Hematopoietic cell transplantation (HCT)-specific comorbidity index: a new tool for risk assessment before allogeneic HCT

Pretreatment pulmonary function testing has limited utility in B-cell lymphoma treated with CD19 CAR T cells

ABSTRACT

Pulmonary function tests (PFTs) are recommended for hematopoietic cell transplantation (HCT) evaluation. However, their prognostic value in chimeric antigen receptor T-cell (CAR-T) therapy remains unclear. We assessed the predictive significance of PFTs and pulmonary comorbidity classifications, per the Hematopoietic Cell Transplantation-Comorbidity Index (HCT-CI), in patients with B-cell lymphoma undergoing autologous CD19 CAR-T therapy. Single-center retrospective analysis encompassing 192 patients with relapsed/refractory B-cell lymphoma (BCL), treated with commercial and point-of-care CD19-directed CAR-T therapy. Pretherapy PFTs were conducted, and patients were stratified into 3 HCT-CI-based pulmonary comorbidity grades, using forced expiratory volume in 1 second (FEV1) and single-breath diffusing capacity for carbon monoxide (DLCO). Outcomes and toxicities were evaluated using univariate and multivariable Cox regression, logistic regression, Kaplan-Meier method, and spline models. Pulmonary comorbidity measures were not correlated with overall response rates or immune toxicities, including cytokine release syndrome grade >2 and immune effector cell-associated neurotoxicity grade >2. Categorical FEV1, DLCO, and pulmonary comorbidity level did not correlate with overall survival (OS; P = .3, P = .4, P = .6, respectively) or progression-free survival (PFS; P = .058, P > .9, P = .2, respectively). FEV1 as a continuous measure was associated with reduced PFS in a multivariable model (hazard ratio, 0.87; 95% confidence interval, 0.78-0.96; P = .007). Spline modeling demonstrated a linear correlation between FEV1 and PFS. Categorical FEV1, DLCO, and pulmonary comorbidity level failed to predict therapy efficacy or toxicity. FEV1 as a continuous measure was the sole PFT measure associated with PFS, independent of OS or severe toxicities.

Body Composition Assessment Provides Prognostic Information in Patients With Cancer Affected by Chronic Graft vs. Host Disease

BACKGROUND

Additional tools are needed to assess mortality risk among patients with cancer. Patients with chronic graft vs. host disease (cGVHD) after allogeneic haematopoietic cell transplantation (HCT) represent a high-risk cancer population with mortality risk explained by cGVHD severity, but also informed by baseline comorbidities, functional status before and after HCT, and cumulative toxicity from the procedure and its complications. Radiographic body composition metrics from CT scans have previously shown association with complications in other populations.

METHODS

We examined a single-centre consecutive series (2005-2016) of HCT recipients with cGVHD and CT-scans immediately proximal to cGVHD diagnosis to investigate association of radiographic body composition measures and mortality. Skeletal muscle index (SMI) and fat index (FI) were quantified on CT imaging at the 3rd lumbar (L3) and 4th thoracic (T4) vertebra. SM Hounsfield units (HU) were obtained to evaluate SM density. Cut points for SMI were from literature and cut points for FI were established by sex-specific optimal stratification.

RESULTS

A total of n = 113 patients met the inclusion criteria for this analysis, aged 51.2 ± 10.5(SD) years and predominantly male (n = 71, 63%) and diagnosed with NHL (n = 110, 97%). Onset cGVHD NIH overall severity was mild in N = 56 (49%), moderate in 44 (38%) and severe in 15 (13%), with median time to cGVHD onset after HCT of 173 days [IQR 122;295]. A CT scan at 77 days [IQR 33;202] post HCT was selected for analysis. In multivariate analysis, CT-defined body fat ≥ 35% was independently associated with increased mortality (HR 2.094 (95% CI 1.060, 4.136), p = 0.033) overall. Patients of male sex had higher FI than females and showed a more prominent association between high FI and mortality. SMI as well as other indices of adiposity were not associated with survival in multivariable analysis including BMI, sarcopenic obesity and low skeletal muscle radiodensity. In exploratory analyses, we demonstrated similar results per CT chest at T4, suggesting possible future application to a larger HCT population.

CONCLUSIONS

These data support that radiographic body composition measures provide prognostic information among patients with cancer affected by cGVHD post-HCT and suggest that high body fat % is a promising candidate for future study. These findings suggest that low skeletal muscle mass alone does not predict for poor outcomes in HCT patients with cGVHD as previously described in other cancers. Independent validation of this work is needed, including further studies based on CT chest to enhance application to a larger HCT population.

Higher relapse and worse overall survival in recipients with CTLA-4 AA genotype of rs231775 following single-unit cord blood transplantation in adults

We retrospectively investigated the impact of CTLA-4 polymorphism on outcomes for adult patients who received single-unit cord blood transplantation (CBT) at our institution. CTLA-4 genotyping was performed using real-time polymerase chain reaction with the TaqMan® SNP genotyping assay for rs231775. This study included 143 recipient-donor pairs. The multivariate analysis showed that recipient rs231775 AA was associated with worse overall survival (OS) (hazard ratio [HR], 2.92; p = 0.008) and a higher relapse rate (HR, 4.79; p = 0.002), but donor rs231775 was not. The rs231775 polymorphism in recipients and donors did not affect non-relapse mortality, hematopoietic recovery, or acute and chronic graft-versus-host disease. The beneficial effects of rs231775 GG+GA recipients on OS and relapse were notable in subgroups of patients with high-risk disease status and those with myeloid diseases. The polymorphism of CTLA-4 rs231775in recipients might be associated with the clinical outcomes of single-unit CBT.

Comparison of HiDAC Versus FLAG-IDA in the Treatment of Relapsed Acute Myeloid Leukemia and High-Risk Myelodysplastic Syndrome

BACKGROUND

Relapsed acute myeloid leukemia (AML) and high-risk myelodysplastic syndrome (HR-MDS) are associated with a poor prognosis. It is unknown which re-induction therapy provides the highest chance of durable remission. Commonly used therapies are high dose cytarabine (HiDAC) and triple therapy consisting of fludarabine, cytarabine, and idarubicin combined with granulocyte colony-stimulating factor (FLAG-IDA).

METHODS

Two patient cohorts with relapsed AML or HR-MDS treated with HiDAC or FLAG-IDA between October 2015 and December 2021 in two academic hospitals in the Netherlands were retrospectively analyzed.

RESULTS

Patients were treated with either HiDAC (n=22) or FLAG-IDA (n=25). Rates of CR (71% vs. 74%, P=0.85), 1-year OS (47% vs. 51%, P=0.99) and EFS (38% vs. 35%, P=0.71) were comparable between HiDAC and FLAG-IDA. Durations of neutropenia (median 24 days (IQR 20-26) vs. 30 days (IQR 22-39), P=0.014) and thrombocytopenia (22 days (IQR 17-26) vs. 36 days (IQR 26-53)) were significantly shorter in the HiDAC group than in the FLAG-IDA group.

CONCLUSION

While remission rates and survival outcomes were similar, FLAG-IDA was associated with longer periods of myelosuppression and transfusion dependency compared to HiDAC in these two cohorts. HiDAC can be considered as a salvage chemotherapyfor relapsed AML/HR-MDS based on our study.

Clinical Impact of CD19 Expression Assessed by Quantitative PCR in Lymphoma Patients Undergoing CAR-T Therapy

Introduction

Current guidelines do not mandate CD19 tumor expression assessment before chimeric antigen receptor T-cell (CAR-T) therapy in large B-cell lymphoma (LBCL) patients due to limitations of immunohistochemistry (IHC) or flow cytometry. Quantitative polymerase chain reaction (qPCR) offers a more sensitive alternative for detecting CD19 expression, with the primary advantage that mRNA can be easily extracted from paraffin-embedded tissues.

Methods & Results

In our study, we included 51 adult patients with LBCL treated with axicabtagene ciloleucel. Among them, 16 were classified as CD19-negative by IHC; however, qPCR reclassified six (37.5%) as CD19-positive. We then compared the outcomes between consistently CD19-negative (IHC-qPCR-) and CD19-positive (IHC+ and IHC-qPCR+) patients. CD19-negative cohort showed worse 1-year progression-free survival (15 vs. 45%, p = 0.044) and a trend toward shorter duration of response (29 vs. 55%, p = 0.065). Only one (10%) of the CD19-negative patients remained alive and disease-free at last follow-up (6 months), having previously responded to bridge therapy.

Discussion

If confirmed in a large patient cohort, these findings could form the basis for modifying current patient selection criteria. Consistently negative patients may be suboptimal candidates for anti-CD19 CAR-T therapy. Alternative therapeutic options, such as bispecific antibodies or polatuzumab-based regimens, could be considered for this subset of patients.

Effects of expressive helping writing during stem cell transplant: Randomized controlled trial

OBJECTIVE

Most cancer patients undergoing hematopoietic stem cell transplant report elevated symptoms and reduced health-related quality of life during peritransplant. These concerns can become persistent. A prior randomized controlled trial showed that expressive helping-a low-burden, brief intervention combining expressive writing with a novel peer support writing exercise-reduced psychological distress and physical symptoms in long-term transplant survivors with moderate/high persistent symptoms. The Writing for Insight, Strength, and Ease trial evaluated the use of expressive helping during peritransplant, when symptoms peak and early intervention could prevent the development of persistent symptoms.

METHOD

Three hundred sixty-six adult blood cancer patients (44.3% female, 74.6% White, 13.4% Black, 11.5% Hispanic/Latinx) scheduled for allogeneic (33.9%) or autologous (66.1%) transplant were randomized to complete either expressive helping or a neutral writing task in four writing sessions beginning pretransplant and ending 4 weeks posthospital discharge. Symptom severity (primary outcome), distress (depressive symptoms, generalized and cancer-specific anxiety), health-related quality of life, and fatigue were measured in multiple assessments from prerandomization to 12 months postintervention. Primary endpoints at 3 and 12 months postintervention estimated short- and long-term intervention effects. Moderation analyses explored subgroup differences in intervention efficacy.

RESULTS

Mixed models with repeated measures analyses revealed no statistically or clinically significant intervention effects on primary or secondary outcomes. Moderation analyses did not identify subgroups of participants who benefitted from the intervention.

