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Kordjazy N, Amini S. A review of the therapeutic potential of the cysteinyl leukotriene antagonist Montelukast in the treatment of bronchiolitis obliterans syndrome following lung and hematopoietic-stem cell transplantation and its possible mechanisms. Ther Adv Respir Dis 2024; 18:17534666241232284. [PMID: 38504551 PMCID: PMC10953006 DOI: 10.1177/17534666241232284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 01/26/2024] [Indexed: 03/21/2024] Open
Abstract
Lung and hematopoietic stem cell transplantation are therapeutic modalities in chronic pulmonary and hematological diseases, respectively. One of the complications in these patients is the development of bronchiolitis obliterans syndrome (BOS). The efficacy and safety of available treatment strategies in BOS remain a challenge. A few mechanisms have been recognized for BOS in lung transplant and graft-versus-host disease (GVHD) patients involving the TH-1 and TH-2 cells, NF-kappa B, TGF-b, several cytokines and chemokines, and cysteinyl leukotrienes (CysLT). Montelukast is a highly selective CysLT receptor antagonist that has been demonstrated to exert anti-inflammatory and anti-fibrotic effects in abundant experiments. One area of interest for the use of montelukast is lung transplants or GVHD-associated BOS. Herein, we briefly review data regarding the mechanisms involved in BOS development and montelukast administration as a treatment modality for BOS, and finally, the possible relationship between CysLTs antagonism and BOS improvement will be discussed.
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Affiliation(s)
- Nastaran Kordjazy
- Department of Clinical Pharmacy, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Shahideh Amini
- Rajaei Cardiovascular Medical and Research Institute, Valiasr Ave-Niyayesh Intersection, Tehran 199561-14331, Iran
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2
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Williams KM, Pavletic SZ, Lee SJ, Martin PJ, Farthing DE, Hakim FT, Rose J, Manning-Geist BL, Gea-Banacloche JC, Comis LE, Cowen EW, Justus DG, Baird K, Cheng GS, Avila D, Steinberg SM, Mitchell SA, Gress RE. Prospective phase II trial of montelukast to treat bronchiolitis obliterans syndrome after hematopoietic cell transplant and investigation into BOS pathogenesis. Transplant Cell Ther 2022; 28:264.e1-264.e9. [PMID: 35114411 PMCID: PMC9081205 DOI: 10.1016/j.jtct.2022.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 01/16/2022] [Accepted: 01/24/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Bronchiolitis obliterans syndrome (BOS) is a severe manifestation of chronic graft-versus-host disease (cGVHD) following hematopoietic cell transplantation (HCT). Montelukast interrupts cysteinyl leukotriene activity and may diminish the activation and homing of cells to bronchioles and subsequent fibrosis. OBJECTIVE We performed a prospective phase II trial to test whether montelukast altered lung decline for patients with BOS after HCT. STUDY DESIGN We performed a single arm, open-label, multi-institutional study with primary endpoints of: i) FEV1 stability or improvement (<15% decline) and ii) slope of FEV1<1 point decline after six months treatment. Secondary endpoints included symptom and functional response, and immune correlates investigating the role of leukotrienes in BOS progression. RESULTS 25 patients enrolled with moderate to severe lung disease after three months of stable cGVHD therapy. Montelukast was well-tolerated and no patient required escalation of BOS-directed therapy. At the primary endpoint, all evaluable patients (n=23) met criteria for treatment success using FEV1% predicted, and all but one had stable or improved FEV1 slope. In those with >5% FEV1 improvement, clinically meaningful improvements were seen in the Lee scores of breathing, energy, and mood. Improvements in the Human Activity Profile and 6-minute-walk test were observed in those with <5% FEV1 decline. Overall survival was 87% at two-years. Immune correlates showed elevated leukotriene receptor levels on blood eosinophils and monocytes vs. healthy controls, elevated urine leukotrienes in 45% of cohort, and cysteinyl leukotriene receptors on bronchoalveolar lavage subsets and a predominance of Th2 T cells, all pre-treatment. CONCLUSIONS These data suggest that montelukast may safely halt progression of BOS after HCT and that leukotrienes may play a role in the biology of BOS.
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Affiliation(s)
- Kirsten M Williams
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, 1760 Haygood Drive, 3rd floor W362, Atlanta GA, US, 30322.
| | - Steven Z Pavletic
- Center for Cancer Research, National Cancer Institute, National Institutes of Health, 10 Center Drive, Bethesda MD, US, 20892
| | - Stephanie J Lee
- Fred Hutchinson Cancer Research Center, 1100 Fairview Ave, Seattle, WA, US 98109
| | - Paul J Martin
- Fred Hutchinson Cancer Research Center, 1100 Fairview Ave, Seattle, WA, US 98109
| | - Don E Farthing
- Experimental Transplantation and Immunotherapy Branch, National Cancer Institute, National Institutes of Health, 10 Center Drive, Bethesda, MD, US, 20892
| | - Frances T Hakim
- Experimental Transplantation and Immunotherapy Branch, National Cancer Institute, National Institutes of Health, 10 Center Drive, Bethesda, MD, US, 20892
| | - Jeremy Rose
- Experimental Transplantation and Immunotherapy Branch, National Cancer Institute, National Institutes of Health, 10 Center Drive, Bethesda, MD, US, 20892
| | - Beryl L Manning-Geist
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, US, 10065
| | - Juan C Gea-Banacloche
- Division of Clinical Research, National Institute of Allergy and Immunology, National Institutes of Health, 10 Center Drive, Bethesda, MD, US, 20892
| | - Leora E Comis
- Rehabilitation Medicine Department, Clinical Center, NIH, Bethesda, MD
| | - Edward W Cowen
- Dermatology Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, 10 Center Dr, Room 12N240A, Bethesda, MD, US, 20892
| | - David G Justus
- Department of Laboratory Medicine, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, US
| | - Kristin Baird
- Pediatric Oncology Branch, National Cancer Institute, NIH, Bethesda, MD
| | - Guang-Shing Cheng
- Department of Medicine, University of Washington, Seattle, WA, US, 98109; Fred Hutchinson Cancer Research Center, 1100 Fairview Ave, Seattle, WA, US 98109
| | - Daniele Avila
- Center for Cancer Research, National Cancer Institute, National Institutes of Health, 10 Center Drive, Bethesda MD, US, 20892
| | - Seth M Steinberg
- Biostatistics and Data Management Section, Center for Cancer Research, National Cancer Institute, NIH, Bethesda, MD, US, 20892
| | - Sandra A Mitchell
- Outcomes Research Branch, Division of Cancer Control and Population Sciences, National Cancer Institute, NIH, 9609 Medical Center Drive, Bethesda MD, US, 20892
| | - Ronald E Gress
- Experimental Transplantation and Immunotherapy Branch, National Cancer Institute, National Institutes of Health, 10 Center Drive, Bethesda, MD, US, 20892
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3
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Shiari A, Nassar M, Soubani AO. Major pulmonary complications following Hematopoietic stem cell transplantation: What the pulmonologist needs to know. Respir Med 2021; 185:106493. [PMID: 34107323 DOI: 10.1016/j.rmed.2021.106493] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/28/2021] [Accepted: 05/29/2021] [Indexed: 12/16/2022]
Abstract
Hematopoietic stem cell transplantation (HSCT) is used for treatment of a myriad of both malignant and non-malignant disorders. However, despite many advances over the years which have resulted in improved patient mortality, this subset of patients remains at risk for a variety of post-transplant complications. Pulmonary complications of HSCT are categorized into infectious and non-infectious and occur in up to one-third of patients undergoing HSCT. Infectious etiologies include bacterial, viral and fungal infections, each of which can have significant mortality if not identified and treated early in the course of infection. Advances in the diagnosis and management of infectious complications highlight the importance of non-infectious pulmonary complications related to chemoradiation toxicities, immunosuppressive drugs toxicities, and graft-versus-host disease. This report aims to serve as a guide and clinical update of pulmonary complications following HSCT for the general pulmonologist who may be involved in the care of these patients.
