, Schouten HC, Braakman E, Steijaert MMC, Zijlmans MJM, Slaper-Cortenbach I, Boogaerts MA, Löwenberg B, Verdonck LF. A randomized multicenter comparison of CD34(+)-selected progenitor cells from blood vs from bone marrow in recipients of HLA-identical allogeneic transplants for hematological malignancies. Exp Hematol 2003; 31:855-64. [PMID: 14550800 DOI: 10.1016/s0301-472x(03)00195-4] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Peripheral blood progenitor cells (PBPC) have been established as an alternative source of hematopoietic stem cells for allogeneic transplantation, but an increased incidence of both acute and chronic graft-vs-host disease (GVHD) has become apparent. We performed a prospective randomized trial comparing bone marrow transplantation (BMT) vs PBPC transplantation (PBPCT) using CD34(+) selection for T-cell depletion (TCD) in both study arms. PATIENTS AND METHODS Between January 1996 and October 2000, 120 patients with a diagnosis of acute leukemia, myelodysplasia, multiple myeloma, or lymphoma were randomized to receive either filgrastim-mobilized PBPC or BM from HLA-identical sibling donors after standard high-dose chemoradiotherapy. Patient characteristics did not differ between study arms. RESULTS Recipients of PBPC received more CD3(+) T cells (median: 3.0 vs 2.0 x 10(5)/kg, p<0.0001) and more CD34(+) cells (median: 3.6 vs 0.9 x 10(6)/kg, p<0.0001). Neutrophil and platelet recoveries occurred significantly faster after PBPCT. The cumulative incidence of acute GVHD grades II-IV was 37% after BMT vs 52% after PBPCT and was most significantly (p=0.007) affected by the number of CD3(+) T cells in the graft. Acute GVHD appeared strongly associated with increased treatment-related mortality (TRM) in a time-dependent analysis. Higher numbers of CD34(+) cells were associated with less TRM. With a median follow-up of 37 months (range: 12-75), overall survival at 4 years from transplantation was 60% after BMT and 34% for recipients of PBPCT (p=0.04), which difference was largely due to increased GVHD and TRM in PBPC recipients receiving T-cell dosages greater than 2 x 10(5)/kg. CONCLUSION Outcome following T cell-depleted PBPCT critically depends on the number of CD3(+) T cells, whereby high T-cell numbers may blunt a favorable effect of higher CD34(+) cell numbers.
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Affiliation(s)
- Jan J Cornelissen
- Department of Hematology, Erasmus MC-Daniel den Hoed Cancer Center, Rotterdam, The Netherlands.
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Heldal D, Brinch L, Tjønnfjord G, Solheim BG, Egeland T, Albrechtsen D, Aamodt G, Evensen SA. Fewer relapses and increased chronic GVHD in patients transplanted with blood stem cells: a 5-year follow-up in a single centre study. Bone Marrow Transplant 2003; 32:257-64. [PMID: 12858196 DOI: 10.1038/sj.bmt.1704127] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
A total of 61 consecutive adult patients with haematological malignancies with an HLA-identical or one antigen-mismatched haploidentical family donor were randomised to allogeneic transplantation with blood stem cells (BSC) or bone marrow (BM). The median observation time was 5 years. Apart from engraftment parameters and acute graft-versus-host disease (GVHD), transplant-related mortality (TRM), incidence and severity of chronic GVHD, relapse, leukaemia-free survival (LFS) and overall survival (OS) were recorded. In the BSC and BM group, respectively, TRM was 8/30 and 4/30 (P=0.405), the incidence of chronic GVHD was 15/26 and 11/30 (P=0.138), extensive chronic GVHD was 10/26 and 4/30 (P=0.034), and relapse one and 10 patients (P=0.007). In log-rank test restricted to the cases allografted from HLA-identical donors, the difference remained significant with regard to relapse incidence (P=0.039), but not extensive chronic GVHD (P=0.072). No difference in LFS and OS was observed. In conclusion, our study strongly indicates an enhanced graft-versus-leukaemia effect in BSC recipients, which is not expressed in increased survival. The increased chronic GVHD in these patients may contribute, but the relation is complex and not yet understood.
