1
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Oechsler S, Gagelmann N, Wolschke C, Janson D, Badbaran A, Klyuchnikov E, Massoud R, Rathje K, Richter J, Schäfersküpper M, Niederwieser C, Kunte A, Heidenreich S, Ayuk F, Kröger N. Graft-versus-host disease and impact on relapse in myelofibrosis undergoing hematopoietic stem cell transplantation. Bone Marrow Transplant 2024; 59:550-557. [PMID: 38321269 PMCID: PMC10994836 DOI: 10.1038/s41409-024-02220-7] [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: 11/19/2023] [Revised: 01/12/2024] [Accepted: 01/19/2024] [Indexed: 02/08/2024]
Abstract
Allogeneic hematopoietic stem cell transplantation (alloHSCT) remains the only curative treatment for myelofibrosis (MF). Relapse occurs in 10-30% and remains a major factor for dismal outcomes. Previous work suggested that graft-versus-host disease (GVHD) might be associated with risk of relapse. This study included 341 patients undergoing their first (n = 308) or second (n = 33) alloHSCT. Anti-T-lymphocyte or antithymocyte globulin was used for GVHD prophylaxis in almost all patients. Median time to neutrophile and platelet engraftment was 13 days and 19 days, respectively. The cumulative incidence of acute GVHD grade II-IV was 41% (median, 31 days; range, 7-112). Grade III-IV acute GVHD was observed in 22%. The cumulative incidence of chronic GVHD was 61%. Liver was affected in 23% of acute GVHD cases and 46% of chronic GVHD cases. Severe acute GVHD was associated with high non-relapse mortality. The development of acute GVHD grade II and moderate GVHD was an independent factor for reduced risk for relapse after transplantation without increased risk for non-relapse mortality, while especially acute GVHD grade IV was associated with high non-relapse mortality. Last, we identified that ongoing response to ruxolitinib, accelerated-phase MF at time of transplantation and splenectomy prior to transplantation were independent predictors for relapse.
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Affiliation(s)
- Sofia Oechsler
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nico Gagelmann
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | | | - Anita Badbaran
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Radwan Massoud
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kristin Rathje
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Johanna Richter
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | | | - Ameya Kunte
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Francis Ayuk
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nicolaus Kröger
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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2
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Smallbone P, Louw A, Purtill D. Laboratory methods of monitoring disease response after allogeneic haematopoietic stem cell transplantation for myelofibrosis. Pathology 2024; 56:24-32. [PMID: 38071159 DOI: 10.1016/j.pathol.2023.10.003] [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: 07/08/2023] [Revised: 09/10/2023] [Accepted: 10/06/2023] [Indexed: 01/24/2024]
Abstract
The era of molecular prognostication in myelofibrosis has allowed comprehensive assessment of disease risk and informed decisions regarding allogeneic haematopoietic stem cell transplantation (HSCT). However, monitoring disease response after transplantation is difficult, and limited by disease and sample-related factors. The emergence of laboratory techniques sensitive enough to monitor measurable residual disease is promising in predicting molecular and haematological relapse and guiding management. This paper summarises the existing literature regarding methods for detecting and monitoring disease response after HSCT in myelofibrosis and explores the therapeutic use of measurable residual disease (MRD) assays in transplant recipients. Laboratory assessment of disease response in myelofibrosis post-allogeneic transplant is limited by disease and treatment characteristics and by the sensitivity of available conventional molecular assays. The identification of MRD has prognostic implications and may allow early intervention to prevent relapse. Further applicability is limited by mutation-specific assay variability, a lack of standardisation and sample considerations.
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Affiliation(s)
- Portia Smallbone
- Department of Haematology, Fiona Stanley Hospital, Perth, WA, Australia; PathWest, Fiona Stanley Hospital, Perth, WA, Australia.
| | - Alison Louw
- PathWest, Fiona Stanley Hospital, Perth, WA, Australia
| | - Duncan Purtill
- Department of Haematology, Fiona Stanley Hospital, Perth, WA, Australia; PathWest, Fiona Stanley Hospital, Perth, WA, Australia
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3
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Kröger N, Bacigalupo A, Barbui T, Ditschkowski M, Gagelmann N, Griesshammer M, Gupta V, Hamad N, Harrison C, Hernandez-Boluda JC, Koschmieder S, Jain T, Mascarenhas J, Mesa R, Popat UR, Passamonti F, Polverelli N, Rambaldi A, Robin M, Salit RB, Schroeder T, Scott BL, Tamari R, Tefferi A, Vannucchi AM, McLornan DP, Barosi G. Indication and management of allogeneic haematopoietic stem-cell transplantation in myelofibrosis: updated recommendations by the EBMT/ELN International Working Group. Lancet Haematol 2024; 11:e62-e74. [PMID: 38061384 DOI: 10.1016/s2352-3026(23)00305-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 09/26/2023] [Accepted: 10/03/2023] [Indexed: 12/24/2023]
Abstract
New options for medical therapy and risk scoring systems containing molecular data are leading to increased complexity in the management of patients with myelofibrosis. To inform patients' optimal care, we updated the 2015 guidelines on indications for and management of allogeneic haematopoietic stem-cell transplantation (HSCT) with the support of the European Society for Blood and Marrow Transplantation (EBMT) and European LeukemiaNet (ELN). New recommendations were produced using a consensus-building methodology after a comprehensive review of articles released from January, 2015 to December, 2022. Seven domains and 18 key questions were selected through a series of questionnaires using a Delphi process. Key recommendations in this update include: patients with primary myelofibrosis and an intermediate-2 or high-risk Dynamic International Prognostic Scoring System score, or a high-risk Mutation-Enhanced International Prognostic Score Systems (MIPSS70 or MIPSS70-plus) score, or a low-risk or intermediate-risk Myelofibrosis Transplant Scoring System score should be considered candidates for allogeneic HSCT. All patients who are candidates for allogeneic HSCT with splenomegaly greater than 5 cm below the left costal margin or splenomegaly-related symptoms should receive a spleen-directed treatment, ideally with a JAK-inhibitor; HLA-matched sibling donors remain the preferred donor source to date. Reduced intensity conditioning and myeloablative conditioning are both valid options for patients with myelofibrosis. Regular post-transplantation driver mutation monitoring is recommended to detect and treat early relapse with donor lymphocyte infusion. In a disease where evidence-based guidance is scarce, these recommendations might help clinicians and patients in shared decision making.
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Affiliation(s)
- Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Andrea Bacigalupo
- Department of Hematology, Fondazione Policlinico Universitario Gemelli IRCCS, Universita' Cattolica del Sacro Cuore, Rome, Italy
| | - Tiziano Barbui
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Markus Ditschkowski
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital of Essen, Essen, Germany
| | - Nico Gagelmann
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Griesshammer
- University Clinic for Hematology, Oncology, Haemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, University of Bochum, Bochum, Germany
| | - Vikas Gupta
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Nada Hamad
- School of Clinical Medicine, Faculty of Medicine and Health, UNSW Sydney, Sydney, NSW, Australia; Department of Haematology, St Vincent's Hospital, Sydney, NSW, Australia; School of Medicine, University of Notre Dame, Sydney, NSW, Australia
| | | | | | - Steffen Koschmieder
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf, Aachen, Germany; Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
| | - Tania Jain
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA
| | - John Mascarenhas
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ruben Mesa
- Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC, USA
| | - Uday R Popat
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Francesco Passamonti
- Università degli Studi di Milano; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nicola Polverelli
- Division of Hematology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Alessandro Rambaldi
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy; Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Marie Robin
- Department of Hematology, University Hospital of Saint Louis, Paris, France
| | | | - Thomas Schroeder
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital of Essen, Essen, Germany
| | | | - Roni Tamari
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ayalew Tefferi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Alessandro M Vannucchi
- Centro Ricerca e Innovazione delle Malattie Mieloproliferative, Azienda Ospedaliera-Universitaria Careggi, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Donal P McLornan
- Department of Haematology and Stem Cell Transplantation, University College London Hospitals NHS Trust, London, UK
| | - Giovanni Barosi
- Center for the Study of Myelofibrosis, IRCCS Policlinico S Matteo, Pavia, Italy
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4
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Kröger N, Wolschke C, Gagelmann N. How I treat transplant-eligible patients with myelofibrosis. Blood 2023; 142:1683-1696. [PMID: 37647853 DOI: 10.1182/blood.2023021218] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 08/14/2023] [Accepted: 08/18/2023] [Indexed: 09/01/2023] Open
Abstract
Despite the approval of Janus kinase inhibitors and novel agents for patients with myelofibrosis (MF), disease-modifying responses remain limited, and hematopoietic stem cell transplantation (HSCT) remains the only potentially curative treatment option. The number of HSCTs for MF continues to increase worldwide, but its inherent therapy-related morbidity and mortality limit its use for many patients. Furthermore, patients with MF often present at an older age, with cytopenia, splenomegaly, and severe bone marrow fibrosis, posing challenges in managing them throughout the HSCT procedure. Although implementation of molecular analyses enabled improved understanding of disease mechanisms and subsequently sparked development of novel drugs with promising activity, prospective trials in the HSCT setting are often lacking, making an evidence-based decision process particularly difficult. To illustrate how we approach patients with MF with respect to HSCT, we present 3 different clinical scenarios to capture relevant aspects that influence our decision making regarding indication for, or against, HSCT. We describe how we perform HSCT according to different risk categories and, furthermore, discuss our up-to-date approach to reduce transplant-related complications. Last, we show how to harness graft-versus-MF effects, particularly in the posttransplant period to achieve the best possible outcomes for patients.
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Affiliation(s)
- Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christine Wolschke
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nico Gagelmann
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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5
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Rampotas A, Sockel K, Panitsas F, Theuser C, Bornhauser M, Hernani R, Hernandez-Boluda JC, Esquirol A, Avenoso D, Tsirigotis P, Robin M, Czerw T, Helbig G, Roddie C, Lambert J, McLornan DP. Adoptive Immunotherapy via Donor Lymphocyte Infusions following Allogeneic Hematopoietic Stem Cell Transplantation for Myelofibrosis: A Real-World, Retrospective Multicenter Study. Transplant Cell Ther 2023; 29:687.e1-687.e7. [PMID: 37633414 DOI: 10.1016/j.jtct.2023.08.020] [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: 04/06/2023] [Revised: 08/14/2023] [Accepted: 08/18/2023] [Indexed: 08/28/2023]
Abstract
Allogeneic hematopoietic cell transplantation (allo-HCT) remains the sole curative option for myelofibrosis (MF). Relapse remains a significant problem, however, occurring in up to 20% to 30% of cases. Donor lymphocyte infusion (DLI) represents a potentially effective strategy for relapse prevention and management, but the optimal timing based on measurable residual disease/chimerism analyses and the choice of regimen remain undetermined. We performed a retrospective real-world analysis of a multicenter cohort of MF allo-HCT recipients from 8 European transplantation centers who received DLI between 2005 and 2022. Response was assessed using International Working Group-Myeloproliferative Neoplasms Research and Treatment-defined response criteria, and survival endpoints were estimated using the Kaplan-Meier estimator and log-rank test. The study included 28 patients with a median age of 58 years and a Karnofsky Performance Status of >80. The majority of patients had Dynamic International Prognostic Scoring System-plus intermediate-2 or high-risk disease at the time of allo-HCT. In vivo T cell depletion was used in 20 patients (71.2%), with 19 of the 20 receiving antithymocyte globulin. The indication for DLI was either "preemptive" (n = 15), due to a decrease in recipient chimerism (n = 13) or molecular relapse (n = 2), or "therapeutic" (n = 13) for clinician-defined hematologic/clinical relapse. No patient received DLI prophylactically. The median time of DLI administration was 23.4 months post allo-HCT. Of the 16 patients receiving multiple DLIs, 12 were part of a planned escalating dose regimen. The median follow-up from the time of first DLI was 55.4 months. The responses to DLI were complete response in 9 patients, partial response in 1 patient, and clinical improvement in 6 patients. Chimerism levels improved in 16 patients, and stable disease was reported in 5 patients. No response or progression was reported in 7 patients. DLI-induced acute graft-versus-host disease (aGVHD) was reported in 11 patients (39%), with grade III-IV aGVHD in 7 (25%). The median overall survival from the time of first DLI was 62.6 months, and the cumulative incidence of relapse/progression after first DLI was 30.8% at 6 months. This study highlights that good response rates can be achieved with DLI even after frank relapse in some patients in a cohort in which other treatment options are very limited. More prospective studies are warranted to identify the optimal DLI regimen and timing to improve patient outcomes.