CONCLUSION

Findings do not support use of expressive helping during peritransplant. We recommend that survivors with persistent symptoms complete expressive helping at least 9 months posttransplant, consistent with evidence from a prior trial. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

Comparative analysis of allogeneic hematopoietic cell transplantation in patients with therapy-related and de novo acute promyelocytic leukemia A retrospective study

Although allogeneic hematopoietic cell transplantation (HCT) is an alternative treatment for relapsed or refractory (R/R) acute promyelocytic leukemia (APL), little is known regarding the utility of allogeneic HCT for R/R therapy-related APL (t-APL). We retrospectively analyzed data for 144 patients with APL (t-APL, n = 20 and de novo APL, n = 124) who received a first allogeneic HCT between 2008 and 2020. We found no significant differences in survival between the t-APL and de novo APL groups. The 3-year overall survival (OS) rates were 53.8% in the t-APL group and 52.4% in the de novo APL group. However, as previously reported, patients without complete remission (CR) at HCT had significantly worse OS than those with CR (P = 0.004). The 3-year OS rates were 61.1% in patients with CR and 36.5% in those without CR. These findings suggest that allogeneic HCT may be considered a viable treatment option for patients with t-APL and de novo APL, with an emphasis on achieving CR before transplantation to optimize outcomes. However, clinicians should be aware of the potential for worse outcomes in male patients and those with lower performance status, highlighting the need for personalized treatment approaches and careful patient selection.

Comparable Survival Outcomes in HLA-Matched and Haploidentical Hematopoietic Stem Cell Transplantation for Severe Aplastic Anemia Patients Aged 40-50: A CBMTR Registry-Based Propensity Score Matching Analysis Over the Last Decade

Our study includes 278 patients aged between 40 and 50 years from 29 centers who received allogeneic hematopoietic stem cell transplantation (allo-HSCT) from matched sibling donors (MSDs) (n=106) and haploidentical donors (HIDs) (n=172) over the last decade. Univariate analysis revealed that HID recipients was associated with more serious disease severity, a delayed allo-HSCT after diagnosis, a higher pretransplant transfusion burden and poor performance status pre-transplant than MSD recipients in clinical settings. After these pretransplant clinical factors were well balanced following propensity score-matching (PSM), 80 matched pairs were selected for further analysis. Following PSM, the cumulative incidences of neutrophil were comparable between two matched groups (P = 0.14), while the 100-day engraftment rates of platelet were significant lower in HID-HCT (P < 0.001); The HID cohort showed higher cumulative incidence of grade II-IV acute graft-versus-host disease (GVHD) compared with MSD group (P = 0.04). In contrast, the incidence of severe (grade III-IV) acute GVHD and chronic GVHD were not statistically significant (severe acute GVHD P = 0.10; chronic GVHD P = 0.28). Our study observed comparable overall survival (OS) (P = 0.14); failure free survival (FFS) (P = 0.23); GVHD-free/relapse-free survival (GRFS) (P = 0.26) between matched HID and MSD recipients. In conclusion, our data indicates that allo-HSCT from an HID could be considered for SAA patients between 40-50 years old who do not have an MSD.

Early cardiotoxicity in post-transplant cyclophosphamide-based graft-versus-host disease prophylaxis after HLA-haploidentical hematopoietic stem cell transplantation

INTRODUCTION

Post-transplant cyclophosphamide (PTCy)-based prophylaxis for graft-versus-host disease (GVHD) is widely used in HLA-haploidentical hematopoietic cell transplantation (haplo-HCT). One of the major drawbacks of PTCy is the risk of rare but potentially lethal cardiotoxicity, which prompted the development of regimens with reduced doses of PTCy.

METHODS

We retrospectively compared the incidence of early cardiotoxicity with standard-dose of PTCy (cyclophosphamide 50 mg/kg/day for 2 days, PTCy100) versus reduced-dose (40 mg/kg/day for 2 days, PTCy80). In total, 179 patients underwent PTCy-based haplo-HCT, including PTCy100 (n = 111) and PTCy80 (n = 68).

RESULTS

The PTCy80 group included significantly more elderly patients, patients who received reduced-intensity conditioning, and patients with a history of HCT than the PTCy100 group. Nine eligible patients (5.0%) experienced severe cardiotoxicity. The incidence of severe cardiotoxicity did not differ significant between PTCy80 and PTCy100 (4.4% vs. 5.4%; p = 1). The incidence of fatal cardiotoxicity was lower with PTCy80, but the small size may have prevented the difference from reaching statistical significance.

CONCLUSION

Reducing the cyclophosphamide dose in PTCy-based GVHD prophylaxis may lower the risk of fatal cardiotoxicity without significantly altering the overall incidence of severe cardiotoxicity.

Allo-HCT refined ELN 2022 risk classification: validation of the Adverse-Plus risk group in AML patients undergoing allogeneic hematopoietic cell transplantation within the Spanish Group for Hematopoietic Cell Transplantation (GETH-TC)

This multicenter retrospective study by GETH-TC validates the prognostic value of the Allo-HCT Refined ELN 2022 risk classification in allografted AML patients. The new classification refines the ELN 2022 risk classification, dividing adverse-risk patients into two subgroups: Adv-Plus (AdvP), including those with complex karyotype, MECOM (EVI1) rearrangement, or TP53 mutations/del(17p), and an additional adverse group (Adv*). The study included 651 AML patients treated with at least one line of anthracycline-based induction therapy and in complete remission. According to the Allo-HCT Refined ELN 2022 risk classification, 19.4% (n = 126) patients were classified into the Favorable (Fav) risk, 38.1% (n = 248) into the Intermediate (Int) risk, 27.2% (n = 177) in the Adv* and 15.4% (n = 100) in the AdvP. Outcomes were significantly poorer for patients allocated in the AdvP risk group (5-year OS rate: 32.3%, 5-year LFS rate: 24.3%, both p < 0.001 with the rest of subgroups) and a higher CIR (5-year CIR: 64.3%, p < 0.001). Patients in the Adv* risk group had similar outcomes than patients in the Int risk group (5-year OS rate: 70.2% vs. 66.7%, p = 0.69, 5-year LFS rate: 63.8% vs. 55.9%, p = 0.33). Multivariate analysis confirmed the dismal outcomes for AdvP patients for OS: Hazard Ratio (HR) = 3.05, and LFS: HR = 2.66, both p < 0.001. Our findings validate the Allo-HCT Refined ELN 2022 classification as a robust prognostic tool, particularly highlighting the poor outcomes for the AdvP subgroup.

Comparing Comorbidity Indices to Predict Survival After Pediatric Hematopoietic Stem Cell Transplantation for Nonmalignant Disease

BACKGROUND

Hematopoietic stem cell transplantation (HCT) is a potentially curative treatment for children with hematological or immunological disorders. However, treatment-related morbidity and mortality remain concerning. Various comorbidity indices are currently used to assess the risk of complications following pediatric HCT.

PROCEDURE

We compared four comorbidity indices to determine which can most accurately estimate the risk of morbidity and mortality in pediatric nonmalignant HCT. We analyzed 308 pediatric allogeneic nonmalignant HCTs performed between January 2010 and December 2022. Four indices were evaluated: hematopoietic stem cell transplantation-specific comorbidity index (HCT-CI), youth nonmalignant hematopoietic stem cell transplantation comorbidity index (ynHCT-CI), simplified ynHCT-CI, and simplified comorbidity index (SCI). The primary outcome was overall survival (OS). The secondary outcome was graft-versus-host disease (GvHD)-free event-free survival (EFS), defined as acute GvHD Grade 3 or 4, extensive chronic GvHD, retransplantation, or death. The area under the receiver operator characteristic curve (AUC) was calculated per index and outcome at 100 days, 1 year, and 2 years post-HCT.

RESULTS

For OS, AUC values ranged from 0.611 to 0.755. The simplified ynHCT-CI and ynHCT-CI generally had superior discriminative abilities for OS, although no significant difference was found. For EFS, AUC values were between 0.539 and 0.632. The ynHCT-CI performed best for EFS, with AUC values of the simplified ynHCT-CI marginally lower. The ynHCT-CI significantly outperformed the HCT-CI at 100 days post transplantation (p = 0.045).

CONCLUSION

The ynHCT-CI most accurately predicted outcomes after pediatric nonmalignant HCT. We propose the use of ynHCT-CI in future clinical management guidelines in this cohort.

Non-myeloablative Allogeneic Haematopoietic Stem Cell Transplantation for Myelofibrosis. A Population-Based Study from Eastern Denmark

BACKGROUND

Myeloablative conditioning (MAC) and reduced intensity conditioning (RIC) regimens are both used before allogeneic haematopoietic stem cell transplantation (allo-HCT) for myelofibrosis (MF). The median age of patients with MF treated with allo-HCT is increasing and a high non-relapse mortality (NRM), especially to MAC, has increased utilisation of lesser intense non-myeloablative (NMA) regimens. NMA is used as the standard conditioning regimen before allo-HCT for MF at all transplantation centres in Denmark.

OBJECTIVES

To describe the outcomes of a highly homogenously treated, population derived cohort of MF-patients who received NMA conditioning prior to allo-HCT, and identify factors associated to transplantation outcomes.

STUDY DESIGN

The study is a retrospective cohort study of MF-patients treated with NMA prior to allo-HCT at Copenhagen University Hospital, Rigshospitalet from 2007 to 2023.

RESULTS

Of 70 patients with MF who were treated with allo-HCT for MF from 2007 to 2023, 67 patients received NMA conditioning with fludarabine 90 mg/m2 and total body irradiation of 2-4 Gray. These 67 patients had a median age of 61.1 years, 22 patients (33%) had a Karnofsky performance status below 90, and 28 patients (44%) had a haematopoietic-stem-cell-transplantation comorbidity index (HCT-CI) above 2. With a median follow-up time of 3.4 years (range 0.16-15.58 years), 39 patients (58%) were still alive. Eighteen patients (27%) relapsed and of the 28 patients (42%) that died during the study period, 12 (43%) died from relapse, and 16 (57%) from NRM. Median time to neutrophil engraftment, transfusion independency and platelet engraftment was 21 days (range 11 - 119 days), 69 days (range 0 - 470 days) and 17 days (range 0 - 308 days) respectively with primary graft failure identified in 13 patients (19.7%). Overall survival (OS) after 1, 3, and 5 years was 77%, 68%; 61% %, whereas the NRM was 15%, 15% and 21%. The cumulative incidence of relapse (CIR) was 24% after 1 year, 28 % after 3 years and 28% after 5 years. Multivariable analysis showed that male sex (HR= 5.43, p<0.001), graft from unrelated donor (HR= 3.58, p=0.018) and HCT-CI above 2 (HR= 2.5, p=0.025) remained associated to OS, whereas for progression-free survival, only NRAS mutations remained as an independent factor (HR= 5.88, p=0.013). Both male sex (HR= 8.41, p=0.037) and graft from unrelated donor (HR= 3.15, p=0.043) were associated to NRM in multivariable analysis.

