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Kim DDH, Popradi G, Lepic K, Paulson K, Allan D, Nampoothiri RV, Lachance S, Deotare U, White J, Elemary M, Jamani K, Fraga C, Lemieux C, Novitzky-Basso I, Law AD, Kumar R, Walker I, Schultz KR. Cell Therapy Transplant Canada (CTTC) Consensus-Based Guideline 2024 for Management and Treatment of Chronic Graft-Versus-Host Disease and Future Directions for Development. Curr Oncol 2024; 31:1426-1444. [PMID: 38534941 PMCID: PMC10968999 DOI: 10.3390/curroncol31030108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 01/28/2024] [Accepted: 02/28/2024] [Indexed: 05/26/2024] Open
Abstract
This is a consensus-based Canadian guideline whose primary purpose is to standardize and facilitate the management of chronic graft-versus-host disease (cGvHD) across the country. Creating uniform healthcare guidance in Canada is a challenge for a number of reasons including the differences in healthcare authority structure, funding and access to healthcare resources between provinces and territories, as well as the geographic size. These differences can lead to variable and unequal access to effective therapies for GvHD. This document will provide comprehensive and practical guidance that can be applied across Canada by healthcare professionals caring for patients with cGvHD. Hopefully, this guideline, based on input from GvHD treaters across the country, will aid in standardizing cGvHD care and facilitate access to much-needed novel therapies. This consensus paper aims to discuss the optimal approach to the initial assessment of cGvHD, review the severity scoring and global grading system, discuss systemic and topical treatments, as well as supportive therapies, and propose a therapeutic algorithm for frontline and subsequent lines of cGvHD treatment in adults and pediatric patients. Finally, we will make suggestions about the future direction of cGvHD treatment development such as (1) a mode-of-action-based cGvHD drug selection, according to the pathogenesis of cGvHD, (2) a combination strategy with the introduction of newer targeted drugs, (3) a steroid-free regimen, particularly for front line therapy for cGvHD treatment, and (4) a pre-emptive approach which can prevent the progression of cGvHD in high-risk patients destined to develop severe and highly morbid forms of cGvHD.
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Affiliation(s)
- Dennis Dong Hwan Kim
- Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON M5G 2M9, Canada (A.D.L.)
| | - Gizelle Popradi
- Health Centre, McGill University, Montreal, QC H4P 2P5, Canada
| | - Kylie Lepic
- Juravinski Cancer Centre, McMaster University, Hamilton, ON L8V 5C2, Canada
| | - Kristjan Paulson
- CancerCare Manitoba, University of Manitoba, Winnipeg, Manitoba, MB R3E 0V9, Canada
| | - David Allan
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON K1H 8L6, Canada
| | | | - Sylvie Lachance
- Hôpital Maisonneuve-Rosemont, Department of Medicine, University of Montreal, Montreal, QC H3C 3J7, Canada;
| | - Uday Deotare
- London Health Sciences Centre, University of Western Ontario, London, ON N6A 5A5, Canada
| | - Jennifer White
- Vancouver General Hospital, British Columbia Cancer Agency, University of British Columbia, Vancouver, BC V5Z 1M9, Canada
| | - Mohamed Elemary
- Saskatchewan Cancer Agency, University of Saskatchewan, Saskatchewan, SK S7N 4H4, Canada
| | - Kareem Jamani
- Tom Baker Cancer Centre, University of Calgary, Calgary, AB T2N 4N2, Canada;
| | - Christina Fraga
- Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, NS B3H 4R2, Canada
| | - Christopher Lemieux
- CHU de Québec—Université Laval, Université Laval, Québec, QC G1R 2J6, Canada
| | - Igor Novitzky-Basso
- Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON M5G 2M9, Canada (A.D.L.)
| | - Arjun Datt Law
- Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON M5G 2M9, Canada (A.D.L.)
| | - Rajat Kumar
- Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON M5G 2M9, Canada (A.D.L.)
| | - Irwin Walker
- Juravinski Cancer Centre, McMaster University, Hamilton, ON L8V 5C2, Canada
| | - Kirk R. Schultz
- British Columbia Children’s Hospital, University of British Columbia, Vancouver, BC V6H 3N1, Canada
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Oza K, Kang J, Patil D, Owen KL, Cui W, Khan K, Kaufman SS, Kroemer A. Current Advances in Graft-versus-host Disease After Intestinal Transplantation. Transplantation 2024; 108:399-408. [PMID: 37309025 DOI: 10.1097/tp.0000000000004703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Graft-versus-host disease (GvHD) remains a potentially fatal complication following intestinal transplant (ITx). Over the past decade, advances in the understanding of the pathophysiology of this complex immunological phenomenon have led to the reassessment of the host systemic immune response and have created a gateway for novel preventive and therapeutic strategies. Although sufficient evidence dictates the use of corticosteroids as a first-line option, the treatment for refractory disease remains contentious and lacks a standardized therapeutic approach. Timely diagnosis remains crucial, and the advent of chimerism detection and immunological biomarkers have transformed the identification, prognostication, and potential for survival after GvHD in ITx. The objectives of the following review aim to discuss the clinical and diagnostic features, pathophysiology, advances in immune biomarkers, as well as therapeutic opportunities in the prevention and treatment of GvHD in ITx.
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Affiliation(s)
- Kesha Oza
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
- Department of General Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Jiman Kang
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
- Department of Biochemistry and Molecular & Cellular Biology, Georgetown University, Washington, DC
| | - Digvijay Patil
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
| | - Kathryn L Owen
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
| | - Wanxing Cui
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
- Department of Biochemistry and Molecular & Cellular Biology, Georgetown University, Washington, DC
| | - Khalid Khan
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
| | - Stuart S Kaufman
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
| | - Alexander Kroemer
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
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Baumrin E, Loren AW, Falk SJ, Mays JW, Cowen EW. Chronic graft-versus-host disease. Part II: Disease activity grading and therapeutic management. J Am Acad Dermatol 2024; 90:19-36. [PMID: 36572064 PMCID: PMC10287839 DOI: 10.1016/j.jaad.2022.12.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 12/08/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022]
Abstract
Chronic graft-versus-host disease (cGVHD) is a major complication of allogeneic hematopoietic cell transplantation and a leading cause of long-term morbidity, nonrelapse mortality, and impaired health-related quality of life. The skin is commonly affected and presents heterogeneously, making the role of dermatologists critical in both diagnosis and treatment. In addition, new clinical classification and grading schemes inform treatment algorithms, which now include 3 Federal Drug Administration-approved therapies, and evolving transplant techniques are changing disease epidemiology. Part I reviews the epidemiology, pathogenesis, clinical manifestations, and diagnosis of cGVHD. Part II discusses disease grading and therapeutic management.
