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Narula T, Alvarez F, Abdelmoneim Y, Erasmus D, Li Z, Elrefaei M. Induction immunosuppression strategies and outcomes post-lung transplant: A single center experience. Transpl Immunol 2024; 85:102081. [PMID: 38986916 DOI: 10.1016/j.trim.2024.102081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 07/03/2024] [Accepted: 07/07/2024] [Indexed: 07/12/2024]
Abstract
PURPOSE Currently 80% of lung transplant centers use induction immunosuppression. However, there is a lack of standardization of induction protocols within and across lung transplant centers. This study explores the association of two different induction immunosuppression strategies used at our center [single dose rabbit antithymocyte globulin (rATG) vs. alemtuzumab] compared to no induction with immunologic and clinical outcomes after lung transplantation. METHODS A total of 174 consecutive lung transplant recipients (LTR) between 2016 and 2019 were included in the analysis. Twenty nine LTR (16.7%) received no induction, 22 LTR (12.6%) received alemtuzumab, 123 LTR (70.6%) received a single dose of rATG; 1.5 mg/kg within 24 h of transplant for induction. All LTR had a negative flow cytometry crossmatch on the day of the transplant. All LTR were assessed for de novo HLA donor-specific antibodies (DSA) development and clinical outcomes, including the risk of acute cellular rejection (ACR), antibody-mediated rejection (AMR), chronic lung allograft dysfunction (CLAD), and overall survival post-transplant. RESULTS The median lung allocation score (LAS) was significantly higher in LTR that did not receive Induction immunosuppression (76; range = 35.3-94.3) compared to induction with rATG (41.6; range = 31.6-91) and alemtuzumab (51; range = 33.1-88.2) (p < 0.001). De novo HLA DSA were detected in 50/174 (28.7%) LTR within 12 months post-transplant. They were detected in 13/29 (44.8%) LTR without induction immunosuppression compared to 28/123 (22.8%) and 9/22 (40.9%) LTR with rATG and alemtuzumab induction, respectively (p = 0.02). The percent freedom from ACR rates between LTR who received alemtuzumab induction was significantly higher compared to LTR who received rATG or no induction at 1 (p = 0.02), 2 (p = 0.01) and 3 (p = 0.05) years post-transplant. In addition, the overall 1-year survival rates were significantly higher in LTR who received rATG or alemtuzumab induction compared to LTR without induction immunosuppression (p = 0.02). CONCLUSION Induction immunosuppression strategies utilizing rATG or Alemtuzumab have unique and contrasting benefits in LTR. Combination of alemtuzumab induction and a lower dose of maintenance immunosuppression may reduce the incidence of ACR in LTR. Single-dose rATG or alemtuzumab induction immunosuppression may also improve the 1 year overall LTR survival compared to no induction.
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Affiliation(s)
- Tathagat Narula
- Division of Lung Failure and Transplant, Mayo Clinic, Jacksonville, FL, United States of America
| | - Francisco Alvarez
- Division of Lung Failure and Transplant, Mayo Clinic, Jacksonville, FL, United States of America
| | - Yousif Abdelmoneim
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, FL, United States of America
| | - David Erasmus
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University, Nashville, TN, United States of America
| | - Zhuo Li
- Health Sciences Research, Mayo Clinic, Jacksonville, FL, United States of America
| | - Mohamed Elrefaei
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, FL, United States of America.
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Brufau-Cochs M, Mansilla-Polo M, Morgado-Carrasco D. Risk of skin cancer associated with disease-modifying therapies in multiple sclerosis: a modern comprehensive evidence review. ACTAS DERMO-SIFILIOGRAFICAS 2024:S0001-7310(24)00055-3. [PMID: 38307166 DOI: 10.1016/j.ad.2024.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 12/04/2023] [Accepted: 01/10/2024] [Indexed: 02/04/2024] Open
Abstract
The use of disease-modifying therapies (DMT) has led to a paradigm shift in the management of multiple sclerosis. A comprehensive narrative review was conducted through an extensive literature search including Medline and Google Scholar to elucidate the link between DMT and the propensity of cutaneous malignancies. Sphingosine-1-phosphate receptor modulators, such as fingolimod and siponimod are associated with a higher risk of basal cell carcinoma (BCC), but not squamous cell carcinoma, or melanoma. The associated physiopathological mechanisms are not fully understood. Alemtuzumab and cladribine show isolated associations with skin cancer. Regarding other DMT, no increased risk has ever been found. Given the evidence currently available, it is of paramount importance to advocate for necessary dermatological assessments that should be individualized to the risk profile of each patient. Nonetheless, additional prospective studies are still needed to establish efficient dermatological follow-up protocols.