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Affiliation(s)
- D Heldal
- Medical Department, Rikshospitalet University Hospital, 0027 Oslo, Norway
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Chakrabarti S, Brown J, Guttridge M, Pamphilon DH, Lankester A, Marks DI. Early lymphocyte recovery is an important determinant of outcome following allogeneic transplantation with CD34+ selected graft and limited T-cell addback. Bone Marrow Transplant 2003; 32:23-30. [PMID: 12815474 DOI: 10.1038/sj.bmt.1704082] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
We evaluated the outcome of 29 patients (age 22-60 years), who received a CD34+selected related (n=16) or unrelated graft (n=13) with limited T-cell addback (TCAB) (median 5.9 x 10(4)/kg) following full-intensity conditioning for haematological malignancies. In all, 16 patients (55%) had either advanced disease or previous transplants. The cumulative incidences of grade 2-4 acute GVHD were 15.4 and 19.2% and that for chronic extensive GVHD were 35 and 37% in related and unrelated graft recipients, respectively. The strongest predictor of nonrelapse mortality and overall survival was the absolute lymphocyte count (ALC) at 30 days; patients with ALC<0.35 x 10(9)/l having an NRM and OS of 59.2 and 24.7%, compared to 10 and 90% in those with a higher ALC. Patients with acute leukaemia had poorer survival and this was associated with a lower ALC as well. Thus, TCAB with a CD34+ selected graft resulted in a comparable outcome in both older and younger patients, but the survival was strongly influenced by early lymphocyte recovery.
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Affiliation(s)
- S Chakrabarti
- Adult Bone Marrow Transplant Unit, Bristol Royal Hospital for Sick Children, Bristol, UK
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Sohn SK, Kim JG, Kim DH, Lee NY, Suh JS, Lee KB. Impact of transplanted CD34+ cell dose in allogeneic unmanipulated peripheral blood stem cell transplantation. Bone Marrow Transplant 2003; 31:967-72. [PMID: 12774046 DOI: 10.1038/sj.bmt.1704042] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The impact of the CD34+ cell dose on chronic graft-versus-host disease (cGVHD) and the clinical outcome was analyzed in 41 consecutive adult patients submitted to allogeneic peripheral blood stem cell transplantation from HLA-identical siblings. The patients were classified into 'low' or 'high' CD34+ cell dose groups based on whether they received less or more than a median CD34+ cell dose of 10.5 x 10(6)/kg, respectively. There was a significant difference in the incidence of extensive cGVHD (low vs high group, 25.0 vs 66.7%, P=0.021) and relapse (47.6 vs 20.0%, P=0.049) between the two groups. With a median follow-up of 335 days, the 3-year survival estimate for the whole population was 47.9%, while that for the low and high groups was 29.9 and 67.8%, respectively (P=0.0434). An inverse relation was noted between the relapse rate and the incidence of extensive cGVHD (P=0.043). It would appear reasonable that the optimal dose of CD34+ cells should be determined based on the disease status or aggressiveness of the malignant cells in each patient. Yet, in the case of patients with a high risk of relapse, transplantation with a CD34+ cell dose of >10.5 x 10(6)/kg would seem to be acceptable to minimize the risk of relapse.
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MESH Headings
- Adolescent
- Adult
- Anemia, Aplastic/therapy
- Antigens, CD/blood
- Antigens, CD34/blood
- Graft vs Host Disease/epidemiology
- Histocompatibility Testing
- Humans
- Incidence
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/therapy
- Leukemia, Myeloid, Acute/therapy
- Living Donors
- Lymphoma, Non-Hodgkin/therapy
- Middle Aged
- Myelodysplastic Syndromes/therapy
- Retrospective Studies
- Siblings
- Stem Cell Transplantation/adverse effects
- Transplantation, Homologous/adverse effects
- Treatment Outcome
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Affiliation(s)
- S K Sohn
- Department of Hematology/Oncology, Kyungpook National University Hospital, Taegu, South Korea
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Abstract
Chronic graft-versus-host disease (GVHD) remains a vexing and dangerous complication of allogeneic stem cell transplantation. Mild forms of chronic GVHD are often manageable with local or low-dose systemic immunosuppression and do not affect long-term survival. In contrast, more severe forms of chronic GVHD require intensive medical management and adversely affect survival. This report reviews current concepts of the pathogenesis, clinical risk factors, classification systems, organ manifestations, and available treatments for chronic GVHD. It also provides a comprehensive listing of the published clinical trials aimed at prevention and primary treatment of chronic GVHD.
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Affiliation(s)
- Stephanie J Lee
- Department of Adult Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA.
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Recent publications in hematological oncology. Hematol Oncol 2002; 20:95-102. [PMID: 12111872 DOI: 10.1002/hon.691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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