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Affiliation(s)
- Emily Baumrin
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Alison W Loren
- Blood and Marrow Transplant, Cell Therapy and Transplant Program, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Hematology/Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sandy J Falk
- Adult Survivorship Program, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Jacqueline W Mays
- Oral Immunobiology Unit, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland
| | - Edward W Cowen
- Dermatology Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland
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Hong J, Fraebel J, Yang Y, Tkacyk E, Kitko C, Kim TK. Understanding and treatment of cutaneous graft-versus-host-disease. Bone Marrow Transplant 2023; 58:1298-1313. [PMID: 37730800 DOI: 10.1038/s41409-023-02109-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 08/28/2023] [Accepted: 09/08/2023] [Indexed: 09/22/2023]
Abstract
The skin is the outermost mechanical barrier where dynamic immune reactions take place and is the most commonly affected site in both acute and chronic graft-versus-host disease (GVHD). If not properly treated, pain and pruritis resulting from cutaneous GVHD can increase the risk of secondary infection due to erosions, ulcerations, and damage of underlying tissues. Furthermore, resulting disfiguration can cause distress and significantly impact patients' quality of life. Thus, a deeper understanding of skin-specific findings of GVHD is needed. This review will highlight some promising results of recent pre-clinical studies on the pathophysiology of skin GVHD and summarize the diagnostic and staging/grading procedures according to the clinical manifestations of skin GVHD. In addition, we will summarize outcomes of various GVHD treatments, including skin-specific response rates.
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Affiliation(s)
- Junshik Hong
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Johnathan Fraebel
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Yenny Yang
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Eric Tkacyk
- Veterans Affairs Tennessee Valley Health Care, Nashville, TN, USA
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Carrie Kitko
- Monroe Carell Jr Children's Hospital, Vanderbilt Division of Pediatric Hematology-Oncology, Nashville, TN, USA
- Vanderbilt-Ingram Cancer Center, Nashville, TN, USA
| | - Tae Kon Kim
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
- Veterans Affairs Tennessee Valley Health Care, Nashville, TN, USA.
- Vanderbilt-Ingram Cancer Center, Nashville, TN, USA.
- Vanderbilt Center for Immunobiology, Vanderbilt University Medical Center, Nashville, TN, USA.
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Colunga-Pedraza PR, Barbosa-Castillo LM, Coronado-Alejandro EU, Vaquera-Alfaro HA, López-Reyna IG, Colunga-Pedraza JE, Gómez-Almaguer D. Low-dose rituximab in steroid-refractory chronic graft-versus-host disease. Transpl Immunol 2023; 81:101959. [PMID: 37972876 DOI: 10.1016/j.trim.2023.101959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 11/10/2023] [Accepted: 11/12/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Chronic graft-versus-host disease (cGvHD) is a major complication that puts patients undergoing allogeneic hematopoietic stem cell transplantation (allo-HSCT) at risk of death or infection. Currently, there is no gold standard for the first-line treatment of patients who do not respond to steroids, and there are several therapeutic options being evaluated in clinical trials for this disease to be used even in the first-line treatment for GvHD. There is evidence of the benefit of rituximab, an anti-CD20 antibody, at a standard dose of 375 mg/m2 weekly in the treatment of steroid-refractory chronic graft-versus disease (SR-cGvHD). OBJECTIVE To demonstrate the safety and efficacy of low-dose rituximab in a middle-income center in northeastern Mexico STUDY DESIGN: We report the experience of 26 patients with chronic graft-versus-graft disease who received low-dose rituximab (100 mg weekly for 4 weeks). We utilized the advances in the National Institutes of Health (NIH) criteria for diagnosis, scoring, trial design, and assessment of treatment response. RESULTS We obtained a 5-year overall survival of 23.6%, including four patients with complete response. The 1-year event-free survival was 70% for patients with rituximab. During the treatment, there were 3 hospitalizations, and the causes were: immune thrombocytopenia, a parapneumonic effusion, and a cerebral vascular event. The median length of hospital stay was twelve days. CONCLUSION A low dose of rituximab is an available and cost-effective option for patients with steroid-refractory cGvHD.
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Affiliation(s)
- Perla R Colunga-Pedraza
- Hematology service, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Ave. Francisco I. Madero, Monterrey, Nuevo León 64460, Mexico.
| | - Luz María Barbosa-Castillo
- Hematology service, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Ave. Francisco I. Madero, Monterrey, Nuevo León 64460, Mexico
| | - Edgar Ulises Coronado-Alejandro
- Hematology service, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Ave. Francisco I. Madero, Monterrey, Nuevo León 64460, Mexico
| | - Héctor Alejandro Vaquera-Alfaro
- Hematology service, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Ave. Francisco I. Madero, Monterrey, Nuevo León 64460, Mexico
| | - Ingrid Gabriela López-Reyna
- Hematology service, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Ave. Francisco I. Madero, Monterrey, Nuevo León 64460, Mexico
| | - Julia E Colunga-Pedraza
- Hematology service, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Ave. Francisco I. Madero, Monterrey, Nuevo León 64460, Mexico
| | - David Gómez-Almaguer
- Hematology service, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Ave. Francisco I. Madero, Monterrey, Nuevo León 64460, Mexico
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Malard F, Mohty M. Updates in chronic graft-versus-host disease management. Am J Hematol 2023; 98:1637-1644. [PMID: 37483142 DOI: 10.1002/ajh.27040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 06/05/2023] [Accepted: 07/09/2023] [Indexed: 07/25/2023]
Abstract
Chronic graft-versus-host disease (cGvHD) remains the most important long-term complication of allogeneic hematopoietic cell transplantation (allo-HCT), but the field has seen significant changes in the last decade. Remarkable advances in the understanding of the biological pathways of cGvHD, lead to the development of targeted therapy with novel drugs thereby minimizing the exposure to harmful corticosteroids, preserving function and mobility, preventing disability, and improving quality of life (QoL) and overall survival (OS). Steroid-refractory cGvHD management has recently experienced significant improvement since ibrutinib and ruxolitinib were approved for patients that failed at least one line of treatment and belumosudil for patients that failed two lines. These recently approved drugs will be discussed in this review, along with perspectives regarding cGVHD management and additional promising drug in development.