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Affiliation(s)
- M Brufau-Cochs
- Servicio de Dermatología, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, España
| | - M Mansilla-Polo
- Servicio de Dermatología, Hospital Universitario y Politécnico La Fe, Valencia, España; Instituto de Investigación Sanitaria (IIS) La Fe, Valencia, España
| | - D Morgado-Carrasco
- Servicio de Dermatología, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, España; Servicio de Dermatología, Hospital de Figueres, Fundació Salut Empordá, Figueres, Girona, España.
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3
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Kreher MA, Konda S, Noland MMB, Longo MI, Valdes-Rodriguez R. Risk of melanoma and nonmelanoma skin cancer with immunosuppressants, part II: Methotrexate, alkylating agents, biologics, and small molecule inhibitors. J Am Acad Dermatol 2023; 88:534-542. [PMID: 36460256 DOI: 10.1016/j.jaad.2022.11.043] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/17/2022] [Accepted: 11/20/2022] [Indexed: 12/05/2022]
Abstract
In solid organ transplant recipients, skin cancer risk associated with posttransplant immunosuppression has been well-described, and screening practices generally reflect these risks. In addition to agents used posttransplant, other classes of immunosuppressants also have the potential to raise the risk of nonmelanoma skin cancer (NMSC) or melanoma. In the present manuscript, the evidence for melanoma and NMSC risk associated with methotrexate, cyclophosphamide, biologic cytokine inhibitors including TNF (tumor necrosis factor)-alpha and interleukin inhibitors, costimulation blockers such as abatacept, integrin inhibitors such as natalizumab, targeted B-cell, and T-cell inhibitors including CD20 (cluster of differentiate 20), CD52, and BTK (Bruton's tyrosine kinase) inhibitors, and JAK (Janus kinase) inhibitors is reviewed. Based on the available data, we recommend regular skin cancer screening for select nontransplant patients receiving immunosuppressive regimens that are shown to raise the risk of NMSC or melanoma. We also offer suggestions for conscientious use of these therapies in high-risk patients. Finally, a comprehensive summary of the relative risk associated with each immunosuppressant class and associated recommendations is presented.
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Affiliation(s)
| | - Sailesh Konda
- Department of Dermatology, University of Florida, Gainesville, Florida
| | | | - Maria I Longo
- Department of Dermatology, University of Florida, Gainesville, Florida
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Bösmüller C, Messner F, Margreiter C, Öllinger R, Maglione M, Oberhuber R, Scheidl S, Neuwirt H, Öfner D, Margreiter R, Schneeberger S. Good Results with Individually Adapted Long-Term Immunosuppression Following Alemtuzumab Versus ATG Induction Therapy in Combined Kidney-Pancreas Transplantation: A Single-Center Report. Ann Transplant 2019; 24:52-56. [PMID: 30679414 PMCID: PMC6363467 DOI: 10.12659/aot.911712] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Claudia Bösmüller
- Department of Transplant Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Franka Messner
- Department of Transplant Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Christian Margreiter
- Department of Transplant Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Robert Öllinger
- Department of General Surgery, Charité Virchow Hospital Berlin, Berlin, Germany
| | - Manuel Maglione
- Department of Transplant Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Rupert Oberhuber
- Department of Transplant Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Stefan Scheidl
- Department of Transplant Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Hannes Neuwirt
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University of Innsbruck, Innsbruck, Austria
| | - Dietmar Öfner
- Department of Transplant Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Raimund Margreiter
- Department of Transplant Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Stefan Schneeberger
- Department of Transplant Surgery, Medical University of Innsbruck, Innsbruck, Austria
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5