CONCLUSION

NMA conditioning in the form of low dose TBI and fludarabine before allo-HCT for MF is feasible. Patients show low 1-year NRM but a relatively high 1-year CIR. Differentiated conditioning with more intensive RIC regiments for younger and fit patients could be considered to reduce the early relapse rate without increasing NRM. In survival analysis, donor-patient relation, patient comorbidity burden and patient sex were independently associated to OS.

Clinical effects of granulocyte colony-stimulating factor administration and the timing of its initiation on allogeneic hematopoietic cell transplantation outcomes for myelodysplastic syndrome

BACKGROUND

Granulocyte colony-stimulating factor (G-CSF) accelerates neutrophil recovery after allogeneic hematopoietic cell transplantation (HCT). However, the optimal use of G-CSF and the timing of its initiation after allogeneic HCT for myelodysplastic syndrome (MDS) according to graft type have not been determined.

OBJECTIVE

This retrospective study aimed to investigate the effects of using G-CSF administration and the timing of its initiation on transplant outcomes in adult patients with MDS undergoing allogeneic HCT.

STUDY DESIGN

Using Japanese registry data, we retrospectively investigated the effects of G-CSF administration and the timing of its initiation on transplant outcomes among 4,140 adults with MDS after bone marrow transplantation (BMT), peripheral blood stem cell transplantation (PBSCT), or single-unit cord blood transplantation (CBT) between 2013 and 2022.

RESULTS

Multivariate analysis showed that early (days 0-4) and late (days 5-10) G-CSF administration significantly accelerated neutrophil recovery compared with no G-CSF administration following BMT, PBSCT, and CBT, but there was no benefit of early G-CSF initiation for early neutrophilic recovery regardless of graft type. Late G-CSF initiation was significantly associated with a higher risk of overall chronic GVHD following PBSCT (hazard ratio [HR], 1.63; 95% confidence interval [CI], 1.18 to 2.24; P = 0.002) and CBT (HR, 2.09; 95% CI, 1.21 to 3.60; P = 0.007) compared with no G-CSF administration. Late G-CSF initiation significantly improved OS compared with no G-CSF administration only following PBSCT (HR, 0.74; 95% CI, 0.58 to 0.94; P = 0.015). However, G-CSF administration and the timing of its initiation did not affect acute GVHD, relapse, or non-relapse mortality, irrespective of graft type.

CONCLUSION

These results suggest that G-CSF administration significantly accelerated neutrophil recovery after BMT, PBSCT, and CBT, but increased risk of overall chronic GVHD after PBSCT and CBT. However, the effect of early and late G-CSF initiation on transplant outcomes needs further study in adult patients with MDS.

Fludarabine Plus Myeloablative Dose of Busulfan Regimen Was Associated with High Nonrelapse Mortality in Allogeneic Hematopoietic Stem Cell Transplantation for Malignant Lymphoma: A Propensity Score-Matched Comparison Study with Fludarabine Plus High-Dose Melphalan

In recent years, there have been notable advancements in the treatment of malignant lymphoma. However, a certain percentage of patients are unlikely to achieve a cure through chemotherapy alone. Therefore, allogeneic hematopoietic stem cell transplantation (allo-HSCT) remains a crucial curative treatment for malignant lymphoma. FluBu4, comprising fludarabine (Flu) combined with a myeloablative dose of intravenous busulfan (Bu; 12.8 mg/kg in total), is a widely used conditioning regimen for allo-HSCT, but its usefulness in malignant lymphoma (ML) has not been fully investigated. The objective of this study was to evaluate the efficacy and safety of FluBu4 in allo-HSCT for lymphoma by comparing the outcomes of two conditioning regimens: FluBu4 and FluMel140. We used a Japanese national database from the Transplant Registry Unified Management Program to retrospectively analyze the first allo-HSCT for ML in patients aged ≥16 years. Allo-HSCT cases treated with posttransplant cyclophosphamide were excluded. Two groups, namely FluBu4 and FluMel140 were selected by propensity score matching (PSM) with a case ratio of 1:2. From 921 cases, 113 were selected by PSM for the FluBu4 group and 226 for the FluMel140 group. The median age was 54 (19 to 68) years, the median observation period of survivors was 33.8 months, and 145 (42.7%) had a history of autologous HSCT. There were no significant differences in patients' backgrounds between the two groups after PSM. Three-year overall survival (OS) was significantly worse for FluBu4 than for FluMel140 (28.0% versus 48.6%; P < .01). The 3-year cumulative relapse rate was comparable for FluBu4 and FluMel140 (40.1% versus 38.5%; P = .65). However, 3-year nonrelapse mortality was significantly higher for FluBu4 than for FluMel140 (35.3% versus 22.5%; P = .02). There was no significant difference between the two treatment groups in the cumulative incidence of acute graft-versus-host disease (aGVHD) at day 100 after allo-HSCT and the 3-year cumulative incidence of chronic GVHD. While the common and major cause of death was the relapse of lymphoma, aGVHD, and noninfectious lung complications were observed more frequently with FluBu4 than with FluMel140. One-year cumulative incidence of interstitial pneumonia was significantly higher for FluBu4 than for FluMel140 (5.3% versus 0.4%; P = .03). FluBu4 use was associated with worse nonrelapse mortality (NRM) and OS in allo-HSCT for ML compared with FluBu4 and FluMel140 adjusted by PSM. Patients treated with FluBu4 had a higher incidence of noninfectious pulmonary complications and an increased number of associated deaths. A higher rate of NRM in the patients treated with FluBu4 was particularly evident in patients aged ≥60, and its use should be avoided in this patient population.

Efficacy and safety of primary letermovir prophylaxis for cytomegalovirus infection in paediatric patients undergoing allogeneic transplantation: a single-centre, retrospective, real-world analysis

Background

Cytomegalovirus (CMV) infection is a common and life-threatening complication following allogeneic haematopoietic stem cell transplantation (allo-HSCT). Letermovir (LET) has been the standard prophylaxis for adult recipients, but studies in children remain limited.

Methods

We retrospectively analyzed children with or without LET prophylaxis after haploidentical donor (HID) for the Beijing protocol or unrelated cord blood (UCB) transplantation.

Results

Of the 151 patients, 67 received LET, including 35 HID recipients and 32 UCB recipients. During the 180 days after transplantation, we found that the LET group had a lower incidence of clinically significant CMV infection (csCMVi) than the non-LET group (13.4% vs. 56.0%, P＜0.001). In the LET group, later LET administration was identified as a risk factor for the occurrence of csCMVi (HR: 1.07, 95% CI: 1.01 - 1.14, P=0.029). Further, the HID subgroup had a lower incidence of csCMVi during follow-up than the UCB subgroup (2.9% vs. 25.0%, P=0.009). In terms of safety, the incidence and severity of adverse events, overall survival, cumulative incidence of relapse, relapse free survival, nonrelapse mortality and graft versus host disease-free, relapse-free survival were similar between the two groups.

Conclusion

LET is effective and safe in preventing csCMVi among Chinese children undergoing allo-HSCT. Compared to UCB recipients, children undergoing HID transplantation for the Beijing protocol develop less scCMVi up to 180 days post-HSCT.

Allogeneic stem cell transplantation for MDS-clinical issues, choosing preparative regimens and outcome

Despite the vast heterogeneity of myelodysplastic neoplasm (MDS), treatment options are limited and an allogeneic hematopoietic stem cell transplantation (allo-HSCT) remains the only curative approach. While, subsequently, allo-HSCT is the treatment of choice in fit high-risk MDS patients younger than 70 years, it should only be considered in young and fit low-risk MDS patients who suffer from severe and life threatening cytopenias, and fail all available conservative treatment options. With the increasing use of mismatched or haploidentical donors, the majority of MDS patients will have a suitable donor available, however, matched donors should still be preferred if rapidly available. Strategies to prevent relapse after allo-HSCT are scarce, and include the use of donor lymphocytes or the experimental use of hypomethylating agents in patients with impeding relapse detected by MRD or chimerism evaluation. Here, we summarize current treatment options and factors to consider in the context of allo-HSCT in MDS.

Advancing drug development in myelodysplastic syndromes

ABSTRACT

Myelodysplastic syndromes/neoplasms (MDSs) are heterogeneous stem cell malignancies characterized by poor prognosis and no curative therapies outside of allogeneic hematopoietic stem cell transplantation. Despite some recent approvals by the US Food and Drug Administration, (eg, luspatercept, ivosidenib, decitabine/cedazuridine, and imetelstat), there has been little progress in the development of truly transformative therapies for the treatment of patients with MDS. Challenges to advancing drug development in MDS are multifold but may be grouped into specific categories, including criteria for risk stratification and eligibility, response definitions, time-to-event end points, transfusion end points, functional assessments, and biomarker development. Strategies to address these challenges and optimize future clinical trial design for patients with MDS are presented here.

Prognostic impact of effusion in multiple body cavities after allogeneic hematopoietic stem cell transplantation

Fluid retention presenting as effusions in body cavities is sometimes encountered following allogeneic stem cell transplantation (allo-HSCT). It is unclear whether cavity effusions at independent sites may serve as cumulative correlates of fluid overload and whether a higher number of effusion sites are associated with a worse prognosis. Here, we comprehensively reviewed pleural, peritoneal, and pericardial effusions in 178 first allo-HSCT recipients retrospectively. A total of 123 (69.1%) patients developed effusions in any cavity. New pleural, peritoneal, and pericardial effusions were found after allo-HSCT in 106, 88, and 53 patients, at a median of 38.0 (range, 2-2950), 22.5 (range, 2-1324), and 40 (range, 2-945) days, respectively. The cumulative incidence at day 100 was 41.0%, 40.4%, and 20.8%, respectively. Of the 92 patients who presented with effusions by day 100, 28 patients presented with effusion in a single cavity, 39 in two cavities, and 25 in all three cavities. The 2-year overall survival rates of patients with effusions in zero, one, two, and three cavities by day 100 were 86.1%, 60.0%, 59.6%, and 18.8%, respectively, showing an additive adverse association with outcome. Prospective studies to further characterize fluid dynamics following allo-HSCT are warranted.