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Affiliation(s)
- Florent Malard
- Sorbonne Université, Centre de Recherche Saint-Antoine INSERM UMRs938, Service d'Hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint-Antoine, AP-HP, Paris, France
| | - Mohamad Mohty
- Sorbonne Université, Centre de Recherche Saint-Antoine INSERM UMRs938, Service d'Hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint-Antoine, AP-HP, Paris, France
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Kassem R, Barzilai A, Pras E, Sizopoulou C, Pavlotsky F. Bath psoralen plus ultraviolet-A photochemotherapy for chronic graft-versus-host disease: a retrospective cohort study. Int J Dermatol 2023; 62:1261-1265. [PMID: 37568259 DOI: 10.1111/ijd.16806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 05/20/2023] [Accepted: 08/01/2023] [Indexed: 08/13/2023]
Abstract
BACKGROUND Chronic graft-versus-host disease is a severe complication of allogeneic stem cell and bone marrow transplantation. First-line immunosuppressive agents, such as steroids, are used to prevent this disease; however, they have multiple side effects. Therefore, bath psoralen plus ultraviolet-A (PUVA) is an alternative second-line treatment. This study aimed to evaluate the clinical efficacy of bath PUVA for managing chronic graft-versus-host disease. METHODS This retrospective, case-control study included 14 patients with extensive cutaneous chronic graft-versus-host disease, resistant to systemic corticosteroid, treated with bath PUVA. Major and partial responses were defined as clinical improvements of >70% and 50-70%, respectively. We analyzed the graft-versus-host disease clinical presentation and timing after allogeneic stem cell and bone marrow transplantation, bath PUVA doses, background diseases, additional treatments, and adverse effects. RESULTS We observed eight major (three lichenoid and five sclerodermatoid) and six partial (three lichenoid and three sclerodermatoid) responses after a mean of 28 treatment sessions. After 6 to 25 months, four of the eight patients with sclerodermatoid lesions and all those with lichenoid lesions experienced relapse but responded to additional treatment cycles. CONCLUSIONS Bath PUVA is well-tolerated and effective for extensive cutaneous chronic graft-versus-host disease. It allows rapid tapering of adjuvant immunosuppressants; however, most patients require prolonged maintenance phototherapy.
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Affiliation(s)
- Riad Kassem
- Department of Dermatology, Sheba Medical Center, Tel HaShomer, Ramat Gan, 52621, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv-Yafo, 69978, Israel
| | - Aviv Barzilai
- Department of Dermatology, Sheba Medical Center, Tel HaShomer, Ramat Gan, 52621, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv-Yafo, 69978, Israel
- Dermatopathology Service, Institute of Pathology, Sheba Medical Center, Tel HaShomer, Ramat Gan, 52621, Israel
| | - Elon Pras
- Sackler School of Medicine, Tel Aviv University, Tel Aviv-Yafo, 69978, Israel
- Institute of Genetics, Sheba Medical Center, Tel HaShomer, Ramat Gan, 52621, Israel
| | - Christina Sizopoulou
- Department of Dermatology, Sheba Medical Center, Tel HaShomer, Ramat Gan, 52621, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv-Yafo, 69978, Israel
| | - Felix Pavlotsky
- Department of Dermatology, Sheba Medical Center, Tel HaShomer, Ramat Gan, 52621, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv-Yafo, 69978, Israel
- Phototherapy Unit, Department of Dermatology, Sheba Medical Center, Tel HaShomer, Ramat Gan, 52621, Israel
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Buxbaum NP, Socié G, Hill GR, MacDonald KPA, Tkachev V, Teshima T, Lee SJ, Ritz J, Sarantopoulos S, Luznik L, Zeng D, Paczesny S, Martin PJ, Pavletic SZ, Schultz KR, Blazar BR. Chronic GvHD NIH Consensus Project Biology Task Force: evolving path to personalized treatment of chronic GvHD. Blood Adv 2023; 7:4886-4902. [PMID: 36322878 PMCID: PMC10463203 DOI: 10.1182/bloodadvances.2022007611] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 10/26/2022] [Accepted: 10/26/2022] [Indexed: 01/26/2023] Open
Abstract
Chronic graft-versus-host disease (cGvHD) remains a prominent barrier to allogeneic hematopoietic stem cell transplantion as the leading cause of nonrelapse mortality and significant morbidity. Tremendous progress has been achieved in both the understanding of pathophysiology and the development of new therapies for cGvHD. Although our field has historically approached treatment from an empiric position, research performed at the bedside and bench has elucidated some of the complex pathophysiology of cGvHD. From the clinical perspective, there is significant variability of disease manifestations between individual patients, pointing to diverse biological underpinnings. Capitalizing on progress made to date, the field is now focused on establishing personalized approaches to treatment. The intent of this article is to concisely review recent knowledge gained and formulate a path toward patient-specific cGvHD therapy.