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Affiliation(s)
- Alexandros Rampotas
- Department of Haematology and Cell Therapy, University College London Hospital NHS Foundation Trust, London, United Kingdom.
| | - Katja Sockel
- Medical Clinic and Policlinic I, University Hospital Dresden, TU Dresden, Germany
| | - Fotios Panitsas
- Department of Haematology, Laikon University Hospital, Athens, Greece
| | - Catrin Theuser
- Medical Clinic and Policlinic I, University Hospital Dresden, TU Dresden, Germany
| | - Martin Bornhauser
- Medical Clinic and Policlinic I, University Hospital Dresden, TU Dresden, Germany
| | - Rafael Hernani
- Haematology Department, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | | | - Albert Esquirol
- Department of Haematology, Hospital de la Santa creu i Sant Pau and Universitat Autonoma de Barcelona, Spain
| | - Daniele Avenoso
- Department of Haematology, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | | | - Marie Robin
- Service d'Hématologie-Greffe, Hôpital Saint-Louis, APHP, Université de Paris Cité, Paris, France
| | - Tomasz Czerw
- Department of Haematology and Bone Marrow Transplantation, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice, Poland
| | - Grzegorz Helbig
- Department of Hematology and Bone Marrow Transplantation, Medical University of Silesia, Katowice, Poland
| | - Claire Roddie
- Department of Haematology and Cell Therapy, University College London Hospital NHS Foundation Trust, London, United Kingdom
| | - Jonathan Lambert
- Department of Haematology and Cell Therapy, University College London Hospital NHS Foundation Trust, London, United Kingdom
| | - Donal P McLornan
- Department of Haematology and Cell Therapy, University College London Hospital NHS Foundation Trust, London, United Kingdom
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6
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Gagelmann N, Wolschke C, Badbaran A, Janson D, Berger C, Klyuchnikov E, Ayuk F, Fehse B, Kröger N. Donor Lymphocyte Infusion and Molecular Monitoring for Relapsed Myelofibrosis After Hematopoietic Cell Transplantation. Hemasphere 2023; 7:e921. [PMID: 37404772 PMCID: PMC10317484 DOI: 10.1097/hs9.0000000000000921] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 05/23/2023] [Indexed: 07/06/2023] Open
Abstract
Hematopoietic cell transplantation (HCT) is a curative approach for myelofibrosis patients, but relapse is a major cause of treatment failure. We investigated the effect of donor lymphocyte infusion (DLI) in 37 patients with molecular (n = 17) or hematological relapse (n = 20) after HCT. Patients received median of 2 (range, 1-5) cumulative DLI (total of 91 infusions). Median starting dose was 1 × 106 cells/kg, escalated by half-log ≥6 weeks if no response nor graft-versus-host disease (GvHD) occurred. Median time to first DLI was 40 weeks for molecular relapse versus 145 weeks for hematological relapse. Overall molecular complete response (mCR) at any time was 73% (n = 27) and was significantly higher for initial molecular relapse (88%) versus hematological relapse (60%; P = 0.05). The 6-year overall survival was 77% versus 32% (P = 0.03). Acute GvHD 2-4 occurred in 22% and half of the patients achieved mCR without any GvHD. All patients who relapsed from mCR achieved after first DLI could be salvaged with subsequent DLI, showing long-term survival. No second HCT was needed for molecular relapse versus 6 for hematological relapse. This comprehensive and largest study to date suggests molecular monitoring together with DLI as standard of care and a crucial approach to achieve excellent outcomes in relapsed myelofibrosis.
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Affiliation(s)
- Nico Gagelmann
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christine Wolschke
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anita Badbaran
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Dietlinde Janson
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Carolina Berger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Evgeny Klyuchnikov
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Boris Fehse
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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7
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Lee JM, Ahn A, Min EJ, Lee SE, Kim M, Kim Y. Monitoring measurable residual disease and chimerism in patients with JAK2 V617F-positive myelofibrosis after allogeneic hematopoietic cell transplantation. Blood Cancer J 2023; 13:97. [PMID: 37365186 DOI: 10.1038/s41408-023-00867-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 05/03/2023] [Accepted: 05/16/2023] [Indexed: 06/28/2023] Open
Affiliation(s)
- Jong-Mi Lee
- Department of Laboratory Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Catholic Genetic Laboratory Center, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ari Ahn
- Catholic Genetic Laboratory Center, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Department of Laboratory Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Eun Jeong Min
- Department of Medical Life Sciences, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sung-Eun Lee
- Department of Hematology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
- Leukemia Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Myungshin Kim
- Department of Laboratory Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
- Catholic Genetic Laboratory Center, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Yonggoo Kim
- Department of Laboratory Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Catholic Genetic Laboratory Center, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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8
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Hernández-Boluda JC, Czerw T. Transplantation algorithm for myelofibrosis in 2022 and beyond. Best Pract Res Clin Haematol 2022; 35:101369. [DOI: 10.1016/j.beha.2022.101369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 07/27/2022] [Indexed: 11/16/2022]
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9
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Gagelmann N, Kröger N. Improving allogeneic stem cell transplantation in myelofibrosis. Int J Hematol 2022; 115:619-625. [PMID: 35419771 DOI: 10.1007/s12185-022-03340-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 03/22/2022] [Accepted: 03/27/2022] [Indexed: 11/30/2022]
Abstract
In this review, we will outline dimensions in which outcome of patients with myelofibrosis undergoing curative treatment can be optimized: patient selection, transplant procedure, and posttransplant prevention or treatment of relapse. For patient selection, fortunately, as with several other hematologic malignancies, the management of patients with myelofibrosis has very much entered the molecular era, with the establishment of several driver and nondriver mutations, allowing more individualized selection for treatment. For the transplant procedure itself, different conditioning intensities do not seem to play a distinctive role with regards to outcome posttransplant but still need to be compared in the molecular era. While many patients nowadays may receive ruxolitinib before transplant, recent studies may facilitate fine-tuning and integration of ruxolitinib into the transplant algorithm. The role of novel inhibitors for the transplant setting remains unclear. For the posttransplant phase, evidence remains scarce, with experiences of donor-lymphocyte infusions for relapse management but more efforts are needed in understanding relapse and identifying and treating patients at high risk for relapse.
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Affiliation(s)
- Nico Gagelmann
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistr 52, 20246, Hamburg, Germany
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistr 52, 20246, Hamburg, Germany.
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10
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Reduced intensity hematopoietic stem cell transplantation for myelofibrosis in accelerated-phase. Blood Adv 2022; 6:1222-1231. [PMID: 35051996 PMCID: PMC8864646 DOI: 10.1182/bloodadvances.2021006827] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 01/06/2022] [Indexed: 11/20/2022] Open
Abstract
Results of this first report in accelerated-phase myelofibrosis may encourage clinicians to refer these patients for curative treatment. Accelerated-phase myelofibrosis without prior cytoreduction showed excellent 5-year survival (65%) but higher relapse vs chronic phase.
Accelerated-phase myelofibrosis, currently defined by circulating blasts 10% to 19%, usually confers very high risk for progression and poor outcome. The outcome of hematopoietic stem cell transplantation for accelerated-phase myelofibrosis has not been evaluated yet. We analyzed the outcome of 349 clinically and genetically annotated patients with primary or secondary myelofibrosis undergoing reduced intensity transplantation, of whom 35 had accelerated-phase myelofibrosis. In comparison with chronic-phase (<10% blasts) myelofibrosis, median leukocyte counts were higher, more patients had constitutional symptoms, and RAS mutations were detected more frequently in the accelerated-phase group. After a median follow-up of 5.9 years, estimated 5-year overall survival was 65% (95% confidence interval [CI], 49% to 81%) vs 64% (95% CI, 59% to 69%) for the chronic-phase group (P = .91), and median overall survival was not reached. In terms of relapse-free survival, estimated 5-year outcome for the accelerated-phase group was 49% (95% CI, 32% to 67%) vs 55% (95% CI, 50% to 61%) for the chronic-phase group (P = .65). Estimated 5-year nonrelapse mortality was 20% (95% CI, 8% to 33%) for the accelerated-phase group vs 30% (95% CI, 24% to 35%; P = .25) for the chronic-phase group. In terms of relapse, 5-year incidence was 30% (95% CI, 14% to 46%) for the accelerated-phase group vs 15% (95% CI, 11% to 19%) for the chronic-phase group (P = .02). Results were confirmed in multivariable analysis and propensity score matching. In conclusion, reduced intensity transplantation showed excellent survival but higher relapse for accelerated-phase myelofibrosis.
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11
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Khanlari M, Wang X, Loghavi S, Wang SA, Li S, Thakral B, Bueso-Ramos CE, Yin CC, Kanagal-Shamanna R, Khoury JD, Patel KP, Popat UR, Medeiros LJ, Konoplev S. Value and pitfalls of assessing bone marrow morphologic findings to predict response in patients with myelofibrosis who undergo hematopoietic stem cell transplantation. Ann Diagn Pathol 2021; 56:151860. [PMID: 34823075 DOI: 10.1016/j.anndiagpath.2021.151860] [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: 11/01/2021] [Accepted: 11/11/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is a curative option for patients with myelofibrosis (MF). Bone marrow (BM) morphologic evaluation of myelofibrosis following allo-HSCT is known to be challenging in this context because resolution of morphologic changes is a gradual process. PATIENTS AND METHODS We compared BM samples of patients with myelofibrosis who underwent first allo-HSCT and achieved molecular remission by day 100 with BM samples of patients who continued to have persistent molecular evidence of disease following allo-HSCT. RESULTS The study group included 29 patients: 17 primary MF, 7 post-polycythemia vera (PV) MF, and 5 post-essential thrombocythemia (ET) MF. In this cohort there were 18 JAK2 p.V617F, 8 CALR; 1 MPL, and 2 patients had concurrent JAK2 p.V617F and MPL mutations. The control group included 5 patients with primary MF, one with post-PV MF, one with post-ET MF (5 JAK2 p.V617F; 2 CALR). Following allo-HSCT, both groups showed reduction in BM cellularity and number of megakaryocytes. The study cohort also less commonly had dense megakaryocyte clusters and endosteal located megakaryocytes and showed less fibrosis. There was no statistical difference in BM cellularity, presence of erythroid islands, degree of osteosclerosis, or megakaryocyte number, size, nuclear lobation, presence of clusters or intrasinusoidal location. CONCLUSIONS Following allo-HSCT at 100 days, morphologic evaluation of BM in patients with MF cannot reliably predict persistence versus clearance of molecular evidence of MF. Disappearance of BM MF, dense megakaryocyte clusters, and endosteal localization of megakaryocytes are suggestive of disease response.