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Affiliation(s)
- Aryan Shiari
- Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine, Detroit, MI, 48201, USA
| | - Mo'ath Nassar
- Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine, Detroit, MI, 48201, USA
| | - Ayman O Soubani
- Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine, Detroit, MI, 48201, USA.
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4
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Haider S, Durairajan N, Soubani AO. Noninfectious pulmonary complications of haematopoietic stem cell transplantation. Eur Respir Rev 2020; 29:190119. [PMID: 32581138 PMCID: PMC9488720 DOI: 10.1183/16000617.0119-2019] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 12/11/2019] [Indexed: 01/01/2023] Open
Abstract
Haematopoietic stem cell transplantation (HSCT) is an established treatment for a variety of malignant and nonmalignant conditions. Pulmonary complications, both infectious and noninfectious, are a major cause of morbidity and mortality in patients who undergo HSCT. Recent advances in prophylaxis and treatment of infectious complications has increased the significance of noninfectious pulmonary conditions. Acute lung injury associated with idiopathic pneumonia syndrome remains a major acute complication with high morbidity and mortality. On the other hand, bronchiolitis obliterans syndrome is the most challenging chronic pulmonary complication facing clinicians who are taking care of allogeneic HSCT recipients. Other noninfectious pulmonary complications following HSCT are less frequent. This review provides a clinical update of the incidence, risk factors, pathogenesis, clinical characteristics and management of the main noninfectious pulmonary complications following HSCT.
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Affiliation(s)
- Samran Haider
- Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine, Detroit, MI, USA
| | - Navin Durairajan
- Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine, Detroit, MI, USA
| | - Ayman O Soubani
- Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine, Detroit, MI, USA
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Contaifer D, Roberts CH, Kumar NG, Natarajan R, Fisher BJ, Leslie K, Reed J, Toor AA, Wijesinghe DS. A Preliminary Investigation towards the Risk Stratification of Allogeneic Stem Cell Recipients with Respect to the Potential for Development of GVHD via Their Pre-Transplant Plasma Lipid and Metabolic Signature. Cancers (Basel) 2019; 11:E1051. [PMID: 31349646 PMCID: PMC6721383 DOI: 10.3390/cancers11081051] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Revised: 07/12/2019] [Accepted: 07/18/2019] [Indexed: 12/15/2022] Open
Abstract
The clinical outcome of allogeneic hematopoietic stem cell transplantation (SCT) may be influenced by the metabolic status of the recipient following conditioning, which in turn may enable risk stratification with respect to the development of transplant-associated complications such as graft vs. host disease (GVHD). To better understand the impact of the metabolic profile of transplant recipients on post-transplant alloreactivity, we investigated the metabolic signature of 14 patients undergoing myeloablative conditioning followed by either human leukocyte antigen (HLA)-matched related or unrelated donor SCT, or autologous SCT. Blood samples were taken following conditioning and prior to transplant on day 0 and the plasma was comprehensively characterized with respect to its lipidome and metabolome via liquid chromatography/mass spectrometry (LCMS) and gas chromatography/mass spectrometry (GCMS). A pro-inflammatory metabolic profile was observed in patients who eventually developed GVHD. Five potential pre-transplant biomarkers, 2-aminobutyric acid, 1-monopalmitin, diacylglycerols (DG 38:5, DG 38:6), and fatty acid FA 20:1 demonstrated high sensitivity and specificity towards predicting post-transplant GVHD. The resulting predictive model demonstrated an estimated predictive accuracy of risk stratification of 100%, with area under the curve of the ROC of 0.995. The likelihood ratio of 1-monopalmitin (infinity), DG 38:5 (6.0), and DG 38:6 (6.0) also demonstrated that a patient with a positive test result for these biomarkers following conditioning and prior to transplant will be at risk of developing GVHD. Collectively, the data suggest the possibility that pre-transplant metabolic signature may be used for risk stratification of SCT recipients with respect to development of alloreactivity.
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Affiliation(s)
- Daniel Contaifer
- Department of Pharmacotherapy and Outcomes Sciences, School of Pharmacy, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Catherine H Roberts
- Department of Internal Medicine, School of Medicine, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Naren Gajenthra Kumar
- Department of Microbiology, School of Medicine, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Ramesh Natarajan
- Department of Internal Medicine, School of Medicine, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Bernard J Fisher
- Department of Internal Medicine, School of Medicine, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Kevin Leslie
- Department of Physics, College of Humanities and Sciences, Virginia Commonwealth University, Richmond, VA 23284, USA
| | - Jason Reed
- Department of Physics, College of Humanities and Sciences, Virginia Commonwealth University, Richmond, VA 23284, USA
| | - Amir A Toor
- Department of Internal Medicine, School of Medicine, Virginia Commonwealth University, Richmond, VA 23298, USA.