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Affiliation(s)
- Nataliya P Buxbaum
- Department of Pediatrics, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Gerard Socié
- Hematology-Transplantation, Assistance Publique-Hopitaux de Paris & University of Paris - INSERM UMR 676, Hospital Saint Louis, Paris, France
| | - Geoffrey R Hill
- Division of Medical Oncology, The University of Washington, Seattle, WA
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Kelli P A MacDonald
- Department of Immunology, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - Victor Tkachev
- Division of Hematology/Oncology, Boston Children's Hospital, Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Takanori Teshima
- Department of Hematology, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Stephanie J Lee
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Jerome Ritz
- Dana-Farber Cancer Institute, Harvard Medical School, Brigham and Women's Hospital, Boston, MA
| | - Stefanie Sarantopoulos
- Department of Medicine, Division of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Duke Cancer Institute, Durham, NC
| | - Leo Luznik
- Division of Hematologic Malignancies, Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Defu Zeng
- Arthur D. Riggs Diabetes and Metabolism Research Institute, The Beckman Research Institute, Hematologic Maligancies and Stem Cell Transplantation Institute, City of Hope National Medical Center, Duarte, CA
| | - Sophie Paczesny
- Department of Microbiology and Immunology and Cancer Immunology Program, Hollings Cancer Center, Medical University of South Carolina, Charleston, SC
| | - Paul J Martin
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Steven Z Pavletic
- Immune Deficiency Cellular Therapy Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Kirk R Schultz
- Michael Cuccione Childhood Cancer Research Program, British Columbia Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Bruce R Blazar
- Department of Pediatrics, Division of Blood & Marrow Transplant & Cellular Therapy, University of Minnesota, Minneappolis, MN
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Yan WL, Zhao FY, Gu ME, Liu N, Guo XP, Xu XJ. Ruxolitinib Treatment of Steroid-Refractory Graft-versus-Host Disease in Children: A Case Series and Review of the Literature. Paediatr Drugs 2023; 25:577-584. [PMID: 37284944 DOI: 10.1007/s40272-023-00577-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/15/2023] [Indexed: 06/08/2023]
Abstract
BACKGROUND Ruxolitinib has been increasingly used in the treatment of steroid-refractory graft-versus-host disease (SR-GVHD) in allogeneic hematopoietic stem cell transplantation (allo-HSCT) patients. However, there are limited data on the use of ruxolitinib in children. OBJECTIVE This study aimed to assess the efficacy and toxicity of ruxolitinib in the treatment of SR-GVHD in children. PATIENTS AND METHODS Data of patients who suffered from SR-GVHD after allo-HSCT and received ruxolitinib treatment between June 2018 and December 2020 at our center were analyzed retrospectively. The characteristics of patients, the dosage of ruxolitinib, the response, toxicity, and the survival data were collected. RESULTS A total of 14 pediatric patients were diagnosed with SR-GVHD after allo-HSCT and received ruxolitinib. The age of the patients ranged from 3 months to 12 years old. The dosage of ruxolitinib ranged from 2.5 mg twice daily to 7.5 mg twice daily, mainly according to patient weight. The total overall response rate (ORR) was 64.3% (9/14), with 63.6% (7/11) in aGVHD and 67% (2/3) in cGVHD. Of the 14 patients, adverse effects were observed in 9 patients (64.3%), including cytopenia, infection, and elevated alanine aminotransferase. In addition, seven reports on the treatment of SR-GVHD in children with ruxolitinib were included for systematic analysis, with the ORR ranging from 45 to 87% in aGVHD and 70-91% in cGVHD. CONCLUSION Given its effectiveness and safety, ruxolitinib could be used to treat SR-GVHD in children after HSCT.
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Affiliation(s)
- Wei-Ling Yan
- Department of Hematology and Oncology, Children's Hospital, Zhejiang University School of Medicine, No. 57 Zhugan Lane, Yan-an Road, Gongshu District, Hangzhou, Zhejiang, China
| | - Fen-Ying Zhao
- Department of Hematology and Oncology, Children's Hospital, Zhejiang University School of Medicine, No. 57 Zhugan Lane, Yan-an Road, Gongshu District, Hangzhou, Zhejiang, China
| | - Min-Er Gu
- Department of Hematology and Oncology, Children's Hospital, Zhejiang University School of Medicine, No. 57 Zhugan Lane, Yan-an Road, Gongshu District, Hangzhou, Zhejiang, China
| | - Nan Liu
- Department of Hematology and Oncology, Children's Hospital, Zhejiang University School of Medicine, No. 57 Zhugan Lane, Yan-an Road, Gongshu District, Hangzhou, Zhejiang, China
| | - Xiao-Ping Guo
- Department of Hematology and Oncology, Children's Hospital, Zhejiang University School of Medicine, No. 57 Zhugan Lane, Yan-an Road, Gongshu District, Hangzhou, Zhejiang, China
| | - Xiao-Jun Xu
- Department of Hematology and Oncology, Children's Hospital, Zhejiang University School of Medicine, No. 57 Zhugan Lane, Yan-an Road, Gongshu District, Hangzhou, Zhejiang, China.
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10
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Maurer K, Soiffer RJ. The delicate balance of graft versus leukemia and graft versus host disease after allogeneic hematopoietic stem cell transplantation. Expert Rev Hematol 2023; 16:943-962. [PMID: 37906445 PMCID: PMC11195539 DOI: 10.1080/17474086.2023.2273847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 10/18/2023] [Indexed: 11/02/2023]
Abstract
INTRODUCTION The curative basis of allogeneic hematopoietic stem cell transplantation (HSCT) relies in part upon the graft versus leukemia (GvL) effect, whereby donor immune cells recognize and eliminate recipient malignant cells. However, alloreactivity of donor cells against recipient tissues may also be deleterious. Chronic graft versus host disease (cGvHD) is an immunologic phenomenon wherein alloreactive donor T cells aberrantly react against host tissues, leading to damaging inflammatory symptoms. AREAS COVERED Here, we discuss biological insights into GvL and cGvHD and strategies to balance the prevention of GvHD with maintenance of GvL in modern HSCT. EXPERT OPINION/COMMENTARY Relapse remains the leading cause of mortality after HSCT with rates as high as 40% for some diseases. GvHD is a major cause of morbidity after HSCT, occurring in up to half of patients and responsible for 15-20% of deaths after HSCT. Intriguingly, the development of chronic GvHD may be linked to lower relapse rates after HSCT, suggesting that GvL and GvHD may be complementary sides of the immunologic foundation of HSCT. The ability to fine tune the balance of GvL and GvHD will lead to improvements in survival, relapse rates, and quality of life for patients undergoing HSCT.