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Affiliation(s)
- Mahsa Khanlari
- Departments of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Pathology and the Hematological Malignancies Program, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Xiaoqiong Wang
- Departments of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sanam Loghavi
- Departments of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sa A Wang
- Departments of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Shaoying Li
- Departments of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Beenu Thakral
- Departments of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Carlos E Bueso-Ramos
- Departments of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - C Cameron Yin
- Departments of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rashmi Kanagal-Shamanna
- Departments of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joseph D Khoury
- Departments of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Keyur P Patel
- Departments of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Uday R Popat
- Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - L Jeffrey Medeiros
- Departments of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sergej Konoplev
- Departments of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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12
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McLornan DP, Hernandez-Boluda JC, Czerw T, Cross N, Joachim Deeg H, Ditschkowski M, Moonim MT, Polverelli N, Robin M, Aljurf M, Conneally E, Hayden P, Yakoub-Agha I. Allogeneic haematopoietic cell transplantation for myelofibrosis: proposed definitions and management strategies for graft failure, poor graft function and relapse: best practice recommendations of the EBMT Chronic Malignancies Working Party. Leukemia 2021; 35:2445-2459. [PMID: 34040148 DOI: 10.1038/s41375-021-01294-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/04/2021] [Accepted: 05/07/2021] [Indexed: 01/31/2023]
Abstract
Allogeneic haematopoietic cell transplantation (allo-HCT) remains the only curative approach in myelofibrosis (MF). Despite advances over recent decades, relapse and non-relapse mortality rates remain significant. Relapse rates vary between 15 and 25% across retrospective studies and management strategies vary widely, ranging from palliation to adoptive immunotherapy and, in some cases, a second allo-HCT. Moreover, in allo-HCT, there is a higher incidence of poor graft function and graft failure due to splenomegaly and a hostile "pro-inflammatory" marrow niche. The Practice Harmonisation and Guidelines subcommittee of the Chronic Malignancies Working Party (CMWP) of EBMT convened an international panel consisting of transplant haematologists, histopathologists and molecular biologists to propose practical, clinically relevant definitions of graft failure, poor graft function and relapse as well as management strategies following allo-HCT. A systematic approach to molecular monitoring, histopathological assessment and chimerism testing is proposed. These proposed recommendations aim to increase the accuracy and uniformity of reporting and to thereby facilitate the development of more consistent approaches to these challenging issues. In addition, we propose management strategies for these complications.
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Affiliation(s)
- Donal P McLornan
- Department of Haematology, Guy's and St. Thomas' NHS Foundation Trust and University College Hospitals, London, UK.
| | | | - Tomasz Czerw
- Maria Sklodowska-Curie Institute, Gliwice, Poland
| | - Nicholas Cross
- National Genetics Reference Laboratory (Wessex), Salisbury District Hospital, Salisbury, UK
| | - H Joachim Deeg
- Fred Hutchinson Cancer Research Center and the University of Washington, Seattle, WA, USA
| | - Marcus Ditschkowski
- Department for Bone Marrow Transplantation, University of Essen, Essen, Germany
| | - Mufaddal T Moonim
- Department of Histopathology, Imperial College Healthcare NHS Trust, London, UK
| | - Nicola Polverelli
- Unit of Blood Diseases and Stem Cell Transplantation, Department of Clinical and Experimental Sciences-University of Brescia, ASST Spedali Civili, Brescia, Italy
| | - Marie Robin
- Hopital Saint-Louis, APHP, Université de Paris, Paris, France
| | - Mahmoud Aljurf
- Oncology Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | | | - Patrick Hayden
- Haematology Department, St. James Hospital, Dublin, Ireland
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13
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Srour SA, Olson A, Ciurea SO, Desai P, Bashir Q, Oran B, Bose P, Mehta R, Patel KP, Pemmaraju N, Daver N, Verstovsek S, Champlin RE, Popat UR. Mixed myeloid chimerism and relapse of myelofibrosis after allogeneic stem cell transplantation. Haematologica 2021; 106:1988-1990. [PMID: 31296578 PMCID: PMC8252931 DOI: 10.3324/haematol.2019.223503] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Indexed: 12/04/2022] Open
Affiliation(s)
| | - Amanda Olson
- The University of Texas MD Anderson Cancer Center
| | | | - Parth Desai
- The University of Texas Health Science Center at San Antonio
| | | | - Betul Oran
- The University of Texas, M.D. Anderson Cancer Center
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14
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Bacigalupo A, Innocenti I, Rossi E, Sora F, Galli E, Autore F, Metafuni E, Chiusolo P, Giammarco S, Laurenti L, Benintende G, Sica S, De Stefano V. Allogeneic Hemopoietic Stem Cell Transplantation for Myelofibrosis: 2021. Front Immunol 2021; 12:637512. [PMID: 34017327 PMCID: PMC8129535 DOI: 10.3389/fimmu.2021.637512] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 04/13/2021] [Indexed: 11/13/2022] Open
Abstract
The aim of this review is to update the current status of allogeneic hemopoietic stem cell transplants (HSCT) for patients with myelofibrosis (MF). We have first summarized the issue of an indication for allogeneic HSCT, discussing several prognostic scoring systems, developed to predict the outcome of MF, and therefore to identify patients who will benefit of an allogeneic HSCT. Patients with low risk MF are usually not selected for a transplant, whereas patients with intermediate or high risk MF are eligible. A separate issue, is how to predict the outcome of HSCT: we will outline a clinical molecular myelofibrosis transplant scoring system (MTSS), which predicts overall survival, ranging from 90% for low risk patients, to 20% for very high risk patients. We will also discuss transfusion burden and spleen size, as predictors of transplant outcome. The choice of a transplant platform including the conditioning regimen, the stem cell source and GvHD prophylaxis, are crucial for a successful program in MF, and will be outlined. Complications such as poor graft function, graft failure, GvHD and relapse of the disease, will also be reviewed. Finally we discuss monitoring the disease after HSCT with donor chimerism, driver mutations and hematologic data. We have made an effort to make this review as comprehensive and up to date as possible, and we hope it will provide some useful data for the clinicians.
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Affiliation(s)
- Andrea Bacigalupo
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy.,Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Idanna Innocenti
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Elena Rossi
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy.,Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Federica Sora
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy.,Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Eugenio Galli
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Francesco Autore
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Elisabetta Metafuni
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Patrizia Chiusolo
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy.,Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Sabrina Giammarco
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Luca Laurenti
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy.,Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Giulia Benintende
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Simona Sica
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy.,Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Valerio De Stefano
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy.,Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Roma, Italy
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15
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Savani M, Dulery R, Bazarbachi AH, Mohty R, Brissot E, Malard F, Bazarbachi A, Nagler A, Mohty M. Allogeneic haematopoietic cell transplantation for myelofibrosis: a real-life perspective. Br J Haematol 2021; 195:495-506. [PMID: 33881169 DOI: 10.1111/bjh.17469] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 03/19/2021] [Indexed: 01/12/2023]
Abstract
Myelofibrosis (MF) is a clonal stem cell neoplasm with heterogeneous clinical phenotypes and well-established molecular drivers. Allogeneic haematopoietic stem cell transplantation (HSCT) offers an important curative treatment option for primary MF and post-essential thrombocythaemia/polycythaemia vera MF or secondary MF. With a disease course that varies from indolent to highly progressive, we are now able to stratify risk of mortality through various tools including patient-related clinical characteristics as well as molecular genetic profile. Owing to the high risk of mortality and morbidity associated with HSCT for patients with myelofibrosis, it is important to improve patient selection for transplant. Our primary goal is to comprehensively define our understanding of current practices including the role of Janus Kinase (JAK) inhibitors, to present the data behind transplantation before and after leukaemic transformation, and to introduce novel personalization of MF treatment with a proposed clinical-molecular prognostic model to help elucidate a timepoint optimal for consideration of HSCT.
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Affiliation(s)
- Malvi Savani
- Division of Hematology and Oncology, University of Arizona Cancer Center, Tucson, AZ, USA
| | - Rémy Dulery
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France
| | - Abdul Hamid Bazarbachi
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France.,Department of Internal Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, New York, New York, USA
| | - Razan Mohty
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France.,Department of Internal Medicine, Bone Marrow Transplantation Program, American University of Beirut Medical Center, Beirut, Lebanon
| | - Eolia Brissot
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France
| | - Florent Malard
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France
| | - Ali Bazarbachi
- Department of Internal Medicine, Bone Marrow Transplantation Program, American University of Beirut Medical Center, Beirut, Lebanon
| | - Arnon Nagler
- Hematology Division, Chaim Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel
| | - Mohamad Mohty
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France
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16
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Nabergoj M, Mauff K, Robin M, Kröger N, Angelucci E, Poiré X, Passweg J, Radujkovic A, Platzbecker U, Robinson S, Rambaldi A, Petersen SL, Stölzel F, Stelljes M, Ciceri F, Mayer J, Ladetto M, de Wreede LC, Koster L, Hayden PJ, Czerw T, Hernández-Boluda JC, McLornan D, Chalandon Y, Yakoub-Agha I. Outcomes following second allogeneic haematopoietic cell transplantation in patients with myelofibrosis: a retrospective study of the Chronic Malignancies Working Party of EBMT. Bone Marrow Transplant 2021; 56:1944-1952. [PMID: 33824436 DOI: 10.1038/s41409-021-01271-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 02/10/2021] [Accepted: 03/10/2021] [Indexed: 11/09/2022]
Abstract
Therapeutic management of patients with primary or secondary myelofibrosis (MF) who experience relapse or graft failure following allogeneic haematopoietic cell transplantation (allo-HCT) remains heterogeneous. We retrospectively analyzed 216 patients undergoing a second allo-HCT for either relapse (56%) or graft failure (31%) between 2010 and 2017. Median age was 57.3 years (range 51-63). The same donor as for the first allo-HCT was chosen in 66 patients (31%) of whom 19 received an HLA-identical sibling donor, whereas a different donor was chosen for 116 patients (54%). Median follow-up was 40 months. Three-year overall survival (OS) and relapse-free survival (RFS) were 42% and 39%, respectively. Three-year non-relapse mortality (NRM) and relapse rates were 36% and 25%, respectively. Grade II-IV and III-IV acute GVHD occurred in 25% and 11% of patients, respectively, and the 3-year incidence of chronic GVHD was 33% including 14% for extensive grade. Graft-failure incidence at 1 year was 14%. In conclusion, our data suggest that a second allo-HCT is a potential option for patients failing first allo-HCT for MF albeit careful patient assessment is fundamental to identify individual patients who could benefit from this approach.