- Massey Cancer Center, Virginia Commonwealth University, Richmond, VA 23298, USA.
| | - Dayanjan S Wijesinghe
- Department of Pharmacotherapy and Outcomes Sciences, School of Pharmacy, Virginia Commonwealth University, Richmond, VA 23298, USA.
- Institute for Structural Biology Drug Discovery and Development (ISB3D), VCU School of Pharmacy, Richmond, VA 23298, USA.
- Da Vinci Center, Virginia Commonwealth University, Richmond, VA 23284, USA.
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6
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Montelukast for bronchiolitis obliterans syndrome after lung transplantation: A randomized controlled trial. PLoS One 2018; 13:e0193564. [PMID: 29624575 PMCID: PMC5889063 DOI: 10.1371/journal.pone.0193564] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 02/06/2018] [Indexed: 12/03/2022] Open
Abstract
Bronchiolitis obliterans syndrome (BOS) remains the major problem which precludes long-term survival after lung transplantation. Previously, an open label pilot study from our group demonstrated a possible beneficial effect of montelukast in progressive BOS patients with low airway neutrophilia (<15%), and already on azithromycin treatment, in whom the further decline in pulmonary function was attenuated. This was, however, a non-randomized and non-placebo controlled trial. The study design is a single center, prospective, interventional, randomized, double blind, placebo-controlled trial, with a two arm parallel group design and an allocation ratio of 1:1. Randomization to additional montelukast (10 mg/day, n = 15) or placebo (n = 15) was performed from 2010 to 2014 at the University Hospitals Leuven (Leuven, Belgium) in all consecutive patients with late-onset (>2years posttransplant) BOS ≥1. Primary end-point was freedom from graft loss 1 year after randomization; secondary end-points were acute rejection, lymphocytic bronchiolitis, respiratory infection rate; and change in FEV1, airway and systemic inflammation during the study period. Graft loss at 1 y and 2y was similar in both groups (respectively p = 0. 981 and p = 0.230). Montelukast had no effect on lung function decline in the overall cohort. However, in a post-hoc subanalysis of BOS stage 1 patients, montelukast attenuated further decline of FEV1 during the study period, both in absolute (L) (p = 0.008) and % predicted value (p = 0.0180). A linear mixed model confirmed this association. Acute rejection, lymphocytic bronchiolitis, respiratory infections, systemic and airway inflammation were comparable between groups over the study period. This randomized controlled trial showed no additional survival benefit with montelukast compared to placebo, although the study was underpowered. The administration of montelukast was associated with an attenuation of the rate of FEV1 decline, however, only in recipients with late-onset BOS stage 1.
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7
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Van Herck A, Verleden SE, Vanaudenaerde BM, Verleden GM, Vos R. Prevention of chronic rejection after lung transplantation. J Thorac Dis 2017; 9:5472-5488. [PMID: 29312757 DOI: 10.21037/jtd.2017.11.85] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Long-term survival after lung transplantation (LTx) is limited by chronic rejection (CR). Therapeutic strategies for CR have been largely unsuccessful, making prevention of CR an important and challenging therapeutic approach. In the current review, we will discuss current clinical evidence regarding prevention of CR after LTx.
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Affiliation(s)
- Anke Van Herck
- Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism & Ageing (CHROMETA), Division of Respiratory Diseases, KU Leuven, Leuven, Belgium
| | - Stijn E Verleden
- Department of Chronic Diseases, Metabolism & Ageing (CHROMETA), Division of Respiratory Diseases, KU Leuven, Leuven, Belgium
| | - Bart M Vanaudenaerde
- Department of Chronic Diseases, Metabolism & Ageing (CHROMETA), Division of Respiratory Diseases, KU Leuven, Leuven, Belgium
| | - Geert M Verleden
- Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism & Ageing (CHROMETA), Division of Respiratory Diseases, KU Leuven, Leuven, Belgium
| | - Robin Vos
- Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism & Ageing (CHROMETA), Division of Respiratory Diseases, KU Leuven, Leuven, Belgium
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8
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Grønningsæter IS, Tsykunova G, Lilleeng K, Ahmed AB, Bruserud Ø, Reikvam H. Bronchiolitis obliterans syndrome in adults after allogeneic stem cell transplantation-pathophysiology, diagnostics and treatment. Expert Rev Clin Immunol 2017; 13:553-569. [DOI: 10.1080/1744666x.2017.1279053] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Ida Sofie Grønningsæter
- Department of Medicine, Hematology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Galina Tsykunova
- Department of Medicine, Hematology, Haukeland University Hospital, Bergen, Norway
| | - Kyrre Lilleeng
- Department of Medicine, Hematology, Haukeland University Hospital, Bergen, Norway
| | - Aymen Bushra Ahmed
- Department of Medicine, Hematology, Haukeland University Hospital, Bergen, Norway
| | - Øystein Bruserud
- Department of Medicine, Hematology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
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9
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How I treat bronchiolitis obliterans syndrome after hematopoietic stem cell transplantation. Blood 2016; 129:448-455. [PMID: 27856461 DOI: 10.1182/blood-2016-08-693507] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 11/05/2016] [Indexed: 12/30/2022] Open
Abstract
In past years, a diagnosis of bronchiolitis obliterans syndrome (BOS) after allogeneic hematopoietic cell transplant (HCT) conferred nearly universal mortality secondary to lack of consensus for diagnostic criteria, poorly understood disease pathogenesis, and very few studies of therapeutic or supportive care interventions. Recently, however, progress has been made in these areas: revised consensus diagnostic guidelines are now available, supportive care has improved, there is greater understanding of potential mechanisms of disease, and prospective trials are being conducted. This article describes these advances and provides suggestions to optimize therapy for patients with BOS after HCT.