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Affiliation(s)
- Katie Maurer
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Robert J Soiffer
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
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11
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[Chinese expert consensus on ocular chronic graft-versus-host disease (2023)]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2023; 44:449-457. [PMID: 37550199 PMCID: PMC10450544 DOI: 10.3760/cma.j.issn.0253-2727.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Indexed: 08/09/2023]
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12
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Raman D, Chêne C, Nicco C, Jeljeli M, Eu JQ, Clément MV, Batteux F, Pervaiz S. Therapeutic Potential of a Senolytic Approach in a Murine Model of Chronic GVHD. BIOLOGY 2023; 12:biology12050647. [PMID: 37237461 DOI: 10.3390/biology12050647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 04/07/2023] [Accepted: 04/18/2023] [Indexed: 05/28/2023]
Abstract
Graft-versus-host disease (GVHD) is a life-threatening systemic complication of allogeneic hematopoietic stem cell transplantation (HSCT) characterized by dysregulation of T and B cell activation and function, scleroderma-like features, and multi-organ pathology. The treatment of cGVHD is limited to the management of symptoms and long-term use of immunosuppressive therapy, which underscores the need for developing novel treatment approaches. Notably, there is a striking similarity between cytokines/chemokines responsible for multi-organ damage in cGVHD and pro-inflammatory factors, immune modulators, and growth factors secreted by senescent cells upon the acquisition of senescence-associated secretory phenotype (SASP). In this pilot study, we questioned the involvement of senescent cell-derived factors in the pathogenesis of cGVHD triggered upon allogeneic transplantation in an irradiated host. Using a murine model that recapitulates sclerodermatous cGVHD, we investigated the therapeutic efficacy of a senolytic combination of dasatinib and quercetin (DQ) administered after 10 days of allogeneic transplantation and given every 7 days for 35 days. Treatment with DQ resulted in a significant improvement in several physical and tissue-specific features, such as alopecia and earlobe thickness, associated with cGVHD pathogenesis in allograft recipients. DQ also mitigated cGVHD-associated changes in the peripheral T cell pool and serum levels of SASP-like cytokines, such as IL-4, IL-6 and IL-8Rα. Our results support the involvement of senescent cells in the pathogenesis of cGVHD and provide a rationale for the use of DQ, a clinically approved senolytic approach, as a potential therapeutic strategy.
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Affiliation(s)
- Deepika Raman
- Department of Physiology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
| | - Charlotte Chêne
- Département 3I, Infection, Immunité et Inflammation, Institut Cochin, INSERM U1016, Université de Paris, 75014 Paris, France
| | - Carole Nicco
- Département 3I, Infection, Immunité et Inflammation, Institut Cochin, INSERM U1016, Université de Paris, 75014 Paris, France
| | - Mohamed Jeljeli
- Département 3I, Infection, Immunité et Inflammation, Institut Cochin, INSERM U1016, Université de Paris, 75014 Paris, France
- Université de Paris, Faculté de Médecine, AP-HP-Centre Université de Paris, Hôpital Cochin, Service d'Immunologie Biologique, 75014 Paris, France
| | - Jie Qing Eu
- Department of Physiology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
- Cancer Science Institute, National University of Singapore, Singapore 117597, Singapore
| | - Marie-Véronique Clément
- Department of Biochemistry, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
- NUS Medicine Healthy Longevity Program, National University of Singapore, Singapore 117597, Singapore
- Integrated Science and Engineering Program, NUS Graduate School, National University of Singapore, Singapore 117597, Singapore
| | - Frédéric Batteux
- Département 3I, Infection, Immunité et Inflammation, Institut Cochin, INSERM U1016, Université de Paris, 75014 Paris, France
- Université de Paris, Faculté de Médecine, AP-HP-Centre Université de Paris, Hôpital Cochin, Service d'Immunologie Biologique, 75014 Paris, France
| | - Shazib Pervaiz
- Department of Physiology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
- NUS Medicine Healthy Longevity Program, National University of Singapore, Singapore 117597, Singapore
- Integrated Science and Engineering Program, NUS Graduate School, National University of Singapore, Singapore 117597, Singapore
- NUS Centre for Cancer Research (N2CR), Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
- National University Cancer Institute, National University Health System, Singapore 117597, Singapore
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Holtan SG, Savid-Frontera C, Walton K, Eaton AA, Demorest C, Hoeschen A, Zhang L, Reid K, Kurian T, Sayegh Z, Julia E, Maakaron J, Bachanova V, Jurdi NE, MacMillan ML, Weisdorf DJ, Felices M, Miller JS, Blazar BR, Davila ML, Betts BC. Human Effectors of Acute and Chronic GVHD Overexpress CD83 and Predict Mortality. Clin Cancer Res 2023; 29:1114-1124. [PMID: 36622700 PMCID: PMC10011883 DOI: 10.1158/1078-0432.ccr-22-2837] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 10/31/2022] [Accepted: 01/05/2023] [Indexed: 01/10/2023]
Abstract
PURPOSE Acute and chronic GVHD remain major causes of transplant-related morbidity and mortality (TRM) after allogeneic hematopoietic cell transplantation (alloHCT). We have shown CD83 chimeric antigen receptor (CAR) T cells prevent GVHD and kill myeloid leukemia cell lines. In this pilot study, we investigate CD83 expression on GVHD effector cells, correlate these discoveries with clinical outcomes, and evaluate critical therapeutic implications for transplant recipients. EXPERIMENTAL DESIGN CD83 expression was evaluated among circulating CD4+ T cells, B-cell subsets, T follicular helper (Tfh) cells, and monocytes from patients with/without acute or chronic GVHD (n = 48 for each group), respectively. CD83 expression was correlated with survival, TRM, and relapse after alloHCT. Differential effects of GVHD therapies on CD83 expression was determined. RESULTS CD83 overexpression on CD4+ T cells correlates with reduced survival and increased TRM. Increased CD83+ B cells and Tfh cells, but not monocytes, are associated with poor posttransplant survival. CD83 CAR T eliminate autoreactive CD83+ B cells isolated from patients with chronic GVHD, without B-cell aplasia as observed with CD19 CAR T. We demonstrate robust CD83 antigen density on human acute myeloid leukemia (AML), and confirm potent antileukemic activity of CD83 CAR T in vivo, without observed myeloablation. CONCLUSIONS CD83 is a promising diagnostic marker of GVHD and warrants further investigation as a therapeutic target of both GVHD and AML relapse after alloHCT.