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Affiliation(s)
- Mitja Nabergoj
- Division of Hematology, Hôpitaux Universitaires De Genève and Faculty of Medicine, University of Geneva, Geneva, Switzerland.
| | - Katya Mauff
- EBMT Statistical Unit Date Office, Leiden, the Netherlands
| | - Marie Robin
- Hôpital Saint-Louis, APHP, Université Paris 7, Paris, France
| | | | - Emanuele Angelucci
- Ematologia e Centro Trapianti, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Xavier Poiré
- Cliniques Universitaires St. Luc, Brussels, Belgium
| | | | | | - Uwe Platzbecker
- Department of Hematology and Cellular Therapy, University Hospital of Leipzig, Leipzig, Germany
| | | | - Alessandro Rambaldi
- University of Milan and Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | | | | | | | | | - Jiri Mayer
- University Hospital Brno, Brno, Czech Republic
| | | | - Liesebeth C de Wreede
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Patrick J Hayden
- Department of Haematology, Trinity College Dublin, St. James's Hospital, Dublin, Ireland
| | - Tomasz Czerw
- Maria Skłodowska-Curie Institute - Cancer Center, Gliwice Branch, Gliwice, Poland
| | | | - Donal McLornan
- Department of Haematology, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Yves Chalandon
- Division of Hematology, Hôpitaux Universitaires De Genève and Faculty of Medicine, University of Geneva, Geneva, Switzerland
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17
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Handlos Grauslund J, Holmström MO, Jørgensen NG, Klausen U, Weis-Banke SE, El Fassi D, Schöllkopf C, Clausen MB, Gjerdrum LMR, Breinholt MF, Kjeldsen JW, Hansen M, Koschmieder S, Chatain N, Novotny GW, Petersen J, Kjær L, Skov V, Met Ö, Svane IM, Hasselbalch HC, Andersen MH. Therapeutic Cancer Vaccination With a Peptide Derived From the Calreticulin Exon 9 Mutations Induces Strong Cellular Immune Responses in Patients With CALR-Mutant Chronic Myeloproliferative Neoplasms. Front Oncol 2021; 11:637420. [PMID: 33718228 PMCID: PMC7952976 DOI: 10.3389/fonc.2021.637420] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 01/18/2021] [Indexed: 12/12/2022] Open
Abstract
Background The calreticulin (CALR) exon 9 mutations that are identified in 20% of patients with Philadelphia chromosome negative chronic myeloproliferative neoplasms (MPN) generate immunogenic antigens. Thus, therapeutic cancer vaccination against mutant CALR could be a new treatment modality in CALR-mutant MPN. Methods The safety and efficacy of vaccination with the peptide CALRLong36 derived from the CALR exon 9 mutations was tested in a phase I clinical vaccination trial with montanide as adjuvant. Ten patients with CALRmut MPN were included in the trial and received 15 vaccines over the course of one year. The primary end point was evaluation of safety and toxicity of the vaccine. Secondary endpoint was assessment of the immune response to the vaccination epitope (www.clinicaltrials.gov identifier NCT03566446). Results Patients had a median age of 59.5 years and a median disease duration of 6.5 years. All patients received the intended 15 vaccines, and the vaccines were deemed safe and tolerable as only two grade three AE were detected, and none of these were considered to be related to the vaccine. A decline in platelet counts relative to the platelets counts at baseline was detected during the first 100 days, however this did not translate into neither a clinical nor a molecular response in any of the patients. Immunomonitoring revealed that four of 10 patients had an in vitro interferon (IFN)-γ ELISPOT response to the CALRLong36 peptide at baseline, and four additional patients displayed a response in ELISPOT upon receiving three or more vaccines. The amplitude of the immune response increased during the entire vaccination schedule for patients with essential thrombocythemia. In contrast, the immune response in patients with primary myelofibrosis did not increase after three vaccines. Conclusion Therapeutic cancer vaccination with peptide vaccines derived from mutant CALR with montanide as an adjuvant, is safe and tolerable. The vaccines did not induce any clinical responses. However, the majority of patients displayed a marked T-cell response to the vaccine upon completion of the trial. This suggests that vaccines directed against mutant CALR may be used with other cancer therapeutic modalities to enhance the anti-tumor immune response.
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Affiliation(s)
- Jacob Handlos Grauslund
- National Center for Cancer Immune Therapy (CCIT-DK), Department of Oncology, Copenhagen University Hospital, Herlev, Denmark
| | - Morten Orebo Holmström
- National Center for Cancer Immune Therapy (CCIT-DK), Department of Oncology, Copenhagen University Hospital, Herlev, Denmark
| | - Nicolai Grønne Jørgensen
- National Center for Cancer Immune Therapy (CCIT-DK), Department of Oncology, Copenhagen University Hospital, Herlev, Denmark
| | - Uffe Klausen
- National Center for Cancer Immune Therapy (CCIT-DK), Department of Oncology, Copenhagen University Hospital, Herlev, Denmark
| | - Stine Emilie Weis-Banke
- National Center for Cancer Immune Therapy (CCIT-DK), Department of Oncology, Copenhagen University Hospital, Herlev, Denmark
| | - Daniel El Fassi
- Department of Hematology, Copenhagen University Hospital, Herlev, Denmark.,Department of Medicine, Copenhagen University, Copenhagen, Denmark
| | - Claudia Schöllkopf
- Department of Hematology, Copenhagen University Hospital, Herlev, Denmark
| | - Mette Borg Clausen
- Department of Hematology, Copenhagen University Hospital, Herlev, Denmark
| | | | | | - Julie Westerlin Kjeldsen
- National Center for Cancer Immune Therapy (CCIT-DK), Department of Oncology, Copenhagen University Hospital, Herlev, Denmark
| | - Morten Hansen
- National Center for Cancer Immune Therapy (CCIT-DK), Department of Oncology, Copenhagen University Hospital, Herlev, Denmark
| | - Steffen Koschmieder
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
| | - Nicolas Chatain
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
| | - Guy Wayne Novotny
- Department of Hematology, Copenhagen University Hospital, Herlev, Denmark
| | - Jesper Petersen
- Department of Hematology, Copenhagen University Hospital, Herlev, Denmark
| | - Lasse Kjær
- Department of Hematology, Zealand University Hospital, Roskilde, Denmark
| | - Vibe Skov
- Department of Hematology, Zealand University Hospital, Roskilde, Denmark
| | - Özcan Met
- National Center for Cancer Immune Therapy (CCIT-DK), Department of Oncology, Copenhagen University Hospital, Herlev, Denmark.,Institute for Immunology and Microbiology, Copenhagen University, Copenhagen, Denmark
| | - Inge Marie Svane
- National Center for Cancer Immune Therapy (CCIT-DK), Department of Oncology, Copenhagen University Hospital, Herlev, Denmark
| | | | - Mads Hald Andersen
- National Center for Cancer Immune Therapy (CCIT-DK), Department of Oncology, Copenhagen University Hospital, Herlev, Denmark.,Institute for Immunology and Microbiology, Copenhagen University, Copenhagen, Denmark
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18
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Schmid C, Kuball J, Bug G. Defining the Role of Donor Lymphocyte Infusion in High-Risk Hematologic Malignancies. J Clin Oncol 2021; 39:397-418. [PMID: 33434060 DOI: 10.1200/jco.20.01719] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Affiliation(s)
- Christoph Schmid
- Department of Hematology and Oncology, Augsburg University Hospital, Augsburg, Germany
| | - Jürgen Kuball
- Department of Hematology and Laboratory of Translational Immunology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Gesine Bug
- Department of Medicine 2, Goethe University, Frankfurt am Main, Germany
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19
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Treosulfan-Based Conditioning Regimen for Second Allograft in Patients with Myelofibrosis. Cancers (Basel) 2020; 12:cancers12113098. [PMID: 33114179 PMCID: PMC7690833 DOI: 10.3390/cancers12113098] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 10/15/2020] [Accepted: 10/21/2020] [Indexed: 11/17/2022] Open
Abstract
Simple Summary Currently, the only curative therapy in myelofibrosis is allogeneic hematopoietic stem cell transplantation. Donor lymphocyte infusion and second stem cell transplantation are the two main treatment options for myelofibrosis patients who relapse after the first transplantation. The optimal conditioning regimen for the second transplantation in myelofibrosis patients is not well defined. Our study aimed to address this question and showed that treosulfan-based conditioning for second allograft in relapsed myelofibrosis patients resulted in longtime freedom from disease in about 50% of the patients. This data supports the second allogeneic hematopoietic stem cell transplantation with a less toxic treosulfan-based conditioning regimen that is effective in relapsed, donor lymphocyte infusion resistant myelofibrosis patients with long term low transplant-related mortality and relapse rates. Abstract Relapse after allogeneic hematopoietic stem cell transplantation (AHSCT) in myelofibrosis (MF) patients remains as a significant issue despite advances in transplantation procedures and significant prolongation in survival. Second AHSCT is a potential treatment option but associated with high treatment-related mortality and novel less toxic conditioning regimens are needed. In 33 MF patients with relapse after AHSCT and failure to donor lymphocyte infusion (DLI) we investigated treosulfan (36–42 g/m2) in combination with fludarabine and anti-thymocyte globulin (ATG) as conditioning regimen for a second AHSCT with matched related (n = 2), unrelated (n = 23), or mismatched unrelated (n = 8) donors. All patients achieved leukocyte engraftment after a median of 11 days, and 56 ± 13% experienced acute GVHD grade II–IV at day 100. The therapy-related mortality at day 100 and at 3 years was 16% and 31%, respectively. The cumulative incidence of relapse at 5 years was 16%, resulting in a 5-year disease-free and overall survival of 45% and 47%, respectively. Treosulfan-based conditioning for second allograft in relapsed MF patients resulted in about 50% of the patients in long-term freedom from disease.
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20
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Atagunduz IK, Christopeit M, Ayuk F, Zeck G, Wolschke C, Kröger N. Incidence and Outcome of Late Relapse after Allogeneic Stem Cell Transplantation for Myelofibrosis. Biol Blood Marrow Transplant 2020; 26:2279-2284. [PMID: 32949753 DOI: 10.1016/j.bbmt.2020.09.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 09/01/2020] [Accepted: 09/13/2020] [Indexed: 12/11/2022]
Abstract
In this cross-sectional study, we retrospectively evaluated the files of 227 patients with myelofibrosis who underwent transplantation between 1994 and 2015 for relapse later than 5 years after allogeneic stem cell transplantation (SCT). A total of 94 patients who were alive and in remission at 5 years were identified with follow-up of at least 5 years (median, 9.15 years) after SCT. Thirteen patients (14%) experienced late molecular (n = 6) or hematologic (n = 7) relapse at a median of 7.1 years while 81 patients did not experience relapse. Relapse patients received either donor lymphocyte infusion (DLI) (n = 7) and/or second transplantation (n = 4). Of those, 72.7% achieved again full donor cell chimerism and molecular remission, and after a median follow-up of 45 months, the 3-year overall survival rates for patients with or without relapse were 90.9% (95% confidence interval [CI], 77% to 100%) and 98.8% (95% CI, 96% to 100%), respectively (P = .13). We conclude that late relapse occurs in about 14% of the patients and the majority can be successfully salvaged with DLI and/or second allograft. All patients with molecular relapse are alive and support the long-time molecular monitoring in myelofibrosis patients after allogeneic SCT.
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Affiliation(s)
- Isik Kaygusuz Atagunduz
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Marmara University Pendik Training and Research Hospital, Istanbul, Turkey
| | | | - Francis Ayuk
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gaby Zeck
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Nicolaus Kröger
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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21
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Role of Inflammatory Factors during Disease Pathogenesis and Stem Cell Transplantation in Myeloproliferative Neoplasms. Cancers (Basel) 2020; 12:cancers12082250. [PMID: 32806517 PMCID: PMC7463735 DOI: 10.3390/cancers12082250] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/07/2020] [Accepted: 08/09/2020] [Indexed: 12/14/2022] Open
Abstract
Hematopoiesis is a highly regulated and complex process involving hematopoietic stem cells (HSCs), cell surface adhesion molecules, and cytokines as well as cells of the hematopoietic niche in the bone marrow (BM). Myeloproliferative neoplasms (MPNs) are characterized by clonal expansion of HSCs involving one or more blood cell lineages. Philadelphia-negative MPNs (Ph-neg MPNs) comprise polycythemia vera (PV), essential thrombocythemia (ET), and primary myelofibrosis (PMF). In nearly all patients with Ph-neg MPN, mutations in the genes encoding janus kinase 2 (JAK2), calreticulin (CALR), or the thrombopoietin receptor (MPL) can be detected and, together with additional mutations in epigenetic modifier genes, these genetic aberrations contribute to the clonal expansion of the cells. In addition to these intracellular changes in the malignant clone, inflammatory processes involving both the clonal and the non-clonal cells contribute to the signs and symptoms of the patients, as well as to progression of the disease to myelofibrosis (MF) or acute leukemia, and to thrombotic complications. This contribution has been corroborated in preclinical studies including mouse models and patient-derived iPS cells, and in clinical trials, using anti-inflammatory drugs such as JAK inhibitors and steroids, or immunomodulatory drugs such as IMiDs and interferon-alpha (IFNa), all of which change the (im)balance of circulating inflammatory factors (e.g., TNFa, IL-1b, and TGFβ) in MPN. Currently, allogeneic hematopoietic (stem) cell transplantation (allo-HCT) remains the only curative treatment for Ph-neg MPN and is the treatment of choice in intermediate-2 and high-risk MF. HCT can reverse inflammatory changes induced by MPN as well as fibrosis in a large proportion of patients, but it also induces itself profound changes in inflammatory cells and cytokines in the patient, which may help to eradicate the disease but also in part cause significant morbidity (e.g., by graft-versus-host disease). In this review, we focus on the contribution of aberrant inflammation to disease pathogenesis in Ph-neg MPN as well as the current understanding of its alterations after allogeneic HCT.