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10
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Kim SW, Rhee CK, Kim YJ, Lee S, Kim HJ, Lee JW. Therapeutic effect of budesonide/formoterol, montelukast and N-acetylcysteine for bronchiolitis obliterans syndrome after hematopoietic stem cell transplantation. Respir Res 2016; 17:63. [PMID: 27229850 PMCID: PMC4882858 DOI: 10.1186/s12931-016-0380-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 05/18/2016] [Indexed: 01/16/2023] Open
Abstract
Background Bronchiolitis obliterans syndrome (BOS) after allogeneic hematopoietic stem cell transplantation (HSCT) is currently treated with systemic corticosteroids despite poor efficacy and side effects. This study investigated the therapeutic effect of budesonide/formoterol, montelukast and n-acetylcysteine, which are suggested as treatment options for BOS after HSCT. Methods After diagnosis of BOS, 61 patients were treated with budesonide/formoterol, montelukast and n-acetylcysteine for 3 months. Pulmonary function test and COPD assessment test (CAT) were performed before and after the combination therapy. Therapeutic response was evaluated by changes in forced expiratory volume in 1 s (FEV1) or CAT score. Results After 3 months of combination treatment, mean FEV1 increased by 220 mL (p < 0.001) and residual volume decreased by 200 mL (p =0 .005). Median CAT score also significantly decreased from 15.5 to 11.0 (p = 0.001). The overall response rate to combination therapy was 82 %. Comparing the no-response group and the response group, the forced vital capacity (% predicted) decline between pre-HSCT and BOS diagnosis was significantly greater in the response group (p = 0.036). Conclusion Combination treatment with budesonide/formoterol, montelukast and n-acetylcysteine significantly improved lung function and respiratory symptoms in patients with BOS after allogeneic HSCT without serious side effects.
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Affiliation(s)
- Sei Won Kim
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chin Kook Rhee
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yoo Jin Kim
- Division of Hematology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seok Lee
- Division of Hematology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hee Je Kim
- Division of Hematology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jong Wook Lee
- Division of Hematology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea.
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11
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Williams KM, Cheng GS, Pusic I, Jagasia M, Burns L, Ho VT, Pidala J, Palmer J, Johnston L, Mayer S, Chien JW, Jacobsohn DA, Pavletic SZ, Martin PJ, Storer BE, Inamoto Y, Chai X, Flowers MED, Lee SJ. Fluticasone, Azithromycin, and Montelukast Treatment for New-Onset Bronchiolitis Obliterans Syndrome after Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2016; 22:710-716. [PMID: 26475726 PMCID: PMC4801753 DOI: 10.1016/j.bbmt.2015.10.009] [Citation(s) in RCA: 119] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 10/07/2015] [Indexed: 12/13/2022]
Abstract
Bronchiolitis obliterans syndrome (BOS) after allogeneic hematopoietic cell transplantation (HCT) is associated with high mortality. We hypothesized that inhaled fluticasone, azithromycin, and montelukast (FAM) with a brief steroid pulse could avert progression of new-onset BOS. We tested this in a phase II, single-arm, open-label, multicenter study (NCT01307462). Thirty-six patients were enrolled within 6 months of BOS diagnosis. The primary endpoint was treatment failure, defined as 10% or greater forced expiratory volume in 1 second decline at 3 months. At 3 months, 6% (2 of 36, 95% confidence interval, 1% to 19%) had treatment failure (versus 40% in historical controls, P < .001). FAM was well tolerated. Steroid dose was reduced by 50% or more at 3 months in 48% of patients who could be evaluated (n = 27). Patient-reported outcomes at 3 months were statistically significantly improved for Short-Form 36 social functioning score and mental component score, Functional Assessment of Cancer Therapies emotional well-being, and Lee symptom scores in lung, skin, mouth, and the overall summary score compared to enrollment (n = 24). At 6 months, 36% had treatment failure (95% confidence interval, 21% to 54%, n = 13 of 36, with 6 documented failures, 7 missing pulmonary function tests). Overall survival was 97% (95% confidence interval, 84% to 100%) at 6 months. These data suggest that FAM was well tolerated and that treatment with FAM and steroid pulse may halt pulmonary decline in new-onset BOS in the majority of patients and permit reductions in systemic steroid exposure, which collectively may improve quality of life. However, additional treatments are needed for progressive BOS despite FAM.
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Affiliation(s)
- Kirsten M Williams
- Division of Blood and Marrow Transplantation, Children's Research Institute, Children's National Health System, Washington, DC; Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland.
| | - Guang-Shing Cheng
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Iskra Pusic
- Division of Medicine and Oncology, Washington University, Saint Louis, Missouri
| | - Madan Jagasia
- Division of Hematology/Oncology, Vandebilt University, Nashville, Tennessee
| | - Linda Burns
- Division of Hematology/Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Vincent T Ho
- Division of Hematological Malignancies, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Joseph Pidala
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Jeanne Palmer
- Division of Hematology/Oncology, Mayo Clinic- Scottsdale, Scottsdale, Arizona
| | - Laura Johnston
- Division of Blood and Marrow Transplantation, Stanford University, Stanford, California
| | - Sebastian Mayer
- Department of Medicine, Weill Cornell Medical College, New York, New York
| | | | - David A Jacobsohn
- Division of Blood and Marrow Transplantation, Children's Research Institute, Children's National Health System, Washington, DC
| | - Steven Z Pavletic
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Paul J Martin
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Barry E Storer
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Yoshihiro Inamoto
- Division of Hematopoietic stem cell transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Xiaoyu Chai
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Mary E D Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Stephanie J Lee
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
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A call to arms: a critical need for interventions to limit pulmonary toxicity in the stem cell transplantation patient population. Curr Hematol Malig Rep 2015; 10:8-17. [PMID: 25662904 DOI: 10.1007/s11899-014-0244-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Noninfectious pulmonary toxicity after allogeneic hematopoietic stem cell transplantation (allo-HSCT) causes significant morbidity and mortality. Main presentations are idiopathic pneumonia syndrome (IPS) in the acute setting and bronchiolitis obliterans syndrome (BOS) and cryptogenic organizing pneumonia (COP) at later time point. While COP responds well to corticosteroids, IPS and BOS often are treatment refractory. IPS, in most cases, is rapidly fatal, whereas BOS progresses over time, resulting in chronic respiratory failure, impaired quality of life, and eventually, death. Standard second-line treatments are currently lacking, and current approaches, such as augmented T cell-directed immunosuppression, B cell depletion, TNF blockade, extracorporeal photopheresis, and tyroskine kinase inhibitor therapy, are unsatisfactory with responses in only a subset of patients. Better understanding of underlying pathophysiology hopefully results in the identification of future targets for preventive and therapeutic strategies along with an emphasis on currently underutilized rehabilitative and supportive measures.