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Affiliation(s)
- Shernan G. Holtan
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Constanza Savid-Frontera
- Department of Blood and Marrow Transplantation and Cellular Immunotherapy, Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Kelly Walton
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Anne A. Eaton
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Connor Demorest
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Andrea Hoeschen
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Ling Zhang
- Department of Hematopathology and Laboratory Medicine, Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Kayla Reid
- Department of Blood and Marrow Transplantation and Cellular Immunotherapy, Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Tony Kurian
- Department of Blood and Marrow Transplantation and Cellular Immunotherapy, Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Zena Sayegh
- Department of Hematopathology and Laboratory Medicine, Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Estefania Julia
- Department of Blood and Marrow Transplantation and Cellular Immunotherapy, Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Joseph Maakaron
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Veronika Bachanova
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Najla El Jurdi
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Margaret L. MacMillan
- Division of Pediatric Blood and Marrow Transplantation & Cellular Therapy, Department of Pediatrics, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Daniel J. Weisdorf
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Martin Felices
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Jeffrey S. Miller
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Bruce R. Blazar
- Division of Pediatric Blood and Marrow Transplantation & Cellular Therapy, Department of Pediatrics, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Marco L. Davila
- Department of Blood and Marrow Transplantation and Cellular Immunotherapy, Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Brian C. Betts
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
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14
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Lin C, DiCioccio RA, Haykal T, McManigle WC, Li Z, Anand SM, Poe JC, Bracken SJ, Jia W, Alyea EP, Cardones AR, Choi T, Gasparetto C, Grunwald MR, Hennig T, Kang Y, Long GD, Lopez R, Martin M, Minor KK, Quinones VLP, Sung AD, Wiggins K, Chao NJ, Horwitz ME, Rizzieri DA, Sarantopoulos S. A Phase I Trial of SYK Inhibition with Fostamatinib in the Prevention and Treatment of Chronic Graft-Versus-Host Disease. Transplant Cell Ther 2023; 29:179.e1-179.e10. [PMID: 36577483 PMCID: PMC10433369 DOI: 10.1016/j.jtct.2022.12.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 12/02/2022] [Accepted: 12/19/2022] [Indexed: 12/26/2022]
Abstract
Despite the exciting advancement of novel therapies, chronic graft-versus-host disease (cGVHD) remains the most common cause of non-relapse mortality after allogeneic hematopoietic stem cell transplantation (HCT). Frontline treatment of cGVHD involves systemic steroids, which are associated with significant morbidities. We previously found that inhibition of spleen tyrosine kinase (SYK) with fostamatinib preferentially eradicated aberrantly activated B cells in both ex vivo studies of cGVHD patient B cells, as well as in vivo mouse studies. These and other preclinical studies implicated hyper-reactive B-cell receptor signaling and increased SYK expression in the pathogenesis of cGVHD and compelled this first in-human allogeneic HCT clinical trial. We investigated the safety and efficacy of the oral SYK inhibitor, fostamatinib, for both the prevention and treatment of cGVHD. The primary objective was to evaluate the safety of fostamatinib and determine its maximum tolerated dose in the post-HCT setting. Secondary objectives included assessing the efficacy of fostamatinib in preventing and treating cGVHD, as well as examining alterations in B-cell compartments with treatment. This was a single-institution phase I clinical trial that evaluated the use of fostamatinib in allogeneic HCT patients before the development of cGVHD or at the time of steroid-refractory cGVHD (SR-cGVHD). Patients received fostamatinib at one of three dose levels using a continual reassessment algorithm to determine the maximum tolerated dose. Multiparameter flow cytometry was used to evaluate changes in B cell subpopulations over the first year of treatment with fostamatinib. Nineteen patients were enrolled in this phase I trial, with 5 in the prophylaxis arm and 14 in the therapeutic arm. One patient (5%) required discontinuation of therapy for a dose-limiting toxicity. At a median follow-up of over 3 years, no patients had cancer relapse while on fostamatinib treatment, and recurrent malignancy was observed in 1 patient 2 years after the end of therapy. In the prophylaxis arm, 1 of 5 patients (20%) developed cGVHD while on fostamatinib. In the therapeutic arm, the overall response rate was 77%, with a complete response rate of 31%. The median duration of response was 19.3 months and the 12-month failure-free survival was 69% (95% confidence interval, 48-100). Patients were able to reduce their steroid dose by a median of 80%, with 73% remaining on a lower dose at 1 year compared to baseline. There was an early reduction in the proportion of IgD-CD38hi plasmablast-like cells with fostamatinib treatment, particularly in those SR-cGVHD patients who had an eventual response. B-cell reconstitution was not significantly impacted by fostamatinib therapy after allogeneic HCT. Fostamatinib featured a favorable safety profile in the post-HCT setting. Our data suggests an early efficacy signal that was associated with effects on expected cell targets in both the prophylaxis and treatment of cGVHD, providing rationale for a phase II investigation.
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Affiliation(s)
- Chenyu Lin
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Rachel A DiCioccio
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Tarek Haykal
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - William C McManigle
- Division of Pulmonary and Critical Care, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Zhiguo Li
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Sarah M Anand
- Division of Hematology and Oncology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Jonathan C Poe
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Sonali J Bracken
- Division of Rheumatology and Immunology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Wei Jia
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Edwin P Alyea
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Adela R Cardones
- Division of Dermatology, Department of Internal Medicine, University of Kansas Medical Center, Lawrence, Kansas
| | - Taewoong Choi
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Cristina Gasparetto
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Michael R Grunwald
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Therese Hennig
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Yubin Kang
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Gwynn D Long
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Richard Lopez
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Melissa Martin
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Kerry K Minor
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | | | - Anthony D Sung
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Kristi Wiggins
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Nelson J Chao
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Mitchell E Horwitz
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | | | - Stefanie Sarantopoulos
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine, Durham, North Carolina.