Post-Transplant Cyclophosphamide-Based GVHD Prophylaxis After Peripheral Blood Stem Cell HLA Identical Transplantation in Patients with Lymphoma: A Prospective Observational Study

Allogeneic stem cell transplantation (allo-SCT) from HLA-identical donors (HLAid) could be an effective salvage treatment for relapsed/refractory lymphoma. In this setting, standard graft-versus-host disease (GVHD) prophylaxis is based on cyclosporine and methotrexate, with the addition of anti-thymocyte globulin, at least for matched, unrelated donors. Promising data using post-transplant cyclophosphamide (PT-Cy) have been reported from retrospective studies in patients receiving allo-SCT from HLAid donors. Here, we report the results of a single-center, prospective observational study exploring the main outcomes of GVHD prophylaxis based on PT-Cy in 27 patients receiving HLAid donor transplantation for relapsed/refractory lymphoma. With a median follow-up of 38 months, 3-year GVHD-relapse-free survival and PFS and OS were 70.4%, 81.5%, and 88.9%, respectively. The 1-year cumulative incidence (CI) of non-relapse mortality (NRM) was 7.4%. The 6-month CI of acute GVHD was 7.4%, and the 1-year CI of extensive chronic GVHD was 7.7%, with no grade IV GVHD events or deaths from GVHD. Relapse was reported in three patients (1-year relapse incidence: 11%), and two died of progressive disease. No graft failure was observed. This study shows that PT-Cy may be an effective strategy to prevent GVHD in patients with lymphoma receiving HLAid transplantation. It is associated with low NRM and reasonable disease control.

Clonal Evolution of Myeloid Malignancies Treated With Microtransplantation: A Single-Centre Experience

Microtransplantation is a cellular therapy used in acute myeloid leukaemia and myelodysplastic syndromes as a maintenance therapy in patients ineligible for a regular allogeneic stem cell transplantation. We performed a monocentric retrospective study of acute myeloid leukaemia, myelodysplastic syndromes, and chronic myelomonocytic leukaemia patients who underwent microtransplantations at Nice University Hospital. We analysed the evolution of the disease mutational status after microtransplantation. We report 18 patients who underwent microtransplantation courses, with a total of 47 microtransplantations performed between February 2020 and June 2022. We observed long-term remissions even in high-risk patients. Founder mutations persisted throughout the follow-up, whereas it was more variable for other nonfounder mutations, with most of the nonfounder mutations variant allele frequency decreasing over time. Safety data were reassuring; no graft versus host disease was recorded, and cytokine release syndromes were manageable. Relapses or progressions were associated with the emergence or increase of a TP53 mutated clone. Microtransplantation is a promising therapy for patients ineligible for regular allogeneic stem transplantation. Further larger and randomised studies are required to establish its place as a maintenance therapy in myeloid malignancies.

Outcomes of Allogeneic Hematopoietic Stem Cell Transplantation in Patients Aged 70 Years and Older: A Systematic Review and Meta-Analysis

Allogeneic hematopoietic cell transplantation (allo-HCT) is a potential cure for many hematological malignancies. Historically, older adults were not considered eligible for allo-HCT due to increased toxicity and mortality concerns. This systematic review and meta-analysis aim to explore the outcomes of allo-HCT in patients aged 70 years or older. Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, a comprehensive literature search was performed on PubMed, Cochrane Register of Controlled Trials, and Clinicaltrials.gov using MeSH terms and keywords for "Hematopoietic Stem Cell Transplantation" AND "Outcome Assessment" from the date of inception to June 30, 2024. Our search produced 102 articles. After excluding irrelevant and review articles during primary and secondary screening, eight original studies reporting outcomes of allo-HCT in patients aged 70 years or older were included. The survival data were retrieved from Kaplan-Meier (KM) curves using an online plot digitizer tool to calculate the overall survival (OS) and disease-free survival (DFS). The pooled KM curves were plotted and analyzed using the "MetaSurvival" package of R software version 4.2.1. Proportions and 95% confidence intervals (CIs) were extracted as well. A total of 2519 patients aged 70 years or older with allo-HCT were included in the analysis. The included patients' age ranged from 70 to 84 years, and 68% were male. Median follow-up was 23.2 (0.4 to 122.5) months. The combined median OS was 14.84 months (95% CI: 11.61 to 19.50), with OS rates at 6, 12, 24, and 36 months of 71.8%, 54.5%, 41.9%, and 34.9%, respectively. The estimated pooled mean OS was 28.62 months (95% CI: 23.41 to 31.44). The pooled median DFS was 10.54 months (95% CI: 7.93 to 14.17), with DFS rates at 6, 12, 24, and 36 months of 61.5%, 47.5%, 37%, and 30.6%, respectively. The estimated pooled mean DFS was 24.45 months (95% CI: 18.30 to 23.74). The relapse rate ranged from 28% to 55.6%, while non-relapsed mortality ranged from 5.6% to 42%. The acute graft versus host disease (GvHD) incidence varied from 9.3% to 32%, while chronic GvHD rates ranged from 10% to 43%. Allo-HCT provides promising outcomes for patients aged 70 or older with transplant-eligible diseases. Disease progression, followed by infections, is the leading cause of mortality, underscoring the need for improved post-transplant care, including optimized GvHD regimens and strategies to reduce infection risk.

Clinical outcomes of three haploidentical transplantation protocols for hematologic malignancies based on data from the Chinese Bone Marrow Transplantation Registry Group

This study aimed to demonstrate the clinical outcomes of granulocyte colony-stimulating factor (G-CSF)/antithymocyte globulin (ATG), posttransplantation cyclophosphamide (PTCy) and PTCy combined with low-dose ATG (PTCy with ATGlow)-based haploidentical transplantation protocols in patients with hematologic malignancies. The comparisons were conducted via propensity score matching (PSM) analysis to balance the basic characteristics among different groups and were based on the transplantation data reported to the Chinese Bone Marrow Transplantation Registry Group (CBMTRG) from January 2020 to December 2022. For each patient in the PTCy or PTCy with ATGlow group, patients (at a 1:2 ratio) from the G-CSF/ATG group were selected. In total, the PTCy group (N=122) was matched with the G-CSF/ATG group 1 (N=230), and the PTCy+ATGlow group (N=123) was matched with the G-CSF/ATG group 2 (N=226). Compared with those in the PTCy group, the incidences of 28- day neutrophil engraftment (P=0.005), 100-day platelet engraftment (P=0.002), median time to neutrophil engraftment (P<0.001) and platelet engraftment (P=0.011) were significantly greater in the G-CSF/ATG group. No significant differences were observed in acute graft-versus-host disease (aGVHD) incidence or relapse incidence. In addition, patients in the G-CSF/ ATG group had lower non-relapse mortality (NRM; P<0.001), better 3-year overall survival (OS; P<0.001) and leukemia-free survival (P<0.001) rates than those in the PTCy group. Similarly, the G-CSF/ATG group achieved lower NRM (P<0.001) and better 3-year leukemia-free survival (P=0.002) than the PTCy+ATGlow group. In conclusion, G-CSF/ATG-based haplo-HSCT may be a preferential choice for the Chinese population with hematologic malignancies. In the future, a randomized controlled study is needed for further confirmation.

Remdesivir for the Treatment of Human Coronavirus OC43 Encephalitis

Human coronavirus OC43 (HCoV-OC43) is predominantly associated with mild respiratory infections. HCoV-OC43 also has neuroinvasive properties, and severe encephalitis has been described in immunocompromised patients, with fatal outcomes due to the lack of specific antiviral treatment. We report a case of severe febrile encephalitis attributed to HCoV-OC43 that progressively worsened over 3 months in a 65-year-old immunocompromised man. Clinical symptoms improved remarkably after treatment with remdesivir, with an increase of the Glasgow Coma Score from 8 to 14 within 7 days.

Allogeneic hematopoietic stem cell transplantation using reduced intensity conditioning regimen for patients with acute myeloid leukemia not in complete remission

BACKGROUND

Allogeneic hematopoietic stem cell transplantation (HSCT) is the only potentially curative treatment option for patients with refractory and relapsed acute myeloid leukemia (R/R AML) not in complete remission. Many studies investigating the prognosis of patients with R/R AML not in remission focused on patients who received myeloablative conditioning regimen (MAC). Conversely, reduced intensity conditioning regimen (RIC) could be a considerable conditioning regimen for some patients because of the high frequency of R/R AML in older patients who are not candidates for MAC.

OBJECTIVE

This study aimed to evaluate the prognosis and identify factors associated with outcomes in patients with R/R AML who underwent allogeneic HSCT with RIC.

STUDY DESIGN

This study included 707 adult patients with AML not in complete remission who had received RIC. The primary endpoint was progression-free survival (PFS), which was estimated using the Kaplan-Meier method. Prognostic factors were identified using a Cox proportional hazards model with multiple imputations using a chained equation approach.

RESULTS

The 5-year PFS, overall survival, relapse, and nonrelapse mortality were 18.8% (95% confidence interval [CI]: 15.6-22.2), 22.0% (95% CI: 8.5-25.7), 53.6% (95% CI 49.7-57.4%) and 27.5% (95% CI: 24.0-31.2), respectively. Multivariable analysis revealed that male sex, poor performance status, karyotype risk, and blasts in the peripheral blood were significantly associated with PFS.

CONCLUSIONS

This study identified prognostic factors in patients with R/R AML not in complete remission. These results can help to develop a transplant strategy for the treatment of R/R AML.