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Jo KW, Yoon S, Song JW, Shim TS, Lee SW, Lee JS, Kim DY, Lee JH, Lee JH, Choi Y, Lee KH. The efficacy of prophylactic azithromycin on bronchiolitis obliterans syndrome after hematopoietic stem cell transplantation. Int J Hematol 2015; 102:357-63. [DOI: 10.1007/s12185-015-1830-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Revised: 06/16/2015] [Accepted: 06/18/2015] [Indexed: 01/08/2023]
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Brownback KR, Simpson SQ, Pitts LR, Polineni D, McGuirk JP, Ganguly S, Aljitawi OS, Lin TL, Singh A, Abhyankar S. Effect of extracorporeal photopheresis on lung function decline for severe bronchiolitis obliterans syndrome following allogeneic stem cell transplantation. J Clin Apher 2015; 31:347-52. [DOI: 10.1002/jca.21404] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 04/01/2015] [Accepted: 04/29/2015] [Indexed: 12/18/2022]
Affiliation(s)
- Kyle R. Brownback
- Division of Pulmonary and Critical Care Medicine; University of Kansas Medical Center; Kansas City Kansas
| | - Steven Q. Simpson
- Division of Pulmonary and Critical Care Medicine; University of Kansas Medical Center; Kansas City Kansas
| | - Lucas R. Pitts
- Division of Pulmonary and Critical Care Medicine; University of Kansas Medical Center; Kansas City Kansas
| | - Deepika Polineni
- Division of Pulmonary and Critical Care Medicine; University of Kansas Medical Center; Kansas City Kansas
| | - Joseph P. McGuirk
- Division of Hematology and Oncology; University of Kansas Medical Center; Kansas City Kansas
| | - Siddhartha Ganguly
- Division of Hematology and Oncology; University of Kansas Medical Center; Kansas City Kansas
| | - Omar S. Aljitawi
- Division of Hematology and Oncology; University of Kansas Medical Center; Kansas City Kansas
| | - Tara L. Lin
- Division of Hematology and Oncology; University of Kansas Medical Center; Kansas City Kansas
| | - Anurag Singh
- Division of Hematology and Oncology; University of Kansas Medical Center; Kansas City Kansas
| | - Sunil Abhyankar
- Division of Hematology and Oncology; University of Kansas Medical Center; Kansas City Kansas
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15
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Pulmonary Manifestations of Hematological Malignancies: Focus on Pulmonary Chronic Graft-Versus Host Disease. ORPHAN LUNG DISEASES 2015. [PMCID: PMC7120310 DOI: 10.1007/978-1-4471-2401-6_32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Advances in the management of patients in terms of the diagnosis and treatment of hematologic malignancies and treatment-related complications, especially infectious complications, have increased survival time. However, more than half of the patients treated for hematologic malignancies will develop a pulmonary complication during their follow-up, infectious pneumonia remaining the most common diagnosis that should be considered first in regard to its potential severity. Otherwise, new complications that may involve different organs, including the lungs, have been increasingly reported. Currently, over a quarter of lung infiltrates occurring in the context of hematological diseases are due to noninfectious causes. Thus, lung physicians may be increasingly confronted with these lung disorders. Various noninfectious pulmonary complications have been described in the different hematological malignancies; however, these complications are most often studied in the context of allogeneic hematopoietic stem cell transplantation (HSCT). In this chapter, we will briefly review the lung diseases associated with various hematological malignancies before focusing on noninfectious pulmonary complications following allogeneic HSCT.
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16
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Chien JW. Preventing and managing bronchiolitis obliterans syndrome after allogeneic hematopoietic cell transplantation. Expert Rev Respir Med 2014; 5:127-35. [DOI: 10.1586/ers.10.79] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Abstract
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HCT) is an effective immunotherapy for human cancer. More than 20 000 allo-HCTs are performed each year worldwide, primarily for the treatment of hematologic malignancies. Several technical innovations implemented in allo-HCT over past 2 decades have reduced NRM by 50% and improved overall survival. The allo-HCT practice has changed with the introduction of peripheral blood, cord blood, and haploidentical transplantations and reduced-intensity conditioning, and the patient population is also different regarding age and diagnosis. However, both acute and chronic GVHD remain serious barriers to successful allo-HCT and it is not clear that a major improvement has occurred in our ability to prevent or treat GVHD. Nevertheless, there is an increasing knowledge of the biology and clinical manifestations and the field is getting better organized. These advances will almost certainly lead to major progress in the near future. As the long list of new potential targets and respective drugs are developed, systems need to be developed for rapid testing of them in clinical practice. The current reality is that no single agent has yet to be approved by the US Food and Drug Administration for GVHD prevention or therapy. Although a primary goal of these efforts is to develop better therapies for GVHD, the ultimate goal is to develop treatments that lead to effective prevention or preemption of life-threatening and disabling GVHD manifestations while harnessing the desirable graft-versus-tumor effects.
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19
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Bergeron A, Godet C, Chevret S, Lorillon G, Peffault de Latour R, de Revel T, Robin M, Ribaud P, Socié G, Tazi A. Bronchiolitis obliterans syndrome after allogeneic hematopoietic SCT: phenotypes and prognosis. Bone Marrow Transplant 2012. [PMID: 23208317 PMCID: PMC7091913 DOI: 10.1038/bmt.2012.241] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Bronchiolitis obliterans syndrome (BOS) after allogeneic hematopoietic SCT (HSCT) is recognized as a new-onset obstructive lung defect (OLD) in pulmonary function testing and is related to pulmonary chronic GVHD. Little is known about the different phenotypes of patients with BOS and their outcomes. We reviewed the data of all allogeneic HSCT recipients referred to our pulmonary department for a non-infectious bronchial disease between 1999 and 2010. We identified 103 patients (BOS (n=77), asthma (n=11) and chronic bronchitis (n=15)). In patients with BOS, we identified two functional phenotypes: a typical OLD, that is, forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) ratio <0.7 (n=53), and an atypical OLD with a concomitant decrease in the FEV1 <80% and FVC <80% predicted with a normal total lung capacity (n=24). The typical OLD was characterized by more severe FEV1 and fewer centrilobular nodules on the computed tomography scan. The FEV1 was not significantly affected during the follow-up, regardless of the phenotype. In addition to acute and extensive chronic GVHD, only the occurrence of BOS soon after transplantation and the intentional treatment of BOS with steroids were associated with a poor survival. The determination of patient subgroups should be explored to improve the management of this condition.