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22
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Zhang L, Yang F, Feng S. Allogeneic hematopoietic stem-cell transplantation for myelofibrosis. Ther Adv Hematol 2020; 11:2040620720906002. [PMID: 32110286 PMCID: PMC7019406 DOI: 10.1177/2040620720906002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 01/09/2020] [Indexed: 12/22/2022] Open
Abstract
Myelofibrosis is one of the Philadelphia chromosome (Ph)-negative
myeloproliferative neoplasms with heterogeneous clinical course. Though many
treatment options, including Janus kinase (JAK) inhibitors, have provided
clinical benefits and improved survival, allogeneic hematopoietic stem-cell
transplantation (AHSCT) remains the only potentially curative therapy.
Considering the significant transplant-related morbidity and mortality, it is
crucial to decide who to proceed to AHSCT, and when. In this review, we discuss
recent updates in patient selection, prior splenectomy, conditioning regimen,
donor type, molecular mutation, and other factors affecting AHSCT outcomes.
Relapse is a major cause of treatment failure; we also describe recent data on
minimal residual disease monitoring and management of relapse. In addition,
emerging studies have reported pretransplant therapy with ruxolitinib for
myelofibrosis showing favorable results, and further research is needed to
explore its use in the post-transplant setting.
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Affiliation(s)
- Lining Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Fan Yang
- Aerospace Center Hospital, Beijing, China
| | - Sizhou Feng
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 288 Nanjing Road, Heping District, Tianjin, 300020, China
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23
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Yafour N, Couturier MA, Azarnoush S, Girault S, Hermet E, Masouridi Levrat S, Schmidt A, Michallet M, Etancelin P, Guillaume T, Malard F, Sirvent A, Yakoub-Agha I, Poiré X. [Second allogeneic hematopoietic stem cell transplant: Guidelines from the francophone Society of bone marrow transplantation and cellular therapy (SFGM-TC)]. Bull Cancer 2018; 106:S40-S51. [PMID: 30409466 DOI: 10.1016/j.bulcan.2018.05.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 05/31/2018] [Indexed: 01/10/2023]
Abstract
Disease recurrence and graft dysfunction after allogeneic hematopoietic stem cell transplantation (allo-HSCT) currently remain among the major causes of treatment failure in malignant and non-malignant hematological diseases. A second allo-HSCT is a valuable therapeutic option to salvage those situations. During the 8th annual harmonization workshops of the french Society of bone marrow transplantation and cellular therapy (SFGM-TC), a designated working group reviewed the literature in order to elaborate unified guidelines on feasibility, indications, donor choice and conditioning in the case of a second allo-HSCT. In case of relapse, a second allo-HSCT with reduced intensity or non-myeloablative conditioning is a reasonable option, particularly in patients with a good performance status (Karnofsky/Lansky>80%), low co-morbidity score (EBMT score≤3), a longer remission duration after the first allo-HSCT (>6 months), and who present low disease burden at the time of second allo-HSCT. Matched related donors tend to be associated with better outcomes. In the presence of graft dysfunction (primary and secondary graft rejection), an immunoablative conditioning regimen is recommended. A donor change remains a valid option, especially in the absence of graft-versus-host disease after the first allo-HSCT.
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Affiliation(s)
- Nabil Yafour
- Établissement Hospitalier et Universitaire 1er-Novembre 1954, service d'hématologie et de thérapie cellulaire, BP 4166, 31000 Ibn Rochd, Oran, Algérie; Université d'Oran 1, Ahmed Ben Bella, faculté de médecine, Oran, Algérie.
| | - Marie Anne Couturier
- Hôpital Morvan, institut cancérologie-hématologie, CHRU Brest, 2, avenue Foch, 29200 Brest, France
| | - Saba Azarnoush
- Université Paris Diderot, hôpital Robert-Debré, service d'immuno-hématologie pédiatrique, 48, boulevard Sérurier, 75019 Paris, France
| | - Stéphane Girault
- CHU Limoges, hématologie clinique et thérapie cellulaire, 2, avenue Martin-Luther-King, 87042 Limoges, France
| | - Eric Hermet
- Université d'Auvergne EA3846, CIC-501, CHU Estaing, service de thérapie cellulaire et d'hématologie clinique adulte, Clermont-Ferrand, 58, rue Montalembert, 63000 Clermont-Ferrand, France
| | - Stavroula Masouridi Levrat
- Geneva university hospitals, division of hematology, department of medical specialties, rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Suisse
| | - Aline Schmidt
- CHU d'Angers, maladies du sang, 4, rue Larrey, 49100 Angers, France; Université d'Angers, Inserm U892/CNRS 6299, 49035 Angers, France
| | - Mauricette Michallet
- Centre hospitalier Lyon Sud, hématologie clinique, 165, chemin du Grand-Revoyet, 69495 Pierre-Bénite cedex Lyon, France
| | - Pascaline Etancelin
- Centre Henri-Becquerel, laboratoire de génétique oncologique, rue d'Amiens, 76000 Rouen, France
| | - Thierry Guillaume
- CHU de Nantes, Hôtel-Dieu, service d'hématologie, 1, place Ricordeau, 44000 Nantes, France
| | - Florent Malard
- AP-HP, hôpital Saint-Antoine, service d'hématologie et de thérapie cellulaire, 75012 Paris, France
| | - Anne Sirvent
- CHU Montpellier, hôpital Arnaud-de-Villeneuve, service de l'onco-hématologie pédiatrique, 371, avenue du Doyen-Gaston-Giraud, 34090 Montpellier, France
| | - Ibrahim Yakoub-Agha
- CHU de Lille, maladies du sang, unité d'Allogreffe de CSH, 59000 Lille, France; Université de Lille 2, LIRIC, Inserm U995, 59000 Lille, France
| | - Xavier Poiré
- Cliniques universitaires Saint-Luc, service d'hématologie, 10, avenue Hippocrate, 1200 Bruxelles, Belgique
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24
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Raj K, Eikema DJ, McLornan DP, Olavarria E, Blok HJ, Bregante S, Ciceri F, Passweg J, Ljungman P, Schaap N, Carlson K, Zuckerman T, de Wreede LC, Volin L, Koc Y, Diez-Martin JL, Brossart P, Wolf D, Blaise D, Bartolomeo PD, Vitek A, Robin M, Yakoub-Agha I, Chalandon Y, Kroger N. Family Mismatched Allogeneic Stem Cell Transplantation for Myelofibrosis: Report from the Chronic Malignancies Working Party of European Society for Blood and Marrow Transplantation. Biol Blood Marrow Transplant 2018; 25:522-528. [PMID: 30408564 DOI: 10.1016/j.bbmt.2018.10.017] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 10/19/2018] [Indexed: 12/19/2022]
Abstract
This analysis included 56 myelofibrosis (MF) patients transplanted from family mismatched donor between 2009 and 2015 enrolled in the European Society for Blood and Marrow Transplantation database. The median age was 57years (range, 38 to 72); 75% had primary MF and 25% had secondary MF. JAK2 V617F was mutated in 61%. Donors were HLA mismatched at 2 or more loci. Stem cells were sourced from bone marrow in 66% and peripheral blood in 34%. The median CD34+ cell dose was 4.8 × 106/kg (range, 1.7 to 22.9; n = 43). Conditioning was predominantly myeloablative in 70% and reduced intensity in the remainder. Regimens were heterogeneous with thiotepa, busulfan, fludarabine, and post-transplant cyclophosphamide used in 59%. The incidence of neutrophil engraftment by 28days was 82% (range, 70% to 93%), at a median of 21days (range, 19 to 23). At 2years the cumulative incidence of primary graft failure was 9% (95% CI 1% to 16%) and secondary graft failure was 13% (95% CI 4% to 22%). The cumulative incidence of acute graft-versus-host disease (GVHD) grades II to IV and III to IV was 28% (95% CI 16% to 40%) and 9% (95% CI 2% to 17%) at 100days. The cumulative incidence of chronic GVHD at 1 year was 45% (95% CI 32% to 58%), but the cumulative incidence of death without chronic GVHD by 1 year was 20% (95% CI 10% to 31%). With a median follow-up of 32 months, the 1- and 2-year overall survival was 61% (95% CI 48% to 74%) and 56% (95% CI 41% to 70%), respectively. The 1- and 2- year progression-free survival was 58% (95% CI 45% to 71%) and 43% (95% CI 28% to 58%), respectively, with a 2-year cumulative incidence of relapse of 19% (95% CI 7% to 31%). The 2-year nonrelapse mortality was 38% (95% CI 24% to 51%). This retrospective study of MF allo-SCT using family mismatched donors demonstrated feasibility of the approach, timely neutrophil engraftment in over 80% of cases, and acceptable overall and progression-free survival rates with relapse rates not dissimilar to the unrelated donor setting. However, strategies to minimize the risk of graft failure and the relatively high nonrelapse mortality need to be used, ideally in a multicenter prospective fashion.
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Affiliation(s)
- Kavita Raj
- Department of Haematological Medicine,Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom.
| | - Diderik-Jan Eikema
- Department of Medical Statistics & Bioinformatics, EBMT Statistical Unit, Leiden, The Netherlands
| | - Donal P McLornan
- Department of Haematological Medicine,Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Eduardo Olavarria
- Department of Haematological Medicine, Hammersmith Hospital, London, United Kingdom
| | - Henric-Jan Blok
- Department of Medical Statistics & Bioinformatics, EBMT Statistical Unit, Leiden, The Netherlands
| | | | - Fabio Ciceri
- Department of Hematology and Hematopoietic Stem Cell Transplantation Instituto Di Ricovero e Cura a Carattere Scientificio San Raffaele Scientific Institute, Milano, Italy
| | - Jakob Passweg
- Department of Internal Medicine, University Hospital, Basel, Switzerland
| | - Per Ljungman
- Division of Hematology, Karolinska University Hospital, Stockholm, Sweden
| | - Nicolaas Schaap
- Department of Hematology, Radboud University, Medical Centre, Nijmegen, The Netherlands
| | - Kristina Carlson
- Internal Medicine/Hematology, University Hospital, Uppsala, Sweden
| | - Tsila Zuckerman
- Depatment of Hematology and Bone marrow Transplantation,Rambam Medical Center, Haifa, Israel
| | - Liesbeth C de Wreede
- Department of Medical Statistics & Bioinformatics, EBMT Statistical Unit, Leiden, The Netherlands; Deutsche Knochenmarkspenderdatei Clinical Trials Unit, Dresden, Germany
| | - Liisa Volin
- Department of Medicine, Helsinki University Central Hospital Comprehensive Cancer Center, Helsinki, Finland
| | - Yener Koc
- Department of Oncology, Stem cell transplant unit, Medical Park Hospitals, Antalya, Turkey
| | - Jose Luis Diez-Martin
- Department of Hematology, Instituto de investigación sanitaria Gregorio Marañon, Universidad Complutense Medicina, Madrid, Spain
| | - Peter Brossart
- Departmetn of Immuno-oncolgy and Rheumatology, Universitat Bonn, Bonn, Germany
| | - Dominik Wolf
- Departmetn of Immuno-oncolgy and Rheumatology, Universitat Bonn, Bonn, Germany
| | - Didier Blaise
- Department of Onco-Hematology, Transplantation and cell therapy unit, Institut Paoli Calmettes, Marseille, France
| | - Paolo Di Bartolomeo
- Department of Hematology, Transfusion Medicine and Biotechnology, Ospedale Civile, Pescara, Italy
| | - Antonin Vitek
- Institute of Hematology and Blood Transfusion, Prague, Czech Rep
| | - Marie Robin
- Department of Hematology and Bone marrow transplantation, Hopital St. Louis, Paris, France
| | - Ibrahim Yakoub-Agha
- Department of Hematology, Lille University hospital INSERM U995, Universite de Lille, France
| | - Yves Chalandon
- Hôpitaux Universitaires de Genève, Hematology Division and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Nicolaus Kroger
- Department of Stem Cell Transplantation, University Hospital Eppendorf, Hamburg, Germany
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25
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Zimran E, Keyzner A, Iancu-Rubin C, Hoffman R, Kremyanskaya M. Novel treatments to tackle myelofibrosis. Expert Rev Hematol 2018; 11:889-902. [PMID: 30324817 DOI: 10.1080/17474086.2018.1536538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Despite the dramatic progress made in the treatment of patients with myelofibrosis since the introduction of the JAK1/2 inhibitor ruxolitinib, a therapeutic option that can modify the natural history of the disease and prevent evolution to blast-phase is still lacking. Recent investigational treatments including immunomodulatory drugs and histone deacetylase inhibitors benefit some patients but these effects have proven modest at best. Several novel agents do show promising activity in preclinical studies and early-phase clinical trials. We will illustrate a snapshot view of where the management of myelofibrosis is evolving, in an era of personalized medicine and advanced molecular diagnostics. Areas covered: A literature search using MEDLINE and recent meeting abstracts was performed using the keywords below. It focused on therapies in active phases of development based on their scientific and preclinical rationale with the intent to highlight agents that have novel biological effects. Expert commentary: The most mature advances in treatment of myelofibrosis are the development of second-generation JAK1/2 inhibitors and improvements in expanding access to donors for transplantation. In addition, there are efforts to identify drugs that target pathways other than JAK/STAT signaling that might improve the survival of myelofibrosis patients, and limit the need for stem-cell transplantation.