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15
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Buder K, Zirngibl M, Bapistella S, Meerpohl JJ, Strahm B, Bassler D, Weitz M. Extracorporeal photopheresis versus alternative treatment for chronic graft-versus-host disease after haematopoietic stem cell transplantation in children and adolescents. Cochrane Database Syst Rev 2022; 6:CD009898. [PMID: 35679154 PMCID: PMC9181448 DOI: 10.1002/14651858.cd009898.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Chronic graft-versus-host disease (cGvHD) is a major cause of morbidity and mortality after haematopoietic stem cell transplantation, occurring in 6% to 65% of the paediatric recipients. Currently, the therapeutic mainstay for cGvHD is treatment with corticosteroids, frequently combined with other immunosuppressive agents in people with steroid-refractory manifestations. There is no established standard treatment for steroid-refractory cGvHD. The therapeutic options for these patients include extracorporeal photopheresis (ECP), an immunomodulatory treatment that involves ex vivo collection of mononuclear cells from peripheral blood, exposure to the photoactive agent 8-methoxypsoralen, ultraviolet radiation and re-infusion of the processed cell product. The mechanisms of action of ECP are not completely understood. This is the second update of a Cochrane Review first published in 2014 and first updated in 2015. OBJECTIVES To evaluate the effectiveness and safety of ECP for the management of cGvHD in children and adolescents after haematopoietic stem cell transplantation. SEARCH METHODS We searched the Cochrane Register of Controlled Trials (CENTRAL) (2021), MEDLINE (PubMed) and Embase databases from their inception to 25 January 2021. We searched the reference lists of potentially relevant studies without any language restrictions. We searched five conference proceedings and nine clinical trial registries on 9 November 2020 and 12 November 2020, respectively. SELECTION CRITERIA We aimed to include randomised controlled trials (RCTs) comparing ECP with or without alternative treatment versus alternative treatment alone in children and adolescents with cGvHD after haematopoietic stem cell transplantation. DATA COLLECTION AND ANALYSIS Two review authors independently performed the study selection. We resolved disagreements in the selection of trials by consultation with a third review author. MAIN RESULTS We found no studies meeting the criteria for inclusion in this 2021 review update. AUTHORS' CONCLUSIONS We could not evaluate the efficacy of ECP in the treatment of cGvHD in children and adolescents after haematopoietic stem cell transplantation since the second review update again found no RCTs. Current recommendations are based on retrospective or observational studies only. Thus, ideally, ECP should be applied in the context of controlled trials only. However, performing RCTs in this population will be challenging due to the limited number of eligible participants, variable disease presentation and the lack of well-defined response criteria. International collaboration, multicentre trials and appropriate funding for such trials will be needed. If treatment decisions based on clinical data are made in favour of ECP, recipients should be carefully monitored for beneficial and harmful effects. In addition, efforts should be made to share this information with other clinicians, for example by setting up registries for children and adolescents treated with ECP.
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Affiliation(s)
- Kathrin Buder
- Department of General Paediatrics and Haematology/Oncology, University Hospital Tübingen, University Children's Hospital, Tübingen, Germany
| | - Matthias Zirngibl
- Department of General Paediatrics and Haematology/Oncology, University Hospital Tübingen, University Children's Hospital, Tübingen, Germany
| | - Sascha Bapistella
- Department of General Paediatrics and Haematology/Oncology, University Hospital Tübingen, University Children's Hospital, Tübingen, Germany
| | - Joerg J Meerpohl
- Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany
| | - Brigitte Strahm
- Pediatric Hematology and Oncology Centre for Pediatrics and Adolescent Medicine, University Medical School Freiburg, Freiburg, Germany
| | - Dirk Bassler
- Department of Neonatology, University Hospital Zürich, Zürich, Switzerland
| | - Marcus Weitz
- Department of General Paediatrics and Haematology/Oncology, University Hospital Tübingen, University Children's Hospital, Tübingen, Germany
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16
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Link-Rachner CS, Sockel K, Schuetz C. Established and Emerging Treatments of Skin GvHD. Front Immunol 2022; 13:838494. [PMID: 35185931 PMCID: PMC8847139 DOI: 10.3389/fimmu.2022.838494] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 01/11/2022] [Indexed: 01/14/2023] Open
Abstract
Graft-versus-host disease (GvHD) of the skin is a severe allo-immune reaction and complication following allogeneic stem cell transplantation. Over the past years, intensive pre-clinical research has led to an improved understanding of the pathophysiology of acute and to a lesser extend chronic GvHD. This has translated into the approval of several new agents for the treatment of both forms of GvHD. This review summarizes the most recent advances in underlying pathomechanisms, clinical trials and newly approved agents for GvHD, with a special focus on skin involvement.
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Affiliation(s)
- Cornelia S Link-Rachner
- Medizinische Klinik und Poliklinik I, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Center for Regenerative Therapies Dresden, Technische Universität Dresden, Dresden, Germany
| | - Katja Sockel
- Medizinische Klinik und Poliklinik I, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Catharina Schuetz
- Klinik und Poliklinik für Kinder- und Jugendmedizin, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
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Patel DA, Schroeder MA, Choi J, DiPersio JF. Mouse models of graft-versus-host disease. Methods Cell Biol 2022; 168:41-66. [DOI: 10.1016/bs.mcb.2021.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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18
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Hosoi H, Matsuyama Y, Murata S, Mushino T, Sonoki T. Prolonged Epstein-Barr virus reactivation coincident with chronic graft-versus-host disease after allogeneic hematopoietic stem cell transplantation. Leuk Lymphoma 2021; 63:1009-1012. [PMID: 34784844 DOI: 10.1080/10428194.2021.2005047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Hiroki Hosoi
- Department of Hematology/Oncology, Wakayama Medical University, Wakayama, Japan
| | - Yoriko Matsuyama
- Department of Hematology/Oncology, Wakayama Medical University, Wakayama, Japan
| | - Shogo Murata
- Department of Hematology/Oncology, Wakayama Medical University, Wakayama, Japan
| | - Toshiki Mushino
- Department of Hematology/Oncology, Wakayama Medical University, Wakayama, Japan
| | - Takashi Sonoki
- Department of Hematology/Oncology, Wakayama Medical University, Wakayama, Japan
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19
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Mhandire K, Saggu K, Buxbaum NP. Immunometabolic Therapeutic Targets of Graft-versus-Host Disease (GvHD). Metabolites 2021; 11:736. [PMID: 34822394 PMCID: PMC8619522 DOI: 10.3390/metabo11110736] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 10/22/2021] [Accepted: 10/26/2021] [Indexed: 01/17/2023] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is a curative option in the treatment of aggressive malignant and non-malignant blood disorders. However, the benefits of allo-HSCT can be compromised by graft-versus-host disease (GvHD), a prevalent and morbid complication of allo-HSCT. GvHD occurs when donor immune cells mount an alloreactive response against host antigens due to histocompatibility differences between the donor and host, which may result in extensive tissue injury. The reprogramming of cellular metabolism is a feature of GvHD that is associated with the differentiation of donor CD4+ cells into the pathogenic Th1 and Th17 subsets along with the dysfunction of the immune-suppressive protective T regulatory cells (Tregs). The activation of glycolysis and glutaminolysis with concomitant changes in fatty acid oxidation metabolism fuel the anabolic activities of the proliferative alloreactive microenvironment characteristic of GvHD. Thus, metabolic therapies such as glycolytic enzyme inhibitors and fatty acid metabolism modulators are a promising therapeutic strategy for GvHD. We comprehensively review the role of cellular metabolism in GvHD pathogenesis, identify candidate therapeutic targets, and describe potential strategies for augmenting immunometabolism to ameliorate GvHD.