Transplantation outcomes of TP53-mutant AML and MDS: a single transplantation center experience of 63 patients

Allogeneic hematopoietic stem cell transplantation is recommended for TP53-mutant acute myeloid leukemia (AML) and myelodysplastic syndromes (MDS) despite a high relapse rate and poor survival. To understand TP53 alterations on a molecular level and define stratified prognostic outcomes following transplantation, we performed targeted next-generation sequencing on 63 patients who underwent transplantation for TP53-mutant AML/MDS and profiled their molecular spectrum. Sixty-eight TP53 mutations were detected, with a median variant allele frequency of 46.8%. Copy number alterations at the TP53 locus were present in 19 patients (30%). Complex karyotype was detected in 48 patients (76%) and was significantly associated with larger TP53 clone size, bi-allelic status, and the absence of concurrent mutations, reflecting the high TP53 mutational burden. Specifically, 51 patients (81%) with the dominant TP53 clone greatly overlapped with those with the complex karyotype. Multivariable overall survival (OS) analysis identified AML (hazard ratio [HR], 2.51; P = 0.03) and TP53 clonal dominance (HR, 5.30; P = 0.002) as prognostic factors. One-year OS was worse in AML with the dominant TP53 clone than in others (13% vs 61%; P < 0.001). Our results underscore the utility of mutational profile-guided risk stratification in patients with TP53-mutant AML/MDS, and could aid in transplantation-related decision-making.

Retrospective Analysis of Tacrolimus Levels: The First 56 Days Following Allogeneic Hematopoietic Stem Cell Transplant and Patient Outcomes

BACKGROUND

Despite prophylaxis, acute graft-versus-host disease (aGVHD) occurs in up to 40% to 60% of patients undergoing an allogeneic hematopoietic stem cell transplantation (alloHSCT). Tacrolimus remains a common GVHD prophylactic medication used in combination with mycophenolate or methotrexate.

OBJECTIVE

The purpose of this study was to compare tacrolimus levels up to day +56 to clinical outcomes in patients who underwent alloHSCT.

METHODS

This was a retrospective cohort study of adult patients who underwent alloHSCT between January 2009 and April 2019 at Oregon Health and Science University (OHSU) Hospital. A logistic regression analysis was performed using SAS software to evaluate the association between tacrolimus concentration range and the GVHD grade outcome.

RESULTS

There were 295 patients included in the study. The median patient age was 53 years (range 18-72), the majority were males (55%), with a median comorbidity index of 2 (range 0-9). Most patients received peripheral blood stem cell transplant (95%). The median tacrolimus levels were divided into 4 groups: (1) between 3.8 and 4.9 ng/mL, (2) 5.0 and 7.9 ng/mL, (3) 8.0 and 9.9 ng/mL, and (4) 10.0 and 10.7 ng/mL in 8 (2.7%), 206 (69.8%), 71 (24.1%), and 10 (3.4%) of patients, respectively. The odds ratio of 0.193 (95% confidence interval [CI]: 0.045-0.836) suggested that patients in the tacrolimus 8 to 12 ng/mL range were approximately 80.5% less likely to have grade 3 to 4 aGVHD compared to those in the 5 to 8 ng/mL range.

CONCLUSION AND RELEVANCE

Overall, we found that higher levels of tacrolimus (range 8-12 ng/mL) in the first 8 weeks post-transplant were associated with improved outcomes without increased rate of relapse.

Pre-transplant and transplant parameters predict long-term survival after hematopoietic cell transplantation using machine learning

BACKGROUND

Allogeneic hematopoietic stem transplantation (allo-HSCT) constitutes a curative treatment for various hematological malignancies. However, various complications limit the therapeutic efficacy of this approach, increasing the morbidity and decreasing the overall survival of allo-HSCT recipients. In everyday clinical practice, various laboratory and clinical biomarkers and scorning systems have been developed and implemented focusing on the recognition of high-risk patients for organ dysfunction-related complications and those who might experience low overall survival. However, the predictive accuracy of developed scores has been reported deficient in some studies. The aim of the current retrospective study is to develop a machine learning (ML) model to predict the long-term survivorship of patients who receive allo-HSCT based on clinical pre- and post-allo-HSCT variables, and on transplantation-related characteristics.

METHODS

For this purpose, a database of 564 allo-HSCT recipients incorporating 16 clinical and laboratory variables and the survivorship status of the patients during follow-up (Alive, Dead, Alive but follow-up less than 24 months) was used. An ML model was developed and tested, based on the previously published Data Ensemble Refinement Greedy Algorithm (DEGRA) algorithm.

RESULTS

A predictive ML model was built with 92.02 % accuracy. The eight parameters included in the algorithm were the following: CD34+ cells infused, patients' age and gender, conditioning regimen toxicity, disease risk index (DRI), graft source, and platelet and neutrophil engraftment.

CONCLUSION

To our knowledge, this is the first AI model incorporating post-HSCT variables for the prediction of mortality in adult HSCT recipients. In the era of precision medicine, the recognition of patients who undergo allo-HSCT and face a great risk for mortality and morbidity, with high-accuracy algorithms is crucial.

A randomized controlled trial of conventional GVHD prophylaxis with or without teprenone for the prevention of severe acute GVHD

Therapies that effectively suppress graft-versus-host disease (GVHD) without compromising graft-versus-leukemia/lymphoma (GVL) effects is important in allogeneic hematopoietic stem cell transplantation (allo-HSCT) for hematopoietic malignancies. Geranylgeranylacetone (GGA) is a main component of teprenone, a gastric mucosal protectant commonly used in clinical practice. In preclinical models, GGA suppresses proinflammatory cytokines, including interleukin (IL)-1β, IL-6, and tumor necrosis factor-α (TNF-α), which are associated with GVHD as well as induces thioredoxin-1 (Trx-1), which suppresses GVHD while maintaining GVL effects. Here, we investigated whether the addition of teprenone to standard GVHD prophylaxis could reduce the cumulative incidence of severe acute GVHD (aGVHD) without attenuating GVL effects. This open-label, randomized clinical trial enrolled 40 patients (21 control and 19 teprenone group) who received allo-HSCT between May 2022 and February 2023 in our institution. Patients in the teprenone group received 50 mg of teprenone orally thrice daily for 21 days from the initiation of the conditioning regimen. The cumulative incidence of severe aGVHD by day 100 after allo-HSCT was not significantly different in the two groups (27.9 vs. 16.1%, p = 0.25). The exploratory studies revealed no obvious changes in Trx-1 levels, but the alternations from baseline in IL-1β and TNF-α levels at day 28 after allo-HSCT tended to be lower in the teprenone group. In conclusion, we could not demonstrate that teprenone significantly prevented the development of severe aGVHD. Discrepancy with preclinical model suggests that appropriate dose of teprenone may be necessary to induce the expression of antioxidant enzymes that suppress severe aGVHD. Clinical Trial Registration number:jRCTs 061210072.

A model for predicting day-100 stem cell transplant-related mortality in AL amyloidosis

Autologous stem cell Transplant (ASCT)-related mortality (TRM) in AL amyloidosis remains elevated. AL amyloidosis patients (n = 1718) from 9 centers, transplanted 2003-2020 were included. Pre-ASCT variables of interest were assessed for association with day-100 all-cause mortality. A random forest (RF) classifier with 10-fold cross-validation assisted in variable selection. The final model was fitted using logistic regression. The median age at ASCT was 58 years. Day-100 TRM occurred in 75 patients (4.4%) with the predominant causes being shock, high-grade arrhythmia, and organ failure. Ten factors were associated with day-100 TRM on univariate analysis. RF classifier using these variables generated a model with an area under the curve (AUC) of 0.72 ± 0.12. To refine the model selection using importance hierarchy function, a 4-variable model [NT-proBNP/BNP, serum albumin, ECOG performance status (PS), and systolic blood pressure] was built with an AUC of 0.70 ± 0.12. Based on logistic regression coefficients, ECOG PS 2/3 was assigned two points while other adverse predictors 1-point each. The model score range was 0-5, with a day-100 TRM of 0.46%, 3.2%, 5.8%, and 14.5% for 0, 1, 2, and ≥3 points, respectively. This model to predict day-100 TRM in AL amyloidosis allows better-informed decision-making in this heterogeneous disease.

US Geriatric Assessment Practices for Older Adults Undergoing Hematopoietic Cell Transplantation or Chimeric Antigen Receptor T Cell Therapy: An American Society for Transplantation and Cellular Therapy Physician Survey from the Aging Special Interest Group and Committee on Practice Guidelines

Geriatric assessment (GA) may identify vulnerabilities and promote risk-stratification in older adults predisposed to toxicities after autologous (auto), allogeneic (allo) hematopoietic cell transplantation (HCT) and chimeric antigen T-cell therapies (CAR T). With increased utilization cellular therapies for older adults the American Society for Transplantation and Cellular Therapy (ASTCT) Committee on Practice Guidelines and its Special Interest Group for Aging (SIG) conducted an online cross-sectional survey between April 2023 and August 2023 to determine transplantation and cellular therapy physicians' practice patterns regarding GA in older patients receiving HCT and CAR T-cell therapies. E-mail surveys were sent to 1168 ASTCT physician members and only 96 (8.2%) respondents completed the survey. Most (86%) were affiliated with university/teaching centers and 70% had a combined HCT and cellular therapy practice. More than 50% of respondents were interested in pursuing GA but 68% described barriers. The top two recognized barriers to GA were lack of time (96%) and clinical support staff (90%). Despite interest, only 15% respondents reported to know the domains of GA 'well'. Among those using GA, the minimum age used for routine GA was 65 years for allo-HCT and CAR T in over 91% respondents. Taken together, we recommend the HCT community leadership and GA experts combine efforts to address the gap in GA uptake and implementation.

Measurable residual disease as predictor of post-day +100 relapses after allografting in adult AML

ABSTRACT

Measurable residual disease (MRD) by multiparametric flow cytometry (MFC) before allogeneic hematopoietic cell transplantation (HCT) identifies patients at high risk of acute myeloid leukemia (AML) relapse, often occurring early after allografting. To examine the role of MFC MRD testing to predict later relapses, we examined 935 adults with AML or myelodysplastic neoplasm/AML transplanted in first or second morphologic remission who underwent bone marrow restaging studies between day 70 and 100 after HCT and were alive and without relapse by day +100. Of 935 adults, 136 (15%) had MRD before HCT, whereas only 11 (1%) had MRD at day +70 to +100. In day +100 landmark analyses, pre-HCT and day +70 to +100 MFC MRD were both associated with relapse (both P < .001), relapse-free survival (RFS; both P < .001) overall survival (OS; both P < .001), and, for post-HCT MRD, nonrelapse mortality (P = .001) after multivariable adjustment. Importantly, although 126/136 patients (92%) with MRD before HCT tested negative for MRD at day +70 to +100, their outcomes were inferior to those without MRD before HCT and at day +70 to +100, with 3-year relapse risk of 40% vs 15% (P < .001), 3-year RFS of 50% vs 72% (P < .001), and 3-year OS of 56% vs 76% (P < .001), whereas 3-year nonrelapse mortality estimates were similar (P = .53). Thus, despite high MRD conversion rates, outcomes MRD positive/MRD negative (MRDneg) patients are inferior to those of MRDneg/MRDneg patients, suggesting all patients with pre-HCT MRD should be considered for preemptive therapies after allografting.