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Affiliation(s)
- Eran Zimran
- a Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai , Myeloproliferative Neoplasms Research Program , New York , NY , USA
| | - Alla Keyzner
- a Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai , Myeloproliferative Neoplasms Research Program , New York , NY , USA
| | - Camelia Iancu-Rubin
- a Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai , Myeloproliferative Neoplasms Research Program , New York , NY , USA
| | - Ronald Hoffman
- a Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai , Myeloproliferative Neoplasms Research Program , New York , NY , USA
| | - Marina Kremyanskaya
- a Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai , Myeloproliferative Neoplasms Research Program , New York , NY , USA
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26
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McLornan DP, Szydlo R, Robin M, van Biezen A, Koster L, Blok HJP, Van Lint MT, Finke J, Vitek A, Carlson K, Griskevicius L, Holler E, Itälä-Remes M, Schaap M, Socié G, Bay JO, Beguin Y, Bruno B, Cornelissen JJ, Gedde-Dahl T, Ljungman P, Rubio MT, Yakoub-Agha I, Klyuchnikov E, Olavarria E, Chalandon Y, Kröger N. Outcome of patients with Myelofibrosis relapsing after allogeneic stem cell transplant: a retrospective study by the Chronic Malignancies Working Party of EBMT. Br J Haematol 2018; 182:418-422. [PMID: 29808926 DOI: 10.1111/bjh.15407] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Accepted: 03/19/2018] [Indexed: 11/29/2022]
Abstract
Allogeneic Haematopoietic Stem Cell Transplant (allo-HSCT) remains the only curative approach for Myelofibrosis (MF). Scarce information exists in the literature on the outcome and, indeed, management of those MF patients who relapse following transplant. We hereby report on the management and outcome of 202 patients who relapsed post allo-HSCT for MF.
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Affiliation(s)
- Donal P McLornan
- Comprehensive Cancer Centre, Division of Haematology, King's College, London
| | - Richard Szydlo
- Hammersmith Hospital NHS Foundation Trust, London, United Kingdom
| | - Marie Robin
- Service d'Hématologie-Greffe, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Anja van Biezen
- EBMT Data Office, University Medical Centre, Leiden, the Netherlands
| | - Linda Koster
- EBMT Data Office, University Medical Centre, Leiden, the Netherlands
| | - Henrik J P Blok
- EBMT Data Office, University Medical Centre, Leiden, the Netherlands
| | | | | | - Antonin Vitek
- Institute of Haematology and Blood Transfusion, Prague, Czech Republic
| | | | - Laimonas Griskevicius
- Haematology, Oncology& Transfusion Centre, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Ernst Holler
- Department of Haematology and Oncology, University of Regensburg, Regensburg, Germany
| | - Maija Itälä-Remes
- Stem Cell Transplant Unit, Turku University Hospital, Turku, Finland
| | - Michel Schaap
- Department of Haematology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Gerard Socié
- Service d'Hématologie-Greffe, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Jacques-Olivier Bay
- Service d'hématologie clinique Adulte et pédiatrie, CHU ESTAING, Clermont, France
| | - Yves Beguin
- Department of Haematology, University of Liege, Liege, Belgium
| | - Benedetto Bruno
- A.O.U Citta della Salute e della Scienza di Torino, S.S.C.V.D Trapianto di Cellule Staminali, Torino, Italy
| | - Jan J Cornelissen
- Erasmus MC Cancer Institute, University Medical Centre, Rotterdam, the Netherlands
| | - Tobias Gedde-Dahl
- Clinic for Cancer, Surgery and Transplantation, Oslo University Hospital, Rikshospitalet, Norway
| | - Per Ljungman
- Department of Haematology, Karolinska University Hospital, Stockholm, Sweden
| | - Marie T Rubio
- Department of Haematology, Hopital d`Enfants, Nancy, France
| | | | | | | | - Yves Chalandon
- Division of Haematology, Geneva University Hospitals, Geneva, Switzerland
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27
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Abstract
PURPOSE OF REVIEW Allogeneic hematopoietic stem-cell transplantation (HSCT) remains the only curative therapy for myelofibrosis. The number of HSCTs performed for this indication has been steadily increasing over the past years, even after the approval of the Janus kinase (JAK) inhibitor, ruxolitinib. This increase may be attributed to improved patient selection based on new prognostic molecular markers, more frequent use of matched unrelated donors, secondary to better (high-resolution) human leukocyte antigen typing and supportive care. Ruxolitinib approval raises new questions regarding the role of JAK inhibitors in the transplant setting. RECENT FINDINGS The current review summarizes recent updates on HSCT in myelofibrosis. Predictors for transplant outcomes, and specific considerations related to myelofibrosis patient selection for HSCT (e.g. molecular risk stratification) are reviewed. In addition, this review will consider management of myelofibrosis patients in the peritransplant period, including the role of ruxolitinib in the pretransplant period, pre and posttransplant splenomegaly, transplant protocols, posttransplant follow-up of minimal residual disease and interventions in the event of poor engraftment. SUMMARY HSCT remains a highly relevant treatment option for myelofibrosis in the era of JAK inhibitors. Recent advances may contribute to a refined definition of HSCT eligibility and identification of the optimal transplantation time, conditioning protocols and posttransplant management.
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28
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Jain T, Mesa RA, Palmer JM. Allogeneic Stem Cell Transplantation in Myelofibrosis. Biol Blood Marrow Transplant 2017; 23:1429-1436. [PMID: 28499938 PMCID: PMC8148877 DOI: 10.1016/j.bbmt.2017.05.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 05/08/2017] [Indexed: 12/16/2022]
Abstract
Myeloproliferative neoplasm (MPN) is a category in the World Health Organization classification of myeloid tumors. BCR-ABL1-negative MPN is a subcategory that includes primary myelofibrosis (MF), post-essential thrombocythemia MF, and post-polycythemia vera MF. These disorders are characterized by stem cell-derived clonal myeloproliferation. Clinically, these diseases present with anemia and splenomegaly and significant constitutional symptoms such as severe fatigue, symptoms associated with an enlarged spleen and liver, pruritus, fevers, night sweats, and bone pain. Multiple treatment options may provide symptom relief and improved survival; however, allogeneic stem cell transplantation (HCT) remains the only potentially curative option. The decision for a transplant is based on patient prognosis, age, comorbidities, and functional status. This review describes the recent data on various peritransplantation factors and their effect on outcomes of patients with MF and new therapeutic areas, such as the use and timing of Janus kinase inhibitors with HCT and gives overall conclusions from the available data in the published literature.
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Affiliation(s)
- Tania Jain
- Division of Hematology and Medical Oncology, Mayo Clinic, Phoenix, Arizona.
| | - Ruben A Mesa
- Division of Hematology and Medical Oncology, Mayo Clinic, Phoenix, Arizona
| | - Jeanne M Palmer
- Division of Hematology and Medical Oncology, Mayo Clinic, Phoenix, Arizona
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29
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Wolschke C, Badbaran A, Zabelina T, Christopeit M, Ayuk F, Triviai I, Zander A, Alchalby H, Bacher U, Fehse B, Kröger N. Impact of molecular residual disease post allografting in myelofibrosis patients. Bone Marrow Transplant 2017; 52:1526-1529. [PMID: 28714945 DOI: 10.1038/bmt.2017.157] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 03/09/2017] [Accepted: 04/29/2017] [Indexed: 01/13/2023]
Abstract
We screened 136 patients with myelofibrosis and a median age of 58 years who underwent allogeneic stem cell transplantation (AHSCT) for molecular residual disease for JAKV617F (n=101), thrombopoietin receptor gene (MPL) (n=4) or calreticulin (CALR) (n=31) mutation in peripheral blood on day +100 and +180 after AHSCT. After a median follow-up of 78 months, the 5-year estimated overall survival was 60% (95% confidence interval (CI): 50-70%) and the cumulative incidence of relapse at 5 years was 26% (95% CI: 18-34%) for the entire study population. The percentage of molecular clearance on day 100 was higher in CALR-mutated patients (92%) in comparison with MPL- (75%) and JAKV617F-mutated patients (67%). Patients with detectable mutation at day +100 or at day +180 had a significant higher risk of clinical relapse at 5 years than molecular-negative patients (62% vs 10%, P<0.001) and 70% vs 10%, P<0.001, respectively) irrespectively of the underlying mutation. In a multivariate analysis, high-risk diseases status (hazard ratio (HR) 2.5; 95% CI: 1.18-5.25, P=0.016) and detectable MRD at day 180 (HR 8.36, 95% CI: 2.76-25.30, P<0.001) were significant factors for a higher risk of relapse.