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Affiliation(s)
- A Bergeron
- Université Paris Diderot, Sorbonne Cité, Service de Pneumologie, AP-HP, Hôpital Saint Louis, Paris, France.
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20
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Dignan FL, Scarisbrick JJ, Cornish J, Clark A, Amrolia P, Jackson G, Mahendra P, Taylor PC, Shah P, Lightman S, Fortune F, Kibbler C, Andreyev J, Albanese A, Hadzic N, Potter MN, Shaw BE. Organ-specific management and supportive care in chronic graft-versus-host disease. Br J Haematol 2012; 158:62-78. [DOI: 10.1111/j.1365-2141.2012.09131.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
| | | | | | - Andrew Clark
- Bone Marrow Transplant Unit; Beatson Oncology Centre; Gartnavel Hospital; Glasgow
| | - Persis Amrolia
- Department of Bone Marrow Transplantation; Great Ormond Street Hospital; London
| | - Graham Jackson
- Department of Haematology; Freeman Road Hospital; Newcastle
| | - Prem Mahendra
- Department of Haematology; University Hospital Birmingham; Birmingham
| | - Peter C. Taylor
- Department of Haematology; Rotherham General Hospital; Rotherham
| | - Pallav Shah
- Department of Respiratory Medicine; Royal Brompton Hospital; London
| | - Sue Lightman
- University College London/Institute of Opthalmology; Moorfields Eye Hospital; London
| | - Farida Fortune
- Department of Oral Medicine; Barts and the London NHS Trust; London
| | | | - Jervoise Andreyev
- Department of Medicine; The Royal Marsden NHS Foundation Trust; London
| | | | - Nedim Hadzic
- Paediatric Liver Service & Institute of Liver Studies; King's College Hospital; London
| | - Michael N. Potter
- Section of Haemato-oncology; The Royal Marsden NHS Foundation Trust; London
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21
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Sengsayadeth SM, Srivastava S, Jagasia M, Savani BN. Time to explore preventive and novel therapies for bronchiolitis obliterans syndrome after allogeneic hematopoietic stem cell transplantation. Biol Blood Marrow Transplant 2012; 18:1479-87. [PMID: 22449611 DOI: 10.1016/j.bbmt.2012.03.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2012] [Accepted: 03/19/2012] [Indexed: 12/21/2022]
Abstract
Although allogeneic hematopoietic stem cell transplant (allo-HSCT) is performed to treat otherwise incurable and fatal diseases, transplantation itself can lead to life-threatening complications due to organ damage. Pulmonary complications remain a significant barrier to the success of allo-HSCT. Lung injury, a frequent complication after allo-HSCT, and noninfectious pulmonary deaths account for a significant proportion of non-relapse mortality. Bronchiolitis obliterans syndrome (BOS) is a common and potentially devastating complication. BOS is now considered a diagnostic criterion of chronic graft-versus-host-disease (cGVHD), and National Institutes of Health (NIH) consensus has been published to establish guidelines for diagnosis and monitoring of BOS. It usually occurs within the first 2 years but may develop as late as 5 years after transplantation. Recent prevalence estimates suggest that BOS is likely underdiagnosed, and when severe BOS does occur, current treatments have been largely ineffective. Prevention and effective novel approaches remain the primary tools in the clinician's arsenal in managing BOS. This article provides an overview of the currently available and novel strategies for BOS, and we also discuss specific preventive interventions to reduce severe BOS after allo-HSCT. Therapeutic trials continue to be needed for this orphan disease.
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Affiliation(s)
- Salyka M Sengsayadeth
- Section of Hematology and Stem Cell Transplantation, Division of Hematology/Oncology, Department of Medicine, Vanderbilt-Ingram Cancer Center, Nashville, TN 37232, USA
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22
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Soluble tumor necrosis factor receptor: enbrel (etanercept) for subacute pulmonary dysfunction following allogeneic stem cell transplantation. Biol Blood Marrow Transplant 2011; 18:1044-54. [PMID: 22155140 DOI: 10.1016/j.bbmt.2011.11.031] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Accepted: 11/27/2011] [Indexed: 12/23/2022]
Abstract
Subacute lung disease, manifested as either obstructive (OLD) or restrictive (RLD) lung dysfunction, is a common complication following allogeneic stem cell transplantation. In each case, therapeutic options are limited, morbidity remains high, and long-term survival is poor. Between 2001 and 2008, 34 patients with noninfectious, obstructive (25) or RLD restrictive lung dysfunction (nine) received etanercept (Enbrel®, Amgen Inc.) 0.4 mg/kg/dose, subcutaneously, twice weekly, for 4 (group A) or 12 weeks (group B). Corticosteroids (if present at study entry) were kept constant for the initial 4 weeks of therapy and then tapered as tolerated. Thirty-one of 34 (91%) subjects were evaluable for response, and 10 (32%) met primary response criteria. There was no difference in response based on the duration of treatment (29% group A versus 35% group B; P = .99), the presence of RLD or OLD (33% versus 32%; P = .73), or the severity of pulmonary disease at study onset. Estimated 5-year overall survival rates following therapy were 61% (95% confidence interval, 46%-80%) for all subjects and 90% (95% confidence level, 73%-100%) for the 10 who met the primary response criteria. Five-year survival estimates for subjects treated with RLD was 44%, compared with 67% for those treated for OLD (P = .19). Etanercept was well tolerated, with no bacteremia or viremia observed. Pathogens were noted on posttherapy bronchoalveolar lavage in two cases. These data support the development of expanded clinical trials to study etanercept as a therapeutic agent for subacute lung injury after allogeneic stem cell transplantation.