PTCy-based graft-versus-host disease prophylaxis for matched sibling donor allogeneic hematopoietic cell transplantation

ABSTRACT

Posttransplant cyclophosphamide (PTCy) is a promising graft-versus-host disease (GVHD) prophylaxis in haploidentical and matched unrelated donor hematopoietic stem cell transplantation (HSCT), but its role in matched sibling donor (MSD) transplants remains unclear. We conducted a retrospective study of 413 MSD-HSCT patients receiving peripheral blood stem cell (PBSC) grafts from January 2010 to January 2023. Patients were categorized into 4 groups: group I (calcineurin inhibitor [CNI] + methotrexate [MTX] or mycophenolate mofetil [MMF]), group II (CNI + MTX or MMF + antithymocyte globulin [ATG]), group III (PTCy + ATG + CNI), and group IV (PTCy + CNI + MMF). PTCy was associated with a significant reduction in grade 2- 4 and grade 3-4 acute GVHD and moderate-to-severe chronic GVHD compared with CNI + MTX (or MMF)-containing regimens. PTCy did not increase relapse risk; PTCy reduced nonrelapse mortality, leading to improved GVHD-free/relapse-free survival (GRFS; Hazard Ratio, 0.4; P < .001). PTCy was also associated with improved overall survival. Bloodstream infections were increased with PTCy. The addition of ATG to PTCy did not further improve GRFS and was associated with a higher incidence of clinically significant cytomegalovirus (csCMV) and Epstein-Barr virus (csEBV) reactivation and a numerical increase in NRM. PTCy significantly appeared to improve GRFS in the MSD setting using PBSC grafts. The addition of ATG to PTCy increases csCMV and csEBV reactivation without further improving GRFS. Prospective trials and PTCy dose optimization are warranted.

Real-world outcomes with tisagenlecleucel in aggressive B-cell lymphoma: subgroup analyses from the CIBMTR registry

BACKGROUND

Tisagenlecleucel, a CD19 chimeric antigen receptor T-cell therapy, is approved for adults with relapsed or refractory (R/R) diffuse large B-cell lymphoma (DLBCL) or high-grade B-cell lymphoma (HGBCL) after ≥2 lines of therapy. When used in real-world settings, tisagenlecleucel has shown similar efficacy and improved safety compared with previous clinical trials. However, long-term data on real-world outcomes are lacking.

METHODS

Clinical data from a cohort of patients treated with tisagenlecleucel in a real-world setting were captured in the Center for International Blood and Marrow Transplant Research registry. The main clinical outcomes analysed included response rate, duration of response, survival, adverse events and clinicopathologic and treatment characteristics that may affect those outcomes.

RESULTS

As of May 2022, 1159 patients with R/R DLBCL/HGBCL received tisagenlecleucel. The overall response rate was 59.5%, and the complete response rate was 44.5%. With a median follow-up of 23.2 months in the efficacy set (n=968), the 24 month rates of progression-free survival, ongoing response and overall survival were 28.4%, 52.6% and 43.6%, respectively. Grade ≥3 cytokine release syndrome and neurotoxicity were reported in 6% and 7.4% of patients, respectively. Patients with DLBCL (vs HGBCL), complete response before infusion, prior autologous or allogeneic haematopoietic stem cell transplant and lactate dehydrogenase (LDH) within normal limits experienced more favourable efficacy outcomes, and those with Eastern Cooperative Oncology Group performance status of ≥2, ≥3 prior lines of therapy, elevated LDH and fludarabine-based lymphodepleting chemotherapy experienced less favourable safety outcomes.

CONCLUSIONS

This real-world study of tisagenlecleucel for patients with R/R DLBCL/HGBCL shows consistent efficacy and better safety outcomes than the pivotal trial. This study also identifies baseline disease characteristics and prior or concurrent treatments that may affect clinical outcomes.Tisagenlecleucel, a CD19 chimeric antigen receptor T-cell therapy, is approved for adults with relapsed or refractory (R/R) diffuse large B-cell lymphoma (DLBCL) or high-grade B-cell lymphoma (HGBCL) after ≥2 lines of therapy. When used in real-world settings, tisagenlecleucel has shown similar efficacy and improved safety compared with previous clinical trials. However, long-term data on real-world outcomes are lacking.Clinical data from a cohort of patients treated with tisagenlecleucel in a real-world setting were captured in the Center for International Blood and Marrow Transplant Research registry. The main clinical outcomes analysed included response rate, duration of response, survival, adverse events, and clinicopathologic and treatment characteristics that may affect those outcomes.As of May 2022, 1159 patients with R/R DLBCL/HGBCL received tisagenlecleucel. The overall response rate was 59.5%, and the complete response rate was 44.5%. With a median follow-up of 23.2 months in the efficacy set (n=968), the 24 month rates of progression-free survival, ongoing response, and overall survival were 28.4%, 52.6%, and 43.6%, respectively. Grade ≥3 cytokine release syndrome and neurotoxicity were reported in 6% and 7.4% of patients, respectively. Patients with DLBCL (vs HGBCL), complete response before infusion, prior autologous or allogeneic haematopoietic stem cell transplant, and lactate dehydrogenase (LDH) within normal limits experienced more favourable efficacy outcomes, and those with Eastern Cooperative Oncology Group performance status ≥2, ≥3 prior lines of therapy, elevated LDH, and fludarabine-based lymphodepleting chemotherapy experienced less favourable safety outcomes.In conclusion, this real-world study of tisagenlecleucel for patients with R/R DLBCL/HGBCL shows consistent efficacy and better safety outcomes than the pivotal trial. This study also identifies baseline disease characteristics and prior or concurrent treatments that may affect clinical outcomes.

The impact of individual comorbidities in transplant recipients receiving post-transplant cyclophosphamide

Post-transplant cyclophosphamide (PTCY) is increasingly used as effective graft-versus-host disease (GvHD) prophylaxis in allogeneic hematopoietic-cell transplantation (allo-HCT). However, PTCY is associated with toxicities. Whether patients with specific comorbidities are more vulnerable to cyclophosphamide-induced toxicity is unclear. We retrospectively evaluated the impact of individual organ dysfunctions for non-relapse mortality (NRM) risk and overall survival (OS) among 5888 adults who underwent PTCY-based allo-HCT for acute myeloid leukemia between 2010 and 2023. In multivariable analyses 5 of the comorbidities (renal, moderate/severe hepatic, cardiac including arrhythmia/valvular disease, severe pulmonary, infection) were independently associated with adverse NRM and OS without influencing relapse rate. A simplified model using the absence (n = 4390), presence of 1 (n = 1229) or presence of 2 or 3 (n = 269) of the comorbidities which were determined individually to contribute to NRM stratified patients into 3 NRM risk (16.2% vs. 21.6% vs. 36%, retrospectively) and OS categories (64% vs. 56% vs. 36.4%, retrospectively). In Cox model, recipients with 2 or 3 comorbidities had an increased hazard ratio for NRM of 2.38 (95% confidence interval [CI], 1.89-3) and for OS of 1.96 (95% CI 1.64-2.33). Whether patients with concomitant diagnoses, as determined here, may benefit from a reduced PTCY dose remains to be evaluated in prospective clinical trials.

Risk Factors and Long-Term Outcomes of Acute Kidney Disease in Hematopoietic Stem Cell Transplant-Cohort Study

BACKGROUND

Acute kidney disease (AKD) is a recent definition reflecting ongoing physiopathological processes of an acute renal injury (AKI). Information on AKD in hematopoietic stem cell transplant (HSCT) is scarce and there is no available data on long-term outcomes. We aimed to determine the cumulative incidence of AKD in the first 100 days after HSCT; to identify risk factors for AKD in HSCT; and to determine the impact of AKD in 3-year overall survival and relapse-free survival in HSCT.

METHODS

A retrospective cohort study was conducted, considering AKD when AKI was present and the patient continued to meet the KDIGO criteria (creatinine and/or urinary output criteria) for 7 days or more. Survival analysis methods considering competing events were used for risk factors and disease-free survival, Cox proportional regression for overall survival, and stepwise regression methods for multivariable models.

RESULTS

We enrolled 422 patients. AKD incidence was 22.9% (95% CI: 19.2-27.4%). Higher body mass index (HR: 1.05, 95% CI 1.01-1.10; p = 0.034), HCT-CI score ≥ 2 (HR: 1.83, 95% CI 1.11-3.13; p = 0.027), allogeneic transplantation (HR:2.03, 95% CI 1.26-3.33; p = 0.004), higher C-reactive protein (HR:1.01, 95% CI 1.01-1.02; p < 0.001), and exposure to nephrotoxic drugs (HR: 4.81, 95% CI 1.54-4.95; p = 0.038) were independently associated with AKD. AKD had a significant impact on overall survival (HR: 1.75; 95% CI 1.27-2.39; p = 0.001).

CONCLUSION

An awareness of the risk factors for AKD allows the identification of high-risk patients, enabling the timely implementation of preventive measures to alleviate the progression and impact of the disease.