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van der Zwan M, Baan CC, van Gelder T, Hesselink DA. Review of the Clinical Pharmacokinetics and Pharmacodynamics of Alemtuzumab and Its Use in Kidney Transplantation. Clin Pharmacokinet 2018; 57:191-207. [PMID: 28669130 PMCID: PMC5784003 DOI: 10.1007/s40262-017-0573-x] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Alemtuzumab is a humanized monoclonal antibody against CD52 and causes depletion of T and B lymphocytes, monocytes, and NK cells. Alemtuzumab is registered for the treatment of multiple sclerosis (MS) and is also used in chronic lymphocytic leukemia (CLL). Alemtuzumab is used off-label in kidney transplantation as induction and anti-rejection therapy. The objective of this review is to present a review of the pharmacokinetics, pharmacodynamics, and use of alemtuzumab in kidney transplantation. A systematic literature search was conducted using Ovid Medline, Embase, and Cochrane Central Register of controlled trials. No pharmacokinetic or dose-finding studies of alemtuzumab have been performed in kidney transplantation. Although such studies were conducted in patients with CLL and MS, these findings cannot be directly extrapolated to transplant recipients, because CLL patients have a much higher load of CD52-positive cells and, therefore, target-mediated clearance will differ between these two indications. Alemtuzumab used as induction therapy in kidney transplantation results in a lower incidence of acute rejection compared to basiliximab therapy and comparable results as compared with rabbit anti-thymocyte globulin (rATG). Alemtuzumab used as anti-rejection therapy results in a comparable graft survival rate compared with rATG, although infusion-related side effects appear to be less. There is a need for pharmacokinetic and dose-finding studies of alemtuzumab in kidney transplant recipients to establish the optimal balance between efficacy and toxicity. Furthermore, randomized controlled trials with sufficient follow-up are necessary to provide further evidence for the treatment of severe kidney transplant rejection.
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Affiliation(s)
- Marieke van der Zwan
- Division of Nephrology and Kidney Transplantation, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Room NA523, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
| | - Carla C Baan
- Division of Nephrology and Kidney Transplantation, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Room NA523, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Teun van Gelder
- Division of Nephrology and Kidney Transplantation, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Room NA523, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
- Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Dennis A Hesselink
- Division of Nephrology and Kidney Transplantation, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Room NA523, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
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Post-Transplant Malignancy after Pediatric Kidney Transplantation: Retrospective Analysis of Incidence and Risk Factors in 884 Patients Receiving Transplants Between 1963 and 2015 at the University of Minnesota. J Am Coll Surg 2017; 225:181-193. [DOI: 10.1016/j.jamcollsurg.2017.04.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 04/07/2017] [Accepted: 04/10/2017] [Indexed: 12/15/2022]
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7
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Daloul R, Gupta S, Brennan DC. Biologics in Transplantation (Anti-thymocyte Globulin, Belatacept, Alemtuzumab): How Should We Use Them? CURRENT TRANSPLANTATION REPORTS 2017. [DOI: 10.1007/s40472-017-0147-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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El-Fattah MA. Risk of second cancers in survivors of prolymphocytic leukemia: a SEER data analysis. Acta Oncol 2017; 56:115-117. [PMID: 27924652 DOI: 10.1080/0284186x.2016.1265667] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Mohamed Abd El-Fattah
- Department of Internal Medicine, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
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9
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Asciak R, Buttigieg J, Buhagiar L. De novo papillary carcinoma in a renal allograft: the pros and cons of immunosuppression. CEN Case Rep 2016; 5:99-102. [PMID: 28509174 PMCID: PMC5411666 DOI: 10.1007/s13730-015-0202-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Accepted: 10/19/2015] [Indexed: 01/20/2023] Open
Abstract
We present a case of a multifocal kidney transplant renal cell carcinoma in a 35-year-old lady, presenting 16 years after kidney transplantation, diagnosed during investigation of recurrent urinary tract infections. The patient underwent a graft nephrectomy and subsequently maintained on haemodialysis. She remained disease-free after 4 years of surveillance and thus reactivated on the transplant list. This case reinforces the fact that immunosuppressive therapy has made kidney transplantation possible; however, it is accompanied by a higher incidence of malignancy. It also reinforces the importance of lifelong screening of both native and renal transplant grafts.