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Affiliation(s)
- C Wolschke
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - A Badbaran
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - T Zabelina
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - M Christopeit
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - F Ayuk
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - I Triviai
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - A Zander
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - H Alchalby
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - U Bacher
- Department of Hematology and Oncology, University Hospital Göttingen, Göttingen, Germany
| | - B Fehse
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - N Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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30
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Lestang E, Peterlin P, Le Bris Y, Dubruille V, Delaunay J, Godon C, Theisen O, Blin N, Mahe B, Gastinne T, Garnier A, Touzeau C, Voldoire M, Bene MC, Le Gouill S, Milpied N, Mohty M, Moreau P, Guillaume T, Chevallier P. Is allogeneic stem cell transplantation for myelofibrosis still indicated at the time of molecular markers and JAK inhibitors era? Eur J Haematol 2017; 99:60-69. [DOI: 10.1111/ejh.12891] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2017] [Indexed: 12/26/2022]
Affiliation(s)
- Elsa Lestang
- Hematology Department; CHU Hotel-Dieu; Nantes France
| | | | - Yannick Le Bris
- Hematology/Biology Department; CHU Hotel-Dieu; Nantes France
| | | | | | - Catherine Godon
- Hematology/Biology Department; CHU Hotel-Dieu; Nantes France
| | - Olivier Theisen
- Hematology/Biology Department; CHU Hotel-Dieu; Nantes France
| | - Nicolas Blin
- Hematology Department; CHU Hotel-Dieu; Nantes France
| | - Beatrice Mahe
- Hematology Department; CHU Hotel-Dieu; Nantes France
| | | | - Alice Garnier
- Hematology Department; CHU Hotel-Dieu; Nantes France
| | | | - Maud Voldoire
- Hematology Department; CHU Hotel-Dieu; Nantes France
| | - Marie C. Bene
- Hematology/Biology Department; CHU Hotel-Dieu; Nantes France
| | | | - Noel Milpied
- Hematology Department; CHU Hotel-Dieu; Nantes France
| | - Mohamad Mohty
- Hematology Department; CHU Hotel-Dieu; Nantes France
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Zhang LN, Chen X, Feng SZ. [Advances in allogeneic hematopoietic stem cell transplantation for myelofibrosis]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2017; 38:352-356. [PMID: 28468103 PMCID: PMC7342713 DOI: 10.3760/cma.j.issn.0253-2727.2017.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Keyzner A, Han S, Shapiro S, Moshier E, Schorr E, Petersen B, Najfeld V, Kremyanskaya M, Isola L, Hoffman R, Mascarenhas J. Outcome of Allogeneic Hematopoietic Stem Cell Transplantation for Patients with Chronic and Advanced Phase Myelofibrosis. Biol Blood Marrow Transplant 2016; 22:2180-2186. [PMID: 27596130 DOI: 10.1016/j.bbmt.2016.08.029] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 08/31/2016] [Indexed: 01/01/2023]
Abstract
Myelofibrosis (MF) is a chronic progressive hematologic malignancy with a median overall survival (OS) of approximately 6 years. Allogeneic hematopoietic stem cell transplantation (HSCT) is the sole treatment approach that offers curative potential. The use of reduced-intensity conditioning regimens has expanded the application of HSCT to patients with MF up to age 70 years. Recent retrospective and prospective reports have suggested worse HSCT outcomes for patients with MF receiving an unrelated donor graft compared with those receiving a related donor graft. To identify patient- and HSCT-specific variables influencing outcomes, we conducted a retrospective analysis of 42 patients with chronic and advanced-phase MF who underwent HSCT at our institution. For this cohort, at a median follow-up of 43 months, progression-free survival (PFS) was 15 months and OS was 25 months. In multivariable analysis, the sole clinical variable that negatively influenced outcome was the use of an unrelated donor, with a median PFS and OS both of 11 months versus not yet reached in patients receiving a related donor graft. At 2 years, OS was 38% (95% confidence interval [CI], 20%-56%) and nonrelapse mortality (NRM) was 53% (95% CI, 36%-78%) in the unrelated donor graft group, compared with 75% (95% CI, 46%-90%) and 21% (95% CI, 9%-47%) in the related donor graft group. There was no difference in the rates of grade III-IV acute graft-versus-host disease between the unrelated and related donor groups (38% versus 38%). Despite a more aggressive disease state, 2-year PFS and OS were both 42% (95% CI, 15%-67%) in patients with myeloproliferative neoplasm-blast phase undergoing HSCT. Graft failure rate was higher in patients receiving a mismatched donor graft compared with those receiving a matched donor graft (60% versus 13%; P = .0398). Retransplantation of patients with graft failure resulted in long-term survival. Baseline splenomegaly did not affect transplantation outcomes. Given the particularly poor outcomes seen in the unrelated donor cohort here and elsewhere, a formal exploration of alternative hematopoietic stem cell sources is warranted.
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Affiliation(s)
- Alla Keyzner
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sarah Han
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Samantha Shapiro
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Erin Moshier
- Department of Population Health Science and Policy, TCI Biostatistics Shared Resource Facility, Icahn School of Medicine, New York, New York
| | - Emily Schorr
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Bruce Petersen
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Vesna Najfeld
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Marina Kremyanskaya
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Luis Isola
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ronald Hoffman
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - John Mascarenhas
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York.
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Farhadfar N, Cerquozzi S, Patnaik M, Tefferi A. Allogeneic Hematopoietic Stem-Cell Transplantation for Myelofibrosis: A Practical Review. J Oncol Pract 2016; 12:611-21. [DOI: 10.1200/jop.2016.013268] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Myelofibrosis is a myeloproliferative neoplasm with cardinal features of extramedullary hematopoiesis, hepatosplenomegaly, cytopenias, and constitutional symptoms that result in shortened survival and leukemic transformation. It is a disease predominantly of the elderly, and currently available therapies only offer symptom control without curative benefit or ability to alter disease progression. Allogeneic hematopoietic stem-cell transplant (HSCT) is the only potentially curative intervention; however, this is only feasible in younger and medically fit patients and selectively offered to those with high-risk disease. Despite ongoing advancements, HSCT is associated with substantial morbidity and mortality, and the determination of which patients with myelofibrosis are ideal candidates and the selection of the opportune moment to proceed with transplantation remains challenging. This review summarizes our current recommendations for the role of and indications for HSCT in myelofibrosis.
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Risk-Adapted Approach to HLA-Matched Sibling Hematopoietic Cell Allografting: Impact of Adjusting Conditioning Intensity and Integrating Post-Transplant Therapeutic Interventions. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2016; 16:304-10. [DOI: 10.1016/j.clml.2016.01.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Revised: 01/12/2016] [Accepted: 01/26/2016] [Indexed: 11/18/2022]
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Jiang X, Xu L, Zhang Y, Huang F, Liu D, Sun J, Song C, Liang X, Fan Z, Zhou H, Dai M, Liu C, Jiang Q, Xu N, Xuan L, Wu M, Huang X, Liu Q. Rituximab-based treatments followed by adoptive cellular immunotherapy for biopsy-proven EBV-associated post-transplant lymphoproliferative disease in recipients of allogeneic hematopoietic stem cell transplantation. Oncoimmunology 2016; 5:e1139274. [PMID: 27467959 DOI: 10.1080/2162402x.2016.1139274] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 12/27/2015] [Accepted: 01/03/2016] [Indexed: 12/29/2022] Open
Abstract
To improve prognosis of post-transplant lymphoproliferative disease (PTLD), a sequential therapeutic strategy that rituximab-based treatments followed by donor lymphocyte infusion (DLI) or autologous EBV-specific cytotoxic T lymphocytes (EBV-CTL) for biopsy-proven EBV-associated PTLD in recipients of allogeneic hematopoietic stem cell transplantation was designed. 84 patients with EBV-PTLD were enrolled in this prospective study. After two cycles of the rituximab-based treatments, 68 of 84 patients (81% [95% CI 71-88]) responded and 52 (62% [51-72]) had CRs. This increased to 73 of 77 patients (95% [87-98]) with completion of sequential cell infusions, and 70 of 77 (91% [82-96]) achieved CRs after DLI or autologous EBV-CTL infusion. 22 patients experienced acute GVHD (aGVHD) (grade I in 5 and grade II in 13, grade III in 4) and 13 chronic GVHD (limited cGVHD in 7 and extensive cGVHD in 6) in 62 patients undergoing a median of three doses of DLI. The incidences of GVHD were similar between DLI and EBV-CTL group (aGVHD 35% vs. 33%, p = 0.876; cGVHD 21% vs. 13%; p = 0.503). EBV-CTL activity after the rituximab-based treatments did not change, while increased after cell infusions and reached its maximum in the 3rd or 6th month after EBV-CTL or DLI treatment, respectively. The 5-y cumulative incidence of PTLD relapse was 4.5% ± 3.3%. The 5-y overall survival (OS) and progression-free survival (PFS) after PTLD were 70.7% ± 5.2% and 68.9% ± 5.3%, respectively. Rituximab-based treatments combined with adoptive cellular immunotherapy might elevate CR rates and reduce relapse of PTLD after allo-HSCT.
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Affiliation(s)
- Xinmiao Jiang
- Institution of Hematology, Nanfang Hospital, Southern Medical University , Guangzhou, China
| | - Lanping Xu
- Institution of Hematology, People's Hospital, Peking University , Beijing, China
| | - Yu Zhang
- Institution of Hematology, Nanfang Hospital, Southern Medical University , Guangzhou, China
| | - Fen Huang
- Institution of Hematology, Nanfang Hospital, Southern Medical University , Guangzhou, China
| | - Daihong Liu
- Institution of Hematology, People's Hospital, Peking University , Beijing, China
| | - Jin Sun
- Institution of Hematology, Nanfang Hospital, Southern Medical University , Guangzhou, China
| | - Chaoyang Song
- Institution of Hematology, Zhujiang Hospital, Southern Medical University , Guangzhou, China
| | - Xinquan Liang
- The First People's Hospital of Chenzhou , Chenzhou, China
| | - Zhiping Fan
- Institution of Hematology, Nanfang Hospital, Southern Medical University , Guangzhou, China
| | - Hongsheng Zhou
- Institution of Hematology, Nanfang Hospital, Southern Medical University , Guangzhou, China
| | - Min Dai
- Institution of Hematology, Nanfang Hospital, Southern Medical University , Guangzhou, China
| | - Can Liu
- Institution of Hematology, Nanfang Hospital, Southern Medical University , Guangzhou, China
| | - Qianli Jiang
- Institution of Hematology, Nanfang Hospital, Southern Medical University , Guangzhou, China
| | - Na Xu
- Institution of Hematology, Nanfang Hospital, Southern Medical University , Guangzhou, China
| | - Li Xuan
- Institution of Hematology, Nanfang Hospital, Southern Medical University , Guangzhou, China
| | - Meiqing Wu
- Institution of Hematology, Nanfang Hospital, Southern Medical University , Guangzhou, China
| | - Xiaojun Huang
- Institution of Hematology, People's Hospital, Peking University , Beijing, China
| | - Qifa Liu
- Institution of Hematology, Nanfang Hospital, Southern Medical University , Guangzhou, China
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Kiladjian JJ, Giraudier S, Cassinat B. Interferon-alpha for the therapy of myeloproliferative neoplasms: targeting the malignant clone. Leukemia 2015; 30:776-81. [PMID: 26601783 DOI: 10.1038/leu.2015.326] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 11/03/2015] [Accepted: 11/16/2015] [Indexed: 12/15/2022]
Abstract
Interferon alpha (IFN-α) has been used for over 30 years to treat myeloproliferative neoplasms (MPNs). IFN-α was shown to induce clinical, hematological, molecular and histopathological responses in small clinical studies. Such combined efficacy has never been achieved with any other drug to date in such a significant proportion of patients. However, toxicity remains a limitation to its broader use despite the development of pegylated forms with better tolerance. Several on going phase 3 studies of peg- IFN-α versus hydroxyurea will help to define its exact place in MPN management. IFN-α efficacy is likely the consequence of a broad range of biological properties, including enhancement of immune response, direct effects on malignant cells and ability to cycle dormant malignant stem cells. However, comprehensive elucidation of its mechanism of action is still lacking. Sustained clinical, molecular and morphological responses after IFN-α discontinuation raised the hope that this drug could eradicate MPN. There is now consistent evidence showing that IFN-α is able to eliminate malignant clones harboring JAK2V617F or Calreticulin mutations. However, the molecular complexity of these diseases could hamper IFN-α efficacy, as the presence of additional non-driver mutations, like in the TET2 gene, could be associated with resistance to IFN-α. Therefore, combined therapy with another targeted agent could be required to eradicate MPN, and the best IFN-α companion for achieving this challenge remains to be determined.