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23
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Hildebrandt GC, Fazekas T, Lawitschka A, Bertz H, Greinix H, Halter J, Pavletic SZ, Holler E, Wolff D. Diagnosis and treatment of pulmonary chronic GVHD: report from the consensus conference on clinical practice in chronic GVHD. Bone Marrow Transplant 2011; 46:1283-95. [PMID: 21441964 PMCID: PMC7094778 DOI: 10.1038/bmt.2011.35] [Citation(s) in RCA: 130] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2010] [Revised: 11/12/2010] [Accepted: 11/16/2010] [Indexed: 01/03/2023]
Abstract
This consensus statement established under the auspices of the German working group on BM and blood stem cell transplantation (DAG-KBT), the German Society of Hematology and Oncology (DGHO), the Austrian Stem Cell Transplant Working Group, the Swiss Blood Stem Cell Transplantation Group (SBST) and the German-Austrian Pediatric Working Group on SCT (Päd-Ag-KBT) summarizes current evidence for diagnosis, immunosuppressive and supportive therapy to provide practical guidelines for the care and treatment of patients with pulmonary manifestations of chronic GVHD (cGVHD). Pulmonary cGVHD can present with obstructive and/or restrictive changes. Disease severity ranges from subclinical pulmonary function test (PFT) impairment to respiratory insufficiency with bronchiolitis obliterans being the only pulmonary complication currently considered diagnostic of cGVHD. Early diagnosis may improve clinical outcome, and regular post-transplant follow-up PFTs are recommended. Diagnostic work-up includes high-resolution computed tomography, bronchoalveolar lavage and histology. Topical treatment is based on inhalative steroids plus beta-agonists. Early addition of azithromycin is suggested. Systemic first-line treatment consists of corticosteroids plus, if any, continuation of other immunosuppressive therapy. Second-line therapy and beyond includes extracorporeal photopheresis, mammalian target of rapamycin inhibitors, mycophenolate, etanercept, imatinib and TLI, but efficacy is limited. Clinical trials are urgently needed to improve understanding and treatment of this deleterious complication.
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Affiliation(s)
- G C Hildebrandt
- Department of Hematology and Oncology, University of Regensburg Medical Center, Regensburg, Germany.
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24
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Lemonnier F, Dhedin N, Catherinot E, Tcherakian C, Neveu H, Suarez F, Becquemin MH, Devillier P, Vernant JP, Couderc LJ, Rivaud E. [Bronchiolitis obliterans postallogeneic stem cell transplantation: what is new?]. REVUE DE PNEUMOLOGIE CLINIQUE 2011; 67:258-266. [PMID: 21920287 DOI: 10.1016/j.pneumo.2011.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/06/2011] [Indexed: 05/31/2023]
Abstract
Bronchiolitis obliterans (BO) is a severe complication of hematopoietic stem cell transplantation (HSCT). It is considered as a respiratory manifestation of chronic graft-versus-host disease. It is quite similar to the bronchiolitis obliterans after lung transplantation. Classical therapy associates steroids and immunosuppressive drugs, however theses procedure showed a modest efficacy and have an important morbidity. Recent progresses in the physiopathology of BO post-HSCT allow to use new treatments: mTOR inhibitors, immunotherapy, extra-corporeal photochemotherapy, and bronchial anti-inflammatory effects of azithromycin, statins or antileucotriens. This review will focus on the use of these new therapies in BO post-HSCT.
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Affiliation(s)
- F Lemonnier
- Service dePneumologie, Hôpital Foch, 40, rue Worth, 92150 Suresnes, France.
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25
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Uhlving HH, Buchvald F, Heilmann CJ, Nielsen KG, Gormsen M, Müller KG. Bronchiolitis obliterans after allo-SCT: clinical criteria and treatment options. Bone Marrow Transplant 2011; 47:1020-9. [PMID: 21874057 DOI: 10.1038/bmt.2011.161] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Bronchiolitis obliterans (BO) following allogeneic haematopoietic SCT (HSCT) is a serious complication affecting 1.7-26% of the patients, with a reported mortality rate of 21-100%. It is considered a manifestation of chronic graft-versus-host disease, but our knowledge of aetiology and pathogenesis is still limited. Diagnostic criteria are being developed, and will allow more uniform and comparable research activities between centres. At present, no randomised controlled trials have been completed that could demonstrate an effective treatment. Steroids in combination with other immunosuppressive drugs still constitute the backbone of the treatment strategy, and results from our and other centres suggest that monthly infusions of high-dose pulse i.v. methylprednisolone (HDPM) might stabilise the disease and hinder progression. This article provides an overview of the current evidence regarding treatment options for BO and presents the treatment results with HDPM in a paediatric national HSCT-cohort.
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Affiliation(s)
- H H Uhlving
- Paediatric Clinic, National University Hospital Rigshospitalet, Blegdamsvej 9, Copenhagen, Denmark.
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26
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Verleden GM, Verleden SE, Vos R, De Vleeschauwer SI, Dupont LJ, Van Raemdonck DE, Vanaudenaerde BM. Montelukast for bronchiolitis obliterans syndrome after lung transplantation: a pilot study. Transpl Int 2011; 24:651-6. [DOI: 10.1111/j.1432-2277.2011.01248.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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27
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Fluticasone, azithromycin and montelukast therapy in reducing corticosteroid exposure in bronchiolitis obliterans syndrome after allogeneic hematopoietic SCT: a case series of eight patients. Bone Marrow Transplant 2010; 46:1369-73. [PMID: 21132024 PMCID: PMC3987109 DOI: 10.1038/bmt.2010.311] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Bronchiolitis obliterans syndrome (BOS) is a devastating pulmonary complication affecting long-term survivors of allogeneic hematopoietic cell transplantation. Treatment of BOS with prolonged courses of high dose corticosteroids is often associated with significant morbidity. Reducing the exposure to corticosteroids may reduce treatment-related morbidity. Our institution has recently begun to treat patients with emerging therapies in an effort to diminish corticosteroid exposure. We retrospectively reviewed the 6-month corticosteroid exposure, lung function and failure rates in eight patients with newly diagnosed BOS who were treated with a combination of fluticasone, azithromycin and montelukast (FAM) and a rapid corticosteroid taper. These patients were compared with 14 matched historical patients who received high-dose corticosteroids, followed by a standard taper. The median 6-month prednisone exposure in FAM-treated patients was 1819 mg (0-4036 mg) compared with 7163 mg (6551-7829 mg) in the control group (P=0.002). The median forced expiratory volume in 1 s (FEV(1)) change in FAM-treated patients was 2% (-3 to 4%] compared with 1% (-4 to 5%) in the control group (P=1.0). Prednisone exposure in FAM patients was one quarter that of a retrospective-matched group of patients, with minimal change in median FEV(1), suggesting that BOS may be spared of the morbidities associated with long-term corticosteroid use by using alternative agents with less side effects.