Comparison of Nonrelapse Mortality After Haploidentical Hematopoietic Stem Cell Transplantation With Post-transplant Cyclophosphamide Versus Single Umbilical Cord Blood Transplantation in Hematologic Disease

Unrelated cord blood transplantation (UCBT) and haploidentical transplantation using posttransplant cyclophosphamide (PTCy-haplo) are alternatives for patients lacking a human leukocyte antigen-matched donor. CD34+ cell counts in cord blood affect transplantation outcomes, particularly nonrelapse mortality (NRM). The primary objective of this study was to compare the transplantation outcomes after UCBT and PTCy-haplo focusing on CD34+ cell counts in cord blood. This retrospective study used data from 2014 to 2020 from a Japanese nationwide database. UCBT cases were divided into those with UCBT with higher (UCB-H; ≥.84 × 105/kg) and lower (UCB-L; <.84 × 105/kg) CD34+ cell counts, depending on the median CD34+ cell count. The study cohort comprised cases of PTCy-haplo (n = 1142), UCB-H (n = 3185), and UCB-L (n = 3172). In the multivariate analysis, neutrophil engraftment was significantly better in the PTCy-haplo than in the UCB-H (hazard ratio [HR], .64; 95% confidence interval [CI], .57 to .70; P < .001) and UCB-L groups (HR, .45; 95% CI, .41 to .50; P < .001). The UCB-H group showed similar NRM (HR, 1.19, 95% CI, 1.00 to 1.43, P = .051) and OS (HR, 1.05, 95% CI, .94 to 1.18, P = .38) compared with PTCy-haplo, whereas UCB-L was significantly associated with poor NRM (HR, 1.35, 95% CI, 1.13 to 1.61, P = .001) and OS (HR, 1.13, 95% CI, 1.01 to 1.26, P = .038). In contrast, the UCB-H (HR, .86; 95% CI, .75 to .98; P = .027) and UCB-L groups (HR, .80; 95% CI, .70 to .92; P = .001) were associated with lower relapse rate. Regarding the graft-versus-host disease (GVHD), the UCB-H and UCB-L groups were identified as significant risk factors for the development of grade II-IV acute GVHD (UCB-H: HR, 1.73; 95% CI, 1.51 to 1.99; P < .001; UCB-L: HR, 1.55; 95% CI, 1.35 to 1.78; P < .001) and grade III-IV acute GVHD (UCB-H: HR, 2.28; 95% CI, 1.78 to 2.91; P < .001; UCB-L: HR, 1.85; 95% CI, 1.44 to 2.37; P < .001), but neither were associated with the incidence of all-grade GVHD (UCB-H: HR, 1.12; 95% CI, .95 to 1.32; P = .16; UCB-L: HR, 1.08; 95% CI, .91 to 1.27; P = .37) or extensive chronic GVHD (UCB-H: HR, .86; 95% CI, .68 to 1.09; P = .21; UCB-L: HR, .88; 95% CI, .69 to 1.12; P = .31). Furthermore, higher NRM in UCB-L was attributed to higher infection-related mortality (HR, 1.50; 95% CI, 1.15 to 1.95; P = .003) but not GVHD-related mortality (HR, 1.15; 95% CI, .82 to 1.62; P = .43), whereas UCB-H was not a significant risk factor for both infection-related mortality (HR, 1.29; 95% CI, .99 to 1.69; P = .06) and GVHD-related mortality (HR, 1.28; 95% CI, .90 to 1.80; P = .16). UCB-H offered similar NRM and OS to PTCy-haplo, whereas UCB-L had worse outcomes. Our results can provide useful information for optimal donor selection.

HLA evolutionary divergence score after donor lymphocyte infusion following allogeneic hematopoietic stem cell transplantation

Donor lymphocyte infusion (DLI) prevents acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS) relapses following hematopoietic stem cell transplantation. Given the life-threatening toxicities such as graft versus host disease (GVHD), the identification of variables associated with response without toxicities is warranted. We hypothesized that HLA evolutionary divergence (HED), defined by the diversity between two given alleles of the same HLA gene, may be such a factor. A retrospective multicenter case-control study was conducted to evaluate the outcomes of pre-emptive (preDLI) and prophylactic DLI (proDLI) regarding their HED score, in AML or MDS patients. DLI-treated patients were matched with controls (1:2 matched) from French transplantation centers according to hospital, hemopathy, donor type, and risk classification. In total, 201 patients were included (N = 147 in the preDLI group, N = 54 in the proDLI group). Relapse-free survival was significantly better in the preDLI group (hazard ratio [HR] = 0.23, 95% confidence interval [CI]: 0.14-0.55, p < 0.001) than in controls. However, this benefit was offset by a higher incidence of severe GVHD (HR = 4.88, 95% CI: 2.30-10.32, p < 0.001). HED A, B, C, DQA1, DQB1, DPB1, and DRB1 were calculated for 65 DLI-treated patients. High-class II HED was significantly associated with higher GVHD and relapse-free survival (GRFS, HR = 0.33, 95% CI: 0.20-0.77, p = 0.005). Specific DQAB associations directly improved GRFS (HR = 0.23, 95% CI: 0.09-0.58, p = 0.004). In conclusion, screening the class II HED score identifies patients eligible for DLI treatment who will benefit the most from this strategy.

Female-to-male allogeneic transplantation affects outcomes differently according to the type of haplo-transplantation

Allogeneic hematopoietic stem cell transplantation from a female donor to a male recipient (female-to-male allo-HCT) is a well-established risk factor for chronic graft-versus-host disease (GVHD) and non-relapse mortality (NRM). The inferior outcomes of female-to-male allo-HCT are considered to be due to allo-immunity against H-Y antigens. However, the influence of minor histocompatibility antigens in haplo-identical allo-HCT remains to be elucidated. We investigated the impact of female-to-male allo-HCT according to the haplo-HCT subtype. In the post-transplant cyclophosphamide (PTCY) cohort (n = 660), a female-to-male sex-mismatch was significantly associated with a decreased risk of relapse (HR: 0.70 [95% CI: 0.49-0.99], P = 0.045), but not with overall survival (OS) or NRM (HR: OS 0.89 [95% CI: 0.68-1.16], P = 0.40; NRM 0.98 [95% CI: 0.68-1.41], P = 0.90). On the other hand, in the non-PTCY cohort (n = 219), a female-to-male sex-mismatch was associated with inferior risks of OS and NRM, but was not associated with relapse. These results suggested that the survival impact of the haplo-HCT subtype differed according to the presence of a sex-mismatch. PTCY might be feasible for overcoming the inferiority of female-to-male allo-HCT and might preserve a GVL effect against H-Y antigens.

Relationship between donor source, pre-transplant measurable residual disease, and outcome after allografting for adults with acute myeloid leukemia

Lack of HLA-matched related/unrelated donor remains a barrier to allogeneic hematopoietic cell transplantation (HCT) for adult acute myeloid leukemia (AML), with ongoing uncertainty about optimal donor type if more than one alternative donor is available. To assess the relationship between donor type, pre-HCT measurable residual disease (MRD), and post-HCT outcomes, we retrospectively analyzed 1265 myelodysplastic neoplasm (MDS)/AML and AML patients allografted in first or second remission with an HLA-matched sibling (MSD) or unrelated donor (MUD), HLA-mismatched unrelated donor (MMD), an HLA-haploidentical donor, or umbilical cord blood (UCB) at a single institution. Relapse risk was non-significantly higher after HLA-haploidentical and lower after UCB HCT. Non-relapse mortality (NRM) was significantly higher in patients undergoing MMD HCT, HLA-haploidentical HCT, and UCB, translating into significantly lower relapse-free survival (RFS) and overall survival for MMD and HLA-haploidentical HCT. There was a significant interaction between conditioning intensity and post-HCT outcomes for UCB HCT with better RFS for UCB HCT after MAC but higher NRM after non-MAC. In patients with pre-HCT MRD receiving MAC, relapse risk was significantly lower and RFS higher in those who underwent UCB HCT in comparison to MSD/MUD. Together, UCB HCT is a valuable alternative for MAC HCT, particularly in patients with pre-HCT MRD.

Effectiveness of letermovir in preventing cytomegalovirus reactivation after cord blood transplantation

BACKGROUND

Cord blood transplantation (CBT) is associated with a high risk of cytomegalovirus (CMV) infection. Letermovir (LTV) is a prophylactic agent against CMV reactivation after CBT, but data on its effectiveness and the incidence of late CMV reactivation after LTV discontinuation are limited.

METHODS

A single-center retrospective observational study was conducted in 79 adult CMV-seropositive CBT recipients who received their first transplant for acute myeloid leukemia, acute lymphoblastic leukemia, or myelodysplastic syndrome from February 2016 to September 2022. Outcomes were compared between 45 patients who received LTV prophylaxis and 34 patients who did not.

RESULTS

The cumulative incidence of CMV reactivation was significantly lower in patients who received LTV prophylaxis at both day 100 (11.1 % vs. 82.4 %, p < 0.001) and 1 year (45.3 % vs. 82.4 %, p < 0.001). The incidence of late CMV reactivation after LTV discontinuation was 34.2 %. The cumulative incidence of CMV disease was comparable between patients who received and those who did not (0 % vs. 8.8 % at day 100, 2.3 % vs. 8.8 % at 1 year; p = 0.181). Multivariate analysis showed that LTV prophylaxis reduced the cumulative incidence of CMV reactivation (hazard ratio 0.20, 95 % confidence interval 0.09 to 0.42, p < 0.001).

CONCLUSION

LTV prophylaxis is strongly associated with prevention of CMV reactivation after CBT. Due to the high incidence of late CMV reactivation, close monitoring is required after LTV discontinuation and extension of LTV prophylaxis beyond day 100 should be considered.

Haploidentical Stem Cell Transplantation With Dual Source of Cells and Post-Transplant Cyclophosphamide

BACKGROUND

Dual sources of cells (DSC) with peripheral blood stem cell apheresis (PBSC) and surgical bone marrow (BM) for haploidentical hematopoietic cell transplantation (Hid-HCT) are used in China and some Asian countries. The experience of the Baltimore group for haploidentical transplant with post-transplant cyclophosphamide (PT-Cy) and reduced-intensity-conditioning (RIC) regimen used BM as a source of hematopoietic stem cells.

METHODS

We retrospectively analyzed 64 Hid-HCT with DSC and PT-Cy, RIC (n = 57), or myeloablative-conditioning (MAC) (n = 7), from two public health Brazilian centers, with a median follow-up of 23.3 months (6.7-45.4).

RESULTS

The 49 malignant patients were 27/46 (58.7%) beyond the first remission or with no complete response, and three patients did not complete disease status evaluation before transplant. Eight of 62 patients (12.9%) had grade 2 or more Hematopoietic Cell Transplantation-Specific Comorbidity Index (HCT-CI), and two patients had no HCT-CI classified. Cytomegalovirus (CMV) viremia occurred in 26 of 57 (45.6%). The cumulative incidence of 100-day grade III-IV acute GVHD was 12.3% (7/57), with a 95% confidence interval (CI) of 3.8% and 20.8%, and 2-year moderate or severe chronic GVHD was 21.1% (11/52; 95% CI, 10.1%-32.3%). The 2-year relapses were 24.5% for malignant disease (12/49; 95% CI, 12.4%-36.5%). The 2-year overall survival (OS) probability was 54.7% (35/64; 95% CI, 42.5%-66.9%). Benign diseases achieve 2-year OS in 73.3% (11/15; 95% CI, 51%-95.7%) of the patients. The HCT-CI were significant in multivariate analyses for DFS (p = 0.002) and OS in uni- and multivariate analyses (both p < 0.001). The number of CD34+ cells by apheresis collection was significant in multivariate analysis for DFS (p = 0.039).