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Affiliation(s)
- J-J Kiladjian
- Centre d'Investigations Cliniques, Hopital Saint-Louis, APHP, Paris, France.,INSERM UMR-S 1131, Institut Universitaire d'Hématologie, Université Paris Diderot, Paris, France
| | - S Giraudier
- INSERM UMR-S 1131, Institut Universitaire d'Hématologie, Université Paris Diderot, Paris, France.,Hopital Henri Mondor, APHP, Laboratoire d'Hématologie, Créteil, France.,UPEC, Faculté de Medicine, Créteil, France
| | - B Cassinat
- INSERM UMR-S 1131, Institut Universitaire d'Hématologie, Université Paris Diderot, Paris, France.,Hopital Saint-Louis, APHP, Service de Biologie Cellulaire, Paris, France
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Indication and management of allogeneic stem cell transplantation in primary myelofibrosis: a consensus process by an EBMT/ELN international working group. Leukemia 2015; 29:2126-33. [PMID: 26293647 DOI: 10.1038/leu.2015.233] [Citation(s) in RCA: 196] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 08/10/2015] [Indexed: 12/15/2022]
Abstract
The aim of this work is to produce recommendations on the management of allogeneic stem cell transplantation (allo-SCT) in primary myelofibrosis (PMF). A comprehensive systematic review of articles released from 1999 to 2015 (January) was used as a source of scientific evidence. Recommendations were produced using a Delphi process involving a panel of 23 experts appointed by the European LeukemiaNet and European Blood and Marrow Transplantation Group. Key questions included patient selection, donor selection, pre-transplant management, conditioning regimen, post-transplant management, prevention and management of relapse after transplant. Patients with intermediate-2- or high-risk disease and age <70 years should be considered as candidates for allo-SCT. Patients with intermediate-1-risk disease and age <65 years should be considered as candidates if they present with either refractory, transfusion-dependent anemia, or a percentage of blasts in peripheral blood (PB) >2%, or adverse cytogenetics. Pre-transplant splenectomy should be decided on a case by case basis. Patients with intermediate-2- or high-risk disease lacking an human leukocyte antigen (HLA)-matched sibling or unrelated donor, should be enrolled in a protocol using HLA non-identical donors. PB was considered the most appropriate source of hematopoietic stem cells for HLA-matched sibling and unrelated donor transplants. The optimal intensity of the conditioning regimen still needs to be defined. Strategies such as discontinuation of immune-suppressive drugs, donor lymphocyte infusion or both were deemed appropriate to avoid clinical relapse. In conclusion, we provided consensus-based recommendations aimed to optimize allo-SCT in PMF. Unmet clinical needs were highlighted.
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Claudiani S, Marktel S, Piemontese S, Assanelli A, Lupo-Stanghellini MT, Carrabba M, Guggiari E, Giglio F, De Freitas T, Marcatti M, Bernardi M, Corti C, Peccatori J, Lunghi F, Ciceri F. Treosulfan based reduced toxicity conditioning followed by allogeneic stem cell transplantation in patients with myelofibrosis. Hematol Oncol 2014; 34:154-60. [PMID: 25469485 DOI: 10.1002/hon.2183] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Revised: 10/22/2014] [Accepted: 10/23/2014] [Indexed: 11/10/2022]
Abstract
Allogeneic transplantation is the only potentially curative strategy for myelofibrosis, even in the era of new drugs that so far only mitigate symptoms. The choice to proceed to allogeneic transplantation is based on several variables including age, disease phase, degree of splenomegaly, donor availability, comorbidities and iron overload. These factors, along with conditioning regimen and time to transplantation, may influence the outcome of ASCT. We report 14 patients affected by myelofibrosis with a median age of 57 years (range, 41-76) receiving a treosulfan-fludarabine based reduced toxicity conditioning. Patients (pts) received a stem cell transplantation from an HLA identical (n = 10) or matched unrelated donor (n = 4). All pts had a complete myeloablation followed by engraftment and in 12 out of 13 evaluated pts donor chimerism was 100% at 1 month. In most cases a reduction of splenomegaly and a reduction (or resolution) of bone marrow fibrosis was observed. After a median follow-up of 39 months (range, 3-106), the 3-year probability of overall survival and disease free survival was 54 +/- 14% and 46 +/- 14%, respectively. The cumulative incidence of non-relapse mortality at 2 years was 39 +/- 15%. Causes of non-relapse mortality were: infection (n = 2), GvHD (n = 2) and haemorrhage (n = 1). We can conclude that a treosulfan and fludarabine based conditioning has a potent myeloablative and anti-disease activity although non-relapse mortality remains high in this challenging clinical setting. Copyright © 2014 John Wiley & Sons, Ltd.
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Affiliation(s)
- Simone Claudiani
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Sarah Marktel
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Simona Piemontese
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Andrea Assanelli
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | | | - Matteo Carrabba
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Elena Guggiari
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Fabio Giglio
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Tiago De Freitas
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Magda Marcatti
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Massimo Bernardi
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Consuelo Corti
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Jacopo Peccatori
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Francesca Lunghi
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Fabio Ciceri
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milano, Italy
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Rambaldi A, Biagi E, Bonini C, Biondi A, Introna M. Cell-based strategies to manage leukemia relapse: efficacy and feasibility of immunotherapy approaches. Leukemia 2014; 29:1-10. [PMID: 24919807 DOI: 10.1038/leu.2014.189] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Revised: 05/15/2014] [Accepted: 05/27/2014] [Indexed: 12/19/2022]
Abstract
When treatment fails, the clinical outcome of acute leukemia patients is usually very poor, particularly when failure occurs after transplantation. A second allogeneic stem cell transplant could be envisaged as an effective and feasible salvage option in younger patients having a late relapse and an available donor. Unmanipulated or minimally manipulated donor T cells may also be effective in a minority of patients but the main limit remains the induction of severe graft-versus-host disease. This clinical complication has brought about a huge research effort that led to the development of leukemia-specific T-cell therapy aiming at the direct recognition of leukemia-specific rather than minor histocompatibility antigens. Despite a great scientific interest, the clinical feasibility of such an approach has proven to be quite problematic. To overcome this limitation, more research has moved toward the choice of targeting commonly expressed hematopoietic specific antigens by the genetic modification of unselected T cells. The best example of this is represented by the anti-CD19 chimeric antigen receptor (CD19.CAR) T cells. As a possible alternative to the genetic manipulation of unselected T cells, specific T-cell subpopulations with in vivo favorable homing and long-term survival properties have been genetically modified by CAR molecules. Finally, the use of naturally cytotoxic effector cells such as natural killer and cytokine-induced killer cells has been proposed in several clinical trials. The clinical development of these latter cells could also be further expanded by additional genetic modifications using the CAR technology.
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Affiliation(s)
- A Rambaldi
- Hematology and Bone Marrow Transplant Unit and Center of Cell Therapy 'G. Lanzani', Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - E Biagi
- Department of Pediatrics, M Tettamanti Research Center, Laboratory of Cell therapy 'S. Verri' University of Milano-Bicocca, San Gerardo Hospital, Monza, Italy
| | - C Bonini
- Experimental Hematology Unit, San Raffaele Scientific Institute, Milano, Italy
| | - A Biondi
- Department of Pediatrics, M Tettamanti Research Center, Laboratory of Cell therapy 'S. Verri' University of Milano-Bicocca, San Gerardo Hospital, Monza, Italy
| | - M Introna
- Hematology and Bone Marrow Transplant Unit and Center of Cell Therapy 'G. Lanzani', Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
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Babushok D, Hexner E. Allogeneic transplantation for myelofibrosis: for whom, when, and what are the true benefits? Curr Opin Hematol 2014; 21:114-22. [PMID: 24378706 PMCID: PMC4104209 DOI: 10.1097/moh.0000000000000015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE OF REVIEW Allogeneic hematopoietic stem cell transplantation (HSCT) is the only potentially curative therapy for myelofibrosis. Despite improved outcomes, morbidity and mortality of HSCT remain high. Here we examine recent data on patient selection, timing, and outcomes of HSCT in myelofibrosis. RECENT FINDINGS While there is a general effort to restrict HSCT to transplant-eligible intermediate-2 and high-risk patients, this group has comparatively worse HSCT outcomes, largely driven by their high transplant-related mortality (TRM). When adjusted for age, reduced intensity conditioning (RIC) has shown superior outcomes compared with myeloablative conditioning (MAC), making RIC-HSCT a viable option for older patients. Emerging concepts include the use of ruxolitinib pretransplant, optimizing MAC to decrease toxicity, and use of posttransplant JAK2-mutant allele burden to guide prophylactic immunotherapy to prevent relapse. The recognition of prognostic significance of somatic mutations in the ASXL1, EZH2, SRSF2, and IDH1/2 genes, and the improved assessment of risk of leukemic transformation have added a new dimension to risk stratification. SUMMARY Improving our understanding of molecular genetics and leukemic transformation holds promise for more precise patient selection for HSCT. Although RIC-HSCT may reduce TRM, further studies are needed to optimize conditioning regimens and to define the optimal timing of HSCT.
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Affiliation(s)
- Daria Babushok
- Division of Hematology and Oncology and Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Fu B, OK CY, Goswami M, Xei W, Jaso JM, Muzzafar T, Bueso-Ramos C, Verstovsek S, Garcia-Manero G, Medeiros LJ, Wang SA. The clinical importance of moderate/severe bone marrow fibrosis in patients with therapy-related myelodysplastic syndromes. Ann Hematol 2013; 92:1335-43. [PMID: 23660629 PMCID: PMC4190057 DOI: 10.1007/s00277-013-1776-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Accepted: 04/23/2013] [Indexed: 02/07/2023]
Abstract
The presence of moderate to severe bone marrow (BM) fibrosis has been shown to be an adverse feature in patients with primary myelodysplastic syndromes (MDS). However, the clinical importance of BM fibrosis is not clear in therapy-related MDS. We retrieved all therapy-related MDS (t-MDS) cases (n = 266) diagnosed at our hospital over a 10-year period (2003-2012). Reticulin and trichrome stains were performed in cases in which BM fibrosis was suspected on initial evaluation of hematoxylin and eosin-stained slide. BM fibrosis was graded according to European consensus guidelines, and a score of MF2/MF3 was defined as moderate/severe fibrosis. Moderate/severe BM fibrosis was found in 47 (17%) patients. Compared to 219 patients with no/mild BM fibrosis, the patients with moderate/severe fibrosis presented with severer thrombocytopenia (p = 0.039) and higher numbers of circulating blasts (p = 0.051) but with similar degrees of anemia and neutropenia, transfusion requirements, and similar incidences of hepatosplenomegaly and constitutional symptoms. Histological examination revealed a comparable BM cellularity and BM blast percentage, but markedly increased megakaryocytes (p < 0.001) in the fibrotic group. Although the risk distribution of cytogenetic data was similar according to the New Comprehensive Cytogenetic Scoring criteria, -5 and -17 were more frequently observed in t-MDS with moderate/severe BM fibrosis (p = 0.031 and p = 0.043, respectively). With a median follow-up of 11.5 months, patients with moderate/severe BM fibrosis showed a similar risk of acute myeloid leukemia transformation and a comparable overall survival in univariate and multivariate analyses. Moderate/severe BM fibrosis in patients with t-MDS is associated with certain clinicopathological and genetic features. However, unlike the situation in patients with primary MDS, moderate/severe BM fibrosis does not add additional risk to patients with therapy-related MDS.
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Affiliation(s)
- Bin Fu
- Department of Hematopathology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Chi Young OK
- Department of Hematopathology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Maitrayee Goswami
- Department of Hematopathology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Wei Xei
- Department of Hematopathology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Jesse M Jaso
- Department of Hematopathology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Tariq Muzzafar
- Department of Hematopathology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Carlos Bueso-Ramos
- Department of Hematopathology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Srdan Verstovsek
- Department of Leukemia, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Guillermo Garcia-Manero
- Department of Leukemia, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - L. Jeffrey Medeiros
- Department of Hematopathology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Sa A. Wang
- Department of Hematopathology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
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