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28
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Lucid CE, Savani BN, Engelhardt BG, Shah P, Clifton C, Greenhut SL, Vaughan LA, Kassim A, Schuening F, Jagasia M. Extracorporeal photopheresis in patients with refractory bronchiolitis obliterans developing after allo-SCT. Bone Marrow Transplant 2010; 46:426-9. [PMID: 20581885 DOI: 10.1038/bmt.2010.152] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Extracorporeal photopheresis (ECP) has been shown to be a promising treatment for chronic graft-versus-host disease; however, only a few case reports are available that examine the effectiveness of ECP for bronchiolitis obliterans (BO) after allo-SCT. Because of the poor response to traditional therapies, ECP has been explored as a possible therapeutic option for severe BO after allo-SCT. Nine patients received ECP between July 2008 and August 2009 after a median follow-up of 23 months (range 9-93 months) post transplant. The primary indication for ECP was the development of BO in patients who had failed prior multidrug regimens. The median number of drugs used for BO management before ECP was 5 (range 2-7); this included immunosuppressive therapy. Six of nine (67%) patients responded to ECP after a median of 25 days (range 20-958 days). No ECP-related complications occurred. ECP seemed to stabilize rapidly declining pulmonary function tests in about two-thirds of patients with severe and heavily pretreated BO that developed after allo-SCT. This finding supports the need for a larger prospective study to confirm the impact of ECP on BO, and to consider earlier intervention with ECP to improve the outcome of BO after allo-SCT.
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Affiliation(s)
- C E Lucid
- Long-Term Follow-up Transplant Clinic, Hematology and Stem Cell Transplantation Section, Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN-37232-5505, USA
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29
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Bronchiolitis obliterans syndrome after allogeneic hematopoietic stem cell transplantation-an increasingly recognized manifestation of chronic graft-versus-host disease. Biol Blood Marrow Transplant 2009; 16:S106-14. [PMID: 19896545 DOI: 10.1016/j.bbmt.2009.11.002] [Citation(s) in RCA: 136] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Bronchiolitis obliterans syndrome (BOS) is a progressive, insidious, and often fatal lung alloreaction that can occur following allogeneic hematopoietic stem cell transplantation (HSCT) or allogeneic lung transplantation. Current estimates in the literature suggest that approximately 2% to 3% of all allogeneic HSCT recipients and 6% of patients who develop chronic graft-versus-host disease (cGVHD) will develop this syndrome. However, based on newer data it is likely that the true incidence of BOS is higher. Unfortunately, the survival and treatment of patients with BOS after HSCT has not improved over the last 20 years. Attempts at clinical trials have been hindered by the lack of uniform diagnostic criteria and inability to detect the syndrome at a reversible stage in its natural history. Recently, the National Institutes of Health (NIH) consensus project for criteria in cGVHD has made recommendations regarding the diagnosis of BOS and monitoring of lung disease among long-term survivors. Although a rare and poorly understood manifestation of cGVHD, BOS occurs commonly after lung transplantation and is similar in pathology, clinical presentation, radiographic presentation, and presumed immunologic pathogenesis. This review describes the current understanding of the epidemiology and pathogenesis of BOS and presents information on evaluations and therapies for patients with BOS after HSCT.
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30
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Williams KM, Chien JW, Gladwin MT, Pavletic SZ. Bronchiolitis obliterans after allogeneic hematopoietic stem cell transplantation. JAMA 2009; 302:306-14. [PMID: 19602690 PMCID: PMC7357209 DOI: 10.1001/jama.2009.1018] [Citation(s) in RCA: 158] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
With improvements in supportive care, both long-term survival following allogeneic hematopoietic stem cell transplantations (HSCTs) and the indications for this procedure have increased. As a result, the number of patients living with long-term toxic effects due to HSCT has increased. A once rare condition of the donor immune cells attacking healthy host tissues, termed chronic graft-vs-host disease, has become a more common phenomenon. When chronic graft-vs-host disease affects the lung tissue, bronchiolitis obliterans syndrome ensues. Recent data suggest that bronchiolitis obliterans syndrome may affect up to 6% of HSCT recipients and dramatically alters survival, with overall survival of only 13% at 5 years. These statistics have not improved since the first presentation of this disease over 20 years ago. Challenges to the progress of medical management of bronchiolitis obliterans syndrome include difficulties and delays in diagnosis and a paucity of data on pathogenesis to direct new therapies. This article critically evaluates the current diagnostic criteria for bronchiolitis obliterans syndrome and reviews the epidemiology, pathogenesis, and available treatments. Improvements in survival will likely require early disease recognition, allowing for therapeutic modulation of disease prior to the development of irreversible airway obliteration.
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Affiliation(s)
- Kirsten M Williams
- Experimental Transplantation and Immunology Branch, National Cancer Institute, Bldg 10 CRC, Room 3-3288, 10 Center Dr, Bethesda, MD 20892, USA.
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Affiliation(s)
- Paul J Martin
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA.
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32
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Abstract
Hematopoietic-cell transplantation (HCT) has become applicable to a broader range of ages and underlying diagnoses through advances in the utilization of alternative donors and stem-cell sources, reduced-intensity preparative regimens, and improved supportive care. The reduction in early transplant-related mortality means that more survivors will potentially develop chronic graft-versus-host disease (cGVHD) and associated late effects. Recipients of HCT are at risk for late end-organ dysfunction as a complication of chemoradiotherapy given before HCT, but disturbances are often multifactorial. This review focuses on problems arising predominantly as a result of cGVHD and its therapies. Disabilities caused by severe or inadequately treated cGVHD include keratoconjunctivitis sicca, bronchiolitis obliterans, skin ulcers, joint contractures, esophageal and vaginal stenosis, osteoporosis, avascular necrosis, and others. Almost all organ systems may be involved, and a broad approach is needed to allow recognition and anticipation of problems so that prevention or early intervention is possible.
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Affiliation(s)
- Paul A Carpenter
- Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue N, Mailstop D5-290, Seattle, WA 98107, USA.
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