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Affiliation(s)
- Rachelle Asciak
- Mater Dei Hospital Malta, Triq Dun Karm, Msida, 2090, Malta.
| | | | - Louis Buhagiar
- Mater Dei Hospital Malta, Triq Dun Karm, Msida, 2090, Malta
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10
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Gundroo A, Zachariah M, Singh N, Sharma R. Alemtuzumab (Campath-1H) experience in kidney transplantation what we have learned; current practices; and scope for the future? Curr Opin Organ Transplant 2016; 20:638-42. [PMID: 26536426 DOI: 10.1097/mot.0000000000000255] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Alemtuzumab (Campath) usage as a preconditioning agent in kidney transplantation has gained considerable interest in the recent future. Alemtuzumab is currently available only by special request from Sanofi through its Campath distribution program. It is restricted to transplant programs with prior and continued experience with the agent. There may be a resurgence of interest for the utilization of this agent because of its ease of administration, and less cost and comparable or improved outcome in comparison to other induction agents. RECENT FINDINGS Alemtuzumab when combined with standard calcineurin inhibitor and mycophenolate mofetil is well tolerated and efficacious as an induction therapy and allows for long-term steroid avoidance in high-risk renal transplant recipients. SUMMARY The transplant community has advanced through a learning curve with the use of alemtuzumab over time; starting from an agent that was tried out to induce proper tolerance, minimization of nephrotoxic calcineurin inhibitors, and currently as a comparable depletional therapy that can reduce acute rejection in high-risk kidney transplant recipients.
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Affiliation(s)
- Aijaz Gundroo
- aTransplant Unit at Erie County Medical Center bDepartment of Medicine, Division of Nephrology cSchool of Medicine and Biomedical Sciences, University at Buffalo, the State University of New York, Buffalo, New York dDepartment of Medicine, Division Nephrology, Louisiana State University, Shreveport, Louisiana. eDepartment of Surgery, University at Buffalo, State University of New York, Buffalo, New York, USA
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11
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Mayhew D, Ridgway D, Hunter JM. Update on the intraoperative management of adult cadaveric renal transplantation. BJA Educ 2016. [DOI: 10.1093/bjaceaccp/mkv013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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12
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Benjamini O, Jain P, Trinh L, Qiao W, Strom SS, Lerner S, Wang X, Burger J, Ferrajoli A, Kantarjian H, O'Brien S, Wierda W, Estrov Z, Keating M. Second cancers in patients with chronic lymphocytic leukemia who received frontline fludarabine, cyclophosphamide and rituximab therapy: distribution and clinical outcomes. Leuk Lymphoma 2014; 56:1643-50. [PMID: 25308294 DOI: 10.3109/10428194.2014.957203] [Citation(s) in RCA: 122] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Patients with chronic lymphocytic leukemia (CLL) are known to have an increased incidence of second cancers, but the contribution of commonly used frontline therapies to the incidence of second cancers is unclear. We report on the characteristics, incidence, outcomes and factors associated with second cancers in 234 patients receiving fludarabine, cyclophosphamide and rituximab (FCR) based regimens in the frontline setting. The risk of second cancers was 2.38 times higher than the expected risk in the general population. Ninety-three patients (40%) had other cancers before and 66 patients (28%) after FCR. Rates of therapy related acute myeloid leukemia/myelodysplastic syndrome (t-AML/MDS) (5.1%) and Richter transformation (RT) (9%) were high, while solid tumors were not increased. Overall survival of patients with second cancers after frontline FCR was shorter (median of 4.5 years) compared to patients with and without prior cancers. Second cancer risk after frontline FCR is mainly due to high rates of t-AML/MDS and RT, and as speculated the survival of affected patients is shorter.