CONCLUSION

Hid-HCT using PT-Cy, DSC, and RIC is a safe option for benign and malignant diseases.

HLA-matched related peripheral blood stem cell and bone marrow transplantation with RIC regimens yield comparable outcomes for adult AML

Introduction

Understanding differences in clinical outcomes between PBSCT and BMT is important, and this study compared outcomes of HLA-matched related PBSCT and BMT using reduced-intensity conditioning (RIC) in adult acute myeloid leukemia (AML) patients.

Methods

Data from 402 patients who underwent either PBSCT (n = 294) or BMT (n = 108) between 2000 and 2022 were analyzed using the Japanese nationwide registry database. The primary endpoint was overall survival (OS), and secondary endpoints included disease-free survival (DFS), non-relapse mortality (NRM), and GVHD.

Results

Results indicated no significant difference in 3-year OS (44.6% for PBSCT vs. 46.9% for BMT, HR 1.173, P = 0.299) and DFS (42.1% vs. 41.8%, HR 1.073, P = 0.639). PBSCT was more beneficial for avoiding relapse (20.3% vs. 12.4%, HR, 0.715, P = 0.059). However, PBSCT was associated with higher NRM (20.3% vs. 12.4%, HR 1.801, P = 0.025) due to more frequent, chronic GVHD (HR 1.889, P = 0.035). Subgroup analysis did not reveal specific patient groups that benefited more from PBSCT or BMT. Incidence of extensive chronic GVHD and NRM has improved in PBSCT recipients in recent years (2014-2022).

Conclusions

We conclude that related PBSCT with RIC regimens offers comparable prognosis to BMT for adult AML patients. Further optimization of prophylactic strategies for chronic GVHD is required to improve outcomes after PBSCT.

Epigenetic age acceleration in hematopoietic stem cell transplantation

Not available.

Outcomes of Peripheral Blood Haploidentical Stem Cell Transplantation With Post-Transplant Cyclophosphamide and Earlier Initiation of Immunosuppression

INTRODUCTION

Peripheral blood (PB) grafts are increasingly used in haploidentical hematopoietic stem cell transplantation (haplo-HSCT) with post-transplant cyclophosphamide (PT-Cy). The optimal timing for initiation of immunosuppression (IS) with calcineurin inhibitors (CNI) and mycophenolate mofetil (MMF) in PB haplo-HSCT is unclear. This study evaluates the outcomes of early initiation of IS prior to PT-Cy.

METHODS

Medical records of adult patients with hematologic malignancies who received PB haplo-HSCT with PT-Cy between 2017 and 2022 were retrospectively reviewed. IS with CNI and MMF were started on day 0 and 1 postinfusion. Statistical analyses for survival outcomes were performed using the Kaplan-Meier method, and cumulative incidence (CI) models were used to account for competing risks for relapse, and nonrelapse mortality (NRM).

RESULTS

A total of 51 patients were included, with a median age of 37 years (range: 19-63) and a median follow-up of 44 months (range: 37.8-53 months). Neutrophil and platelet engraftment were achieved in 98% and 96% of patients, respectively. CRS occurred in 35.3% of patients, predominantly grade I, with only 1 patient developing grade II CRS. At 3 years, overall survival (OS) and progression free survival (PFS) were 51.8% and 50.2%, respectively, and GVHD-relapse free survival (GFRS) was 43.1%. The CI of relapse and NRM at 3 years were 28.2% and 21.6%, respectively.

CONCLUSION

Early initiation of IS in PB haplo-HSCT was associated with high rates of engraftment, low rates of CRS, and favorable long-term survival outcomes. Prospective studies are needed to validate these findings and refine IS timing.

Fludarabine melphalan reduced intensity conditioning vs radiation-based myeloablative conditioning in patients undergoing allogeneic transplantation for acute myeloid leukemia with measurable residual disease

Patients with AML and measurable residual disease (MRD) undergoing allogeneic hematopoietic cell transplantation (HCT) may benefit from myeloablative conditioning (MAC) when feasible to reduce relapse risk. Fludarabine-Melphalan (FluMel) is a common reduced intensity conditioning (RIC) regimen; however, data in MRD+ patients is sparse. We performed a retrospective review of AML patients who underwent their first HCT (2016-2021) without morphologic disease at City of Hope who had pre-transplant marrow evaluated for MRD using multicolor flow cytometry (MFC) and received radiation-based MAC or FluMel conditioning. We identified 312 patients; 44 with MRD+ disease pre-HCT. The 24-month overall survival (OS), leukemia-free survival (LFS) and cumulative incidence of relapse (CIR) were 47.7%, 40.9%, and 38.6% in MRD+, and 78.0%, 73.9%, and 14.6% in MRD- patients. Radiation-based MAC was given to 136 (43.5%) patients (n = 20 with MRD+) and FluMel was given to 174 (55.8%) patients (n = 24 with MRD+). In patients with MRD+, there was no statistically significant difference between those who received MAC vs. FluMel in 24-month OS (60% vs. 38%, p = 0.21), or CIR (35% vs. 42%, p = 0.59), respectively. Our data substantiates the adverse impact of MRD in patients with AML undergoing HCT; FluMel is a reasonable option for MRD+ patients unfit for MAC.

Relationship between age, conditioning intensity, and outcome after allografting in adults age ≥60 years with AML

Methodological advancements now allow older adults with AML to receive allografts although conflicting data exist regarding relative outcomes across age groups and benefits of different conditioning intensities. We retrospectively analyzed 495 adults aged 60-64 (n = 184), 65-69 (n = 189), or ≥70 (n = 122) allografted for AML in remission at our institution from 2006 to 2023. There were no significant differences in relapse or relapse-free survival (RFS) among the 3 age cohorts after multivariable adjustment. Patients aged ≥70 years had higher non-relapse mortality (NRM) than those aged ≥60-64 (P = 0.022) but their overall survival (OS) was only statistically non-significantly shorter (P = 0.11). There was an important interplay between age, conditioning intensity, and outcomes. Relative to age 60-64, age ≥70 years was associated with a higher risk of relapse (hazard ratio [HR] = 3.47; P = 0.012) and NRM (HR = 3.88; P = 0.001) with reduced intensity conditioning (RIC), leading to shorter RFS (HR = 3.79; P < 0.001) and OS (HR = 3.46; P < 0.001), while no such associations were found with nonmyeloablative (NMA) conditioning. Underlying, patients aged 60-64 and 65-69, but not those aged ≥70, had a significantly lower relapse risk with RIC relative to NMA conditioning, whereas NRM risks increased across all age cohorts. Our findings support allografting for adults ≥70 with AML in remission, especially with NMA conditioning.

Myeloablative conditioning in cord blood transplantation for acute myeloid leukemia patients is efficacious only until age 55

Umbilical cord blood transplantation (CBT) is accepted as an effective treatment for acute myeloid leukemia (AML), and reduced-intensity conditioning (RIC), rather than myeloablative conditioning (MAC) regimens allowed elderly patients to be treated safely. However, appropriate intensities of conditioning regimens are still unclear, especially for middle-aged patients. To compare outcomes after RIC and MAC regimens, we analyzed AML patients aged 16 years or older in the Japanese registry database, who underwent single cord unit CBT between 2010-2019. Median ages of the RIC group (n = 1353) and the MAC group (n = 2101) were 59 and 51 years (P < 0.001), respectively. 5-year overall survival (OS) after MAC was superior to that of RIC (38.3% vs 27.7%, P < 0.001) with lower incidence of relapse (33.9% vs 37.4%, P = 0.029) and better neutrophil engraftment (84.7% vs 75.9%, P < 0.001). Detailed subgroup analysis revealed that age at transplantation is the most important factor affecting 5-year OS in RIC and MAC. This analysis identified a threshold of 55 years, beyond which the superiority of MAC disappeared, irrespective of other factors such as disease status or performance status. In conclusion, RIC may be preferable for patients aged 56 or older in CBT for AML due to higher potential toxicities.

Comparison of Outcomes of Haploidentical Peripheral Blood Stem Cell Transplantation with Post-Transplant Cyclophosphamide in Older Versus Younger Patients

BACKGROUND

Previous studies have shown that allogeneic peripheral blood stem cell transplantation (PBSCT) from an HLA haploidentical (haplo) donor followed by graft-versus-host disease (GVHD) prophylaxis with post-transplant cyclophosphamide (PTCy) results in lower relapse rates and improved DFS when compared to haplo bone marrow transplant (BMT) with PTCy. However, PBSCT leads to higher rates of GVHD. It is unknown whether the benefits of haplo PBSCT may be nullified in older patients (>60 years) by a higher susceptibility to GVHD and transplant related toxicity. Thus, we sought to determine if older patients receiving haplo PBSCT with PTCy experience significantly worse outcomes than younger patients.

METHODS

We evaluated 121 adult patients with hematologic malignancies treated at the Moffitt Cancer Center with allogeneic haplo PBSCT followed by PTCy and compared outcomes of patients ≥60 years (n = 55) versus patients <60 years (n = 66).

RESULTS

The cumulative incidence of non-relapse mortality (NRM) from the competing risk regression analysis was worse for the older patient group (SHR = 4.05, 95% CI: 1.43-11.47, p = 0.008). However, there was no significant difference between groups in graft-versus-host disease (GVHD), relapse, disease-free survival (DFS), or overall survival (OS). Instead, hematopoietic comorbidity index (HCT-CI) ≥ 3 was associated with worse DFS (HR = 1.87, 95% CI: 1.04-3.34, p = 0.035) and OS (HR = 1.98, 95% CI: 1.03-3.84, p-value = 0.042). Subgroup analysis of patients ≥60 years showed a trend toward improved 2-year OS with fludarabine/cyclophosphamide/total body irradiation (Flu/Cy/TBI) versus fludarabine/busulfan: 71% versus 53% (HR = 0.47, p = 0.121). In patients over 70 years (n = 14), NRM was 8% and OS was 76% at 1 year.

CONCLUSION

Given similar OS and DFS between patients aged >60 years and those <60, haplo PBSCT with PTCy appears to be an appropriate transplant platform for older patients.