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Laftavi MR, Sharma R, Feng L, Said M, Pankewycz O. Induction Therapy in Renal Transplant Recipients: A Review. Immunol Invest 2014; 43:790-806. [DOI: 10.3109/08820139.2014.914326] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Chapman JR, Lynch SV. Donor-Transmitted, Donor-Derived, and De Novo Cancer After Liver Transplant. EXP CLIN TRANSPLANT 2014; 12 Suppl 1:50-4. [DOI: 10.6002/ect.25liver.l49] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Zaza G, Tomei P, Granata S, Boschiero L, Lupo A. Monoclonal antibody therapy and renal transplantation: focus on adverse effects. Toxins (Basel) 2014; 6:869-91. [PMID: 24590384 PMCID: PMC3968366 DOI: 10.3390/toxins6030869] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Revised: 02/07/2014] [Accepted: 02/21/2014] [Indexed: 02/06/2023] Open
Abstract
A series of monoclonal antibodies (mAbs) are commonly utilized in renal transplantation as induction therapy (a period of intense immunosuppression immediately before and following the implant of the allograft), to treat steroid-resistant acute rejections, to decrease the incidence and mitigate effects of delayed graft function, and to allow immunosuppressive minimization. Additionally, in the last few years, their use has been proposed for the treatment of chronic antibody-mediated rejection, a major cause of late renal allograft loss. Although the exact mechanism of immunosuppression and allograft tolerance with any of the currently used induction agents is not completely defined, the majority of these medications are targeted against specific CD proteins on the T or B cells surface (e.g., CD3, CD25, CD52). Moreover, some of them have different mechanisms of action. In particular, eculizumab, interrupting the complement pathway, is a new promising treatment tool for acute graft complications and for post-transplant hemolytic uremic syndrome. While it is clear their utility in renal transplantation, it is also unquestionable that by using these highly potent immunosuppressive agents, the body loses much of its innate ability to mount an adequate immune response, thereby increasing the risk of severe adverse effects (e.g., infections, malignancies, haematological complications). Therefore, it is extremely important for clinicians involved in renal transplantation to know the potential side effects of monoclonal antibodies in order to plan a correct therapeutic strategy minimizing/avoiding the onset and development of severe clinical complications.
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Affiliation(s)
- Gianluigi Zaza
- Renal Unit, Department of Medicine, University-Hospital of Verona, Piazzale A. Stefani 1, Verona 37126, Italy.
| | - Paola Tomei
- Renal Unit, Department of Medicine, University-Hospital of Verona, Piazzale A. Stefani 1, Verona 37126, Italy.
| | - Simona Granata
- Renal Unit, Department of Medicine, University-Hospital of Verona, Piazzale A. Stefani 1, Verona 37126, Italy.
| | - Luigino Boschiero
- First Surgical Clinic, Kidney Transplantation Center, University-Hospital of Verona, Piazzale A. Stefani 1, Verona 37126, Italy.
| | - Antonio Lupo
- Renal Unit, Department of Medicine, University-Hospital of Verona, Piazzale A. Stefani 1, Verona 37126, Italy.
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Fiegl M, Stauder R, Steurer M, Mian M, Hopfinger G, Brychtova Y, Skrabs C, Zabernigg A, Schmid F, Haslbaur F, Winder G, Walder A, Lang A, Voskova D, Greil R, Mayer J, Gastl G. Alemtuzumab in chronic lymphocytic leukemia: final results of a large observational multicenter study in mostly pretreated patients. Ann Hematol 2013; 93:267-77. [PMID: 24292560 DOI: 10.1007/s00277-013-1966-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Accepted: 11/13/2013] [Indexed: 12/11/2022]
Abstract
This retrospective study evaluated the benefit of alemtuzumab monotherapy in unselected patients with advanced B-cell chronic lymphocytic leukemia (CLL) and prolymphocytic leukemia (B-PLL) to definitely describe the impact of this antibody in clinical routine use. Data were collected from 208 consecutive, mainly pretreated, patients with CLL (n = 202), and B-PLL (n = 6) who had received alemtuzumab. Response, progression-free survival (PFS), and overall survival (OS) in various settings were assessed, and toxicities were documented. In these routine patients, a comparably low cumulative dose of alemtuzumab (median, 403 mg) was applied. In CLL, overall response rate was 32 %, and various pre-therapeutic parameters were predictive for inferior response, among them, the prior administration of ≥3 therapy lines (P < 0.001), refractoriness to fludarabine (P = 0.002), and bulky lymphadenopathy (P = 0.003). PFS and OS after start of alemtuzumab were 6.2 and 21.0 months, respectively. Bulky lymphadenopathy was the prominent risk factor for both inferior PFS (P < 0.001) and OS (P = 0.002). In B-PLL, four patients experienced a fatal outcome, whereas two patients had some benefit with alemtuzumab. The main adverse effects were CMV reactivation (20 %) and a broad spectrum of infections, which together were the main reasons for treatment interruption and/or premature termination. In conclusion, alemtuzumab administered even at low dose levels was effective but overall considerably toxic in routine CLL patients. We emphasize that alemtuzumab remains an important therapeutic option in subsets of CLL patients.
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Affiliation(s)
- M Fiegl
- Department of Internal Medicine V (Hematology and Oncology), Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria,
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