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20
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Phase 2 multicenter trial of ofatumumab and prednisone as initial therapy of chronic graft-vs-host disease. Blood Adv 2021; 6:259-269. [PMID: 34649279 PMCID: PMC8753213 DOI: 10.1182/bloodadvances.2021005552] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 09/08/2021] [Indexed: 11/20/2022] Open
Abstract
Ofatumumab with glucocorticoid therapy for cGVHD resulted in 62.5% ORR at 6 months and 53% FFS at 12 months. Safety was observed with ofatumumab plus glucocorticoid for initial therapy.
Standard initial therapy of chronic graft vs. host disease (cGVHD) with glucocorticoids results in suboptimal response. Safety and feasibility of therapy with ofatumumab (1000 mg IV on days 0 and 14) and prednisone (1 mg/kg/day) was previously established in our phase I trial (n = 12). We now report the mature results of the phase II expansion of the trial (n = 38). The overall NIH severity of cGVHD was moderate (63%) or severe (37%) with 74% of all patients affected by the overlap subtype of cGVHD and 82% by prior acute cGVHD. The observed 6 month clinician-reported and 2014 NIH-defined overall response rates (ORR = complete + partial response [CR/PR]) of 62.5% (1-sided lower 90% confidence interval=51.5%) were not superior to pre-specified historic benchmark of 60%. Post-hoc comparison of 6 month NIH response suggested benefit compared to more contemporaneous NIH-based benchmark of 48.6% with frontline sirolimus/prednisone (CTN 0801 trial). Baseline cGVHD features (organ involvement, severity, initial immune suppression agents) were not significantly associated with 6-month ORR. The median time to initiation of second-line therapy was 5.4 months (range 0.9-15.1 months). Failure-free survival (FFS) was 64.2% (95% CI 46.5-77.4%) at 6 months and 53.1% (95% CI 35.8-67.7%) at 12 months, whereas FFS with CR/PR at 12 months of 33.5% exceeded a benchmark of 15% in post-hoc analysis, and was associated with greater success in steroid discontinuation by 24 months (odds ratio 8 (95% CI 1.21-52.7). This single-arm phase II trial demonstrated acceptable safety and potential efficacy of the upfront use of ofatumumab in combination with prednisone in cGVHD. This trial was registered at www.clinicaltrials.gov as #NCT01680965.
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21
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Carreno-Galeano JT, Dohlman TH, Kim S, Yin J, Dana R. A Review of Ocular Graft-versus-Host Disease: Pathophysiology, Clinical Presentation and Management. Ocul Immunol Inflamm 2021; 29:1190-1199. [PMID: 34228599 DOI: 10.1080/09273948.2021.1939390] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Graft-versus-host disease is a common complication following allogeneic hematopoetic stem cell transplantation that can affect multiple organ systems, including the eyes. Ocular GVHD (oGVHD) is characterized by a T cell-mediated immune response that leads to immune cell infiltration and inflammation of ocular structures, including the lacrimal glands, eyelids, cornea and conjunctiva. oGVHD has a significant negative impact on visual function and quality of life and successful management requires a multi-disciplinary approach with frequent monitoring. Here, we review the pathophysiology and clinical presentation of oGVHD, along with current therapeutic strategies based on our clinical experience and the reported literature.
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Affiliation(s)
| | - Thomas H Dohlman
- Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Stella Kim
- Department of Ophthalmology, University of Texas McGovern Medical School, Houston, Texas, USA
| | - Jia Yin
- Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Reza Dana
- Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
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22
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Limaye S, Limaye V. Clinical Characteristics of Myositis Associated with Graft-Versus-Host Disease. Curr Rheumatol Rep 2021; 23:30. [PMID: 33893887 DOI: 10.1007/s11926-021-00996-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2021] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW Recipients of allogeneic hematopoietic stem cell transplantation (HSCT) are at increased risk for inflammatory myositis; histological subsets reported include dermatomyositis, necrotising myopathy and chronic graft-versus-host disease (cGVHD)-related myositis. Though corticosteroids and various immunosuppressive therapies have been used, there is a lack of consensus guidelines dictating therapy. RECENT FINDINGS Recent evidence suggests the fascia as a preferential target in cGVHD myositis, with conditioning regimens promoting fascial microtrauma. Positron emission tomography (PET) can be a useful diagnostic tool, and case reports suggest that the Bruton's tyrosine kinase inhibitor ibrutinib may have therapeutic potential. Emerging therapies include targeted B cell depletion with rituximab, and extracorporeal photophoresis. Clinicians need to be vigilant for the development of inflammatory myositis post-allogeneic HSCT as most patients respond to treatment. Advances in immunohistochemistry to determine the dominant cell type and cytokine profile may enable targeted and individualised therapies.
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Affiliation(s)
- Sandhya Limaye
- Department of Immunology, Concord Hospital, Hospital Road, Concord, NSW, 2139, Australia.,Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Vidya Limaye
- Department of Rheumatology, Royal Adelaide Hospital, Port Road, Adelaide, SA, 5000, Australia. .,Discipline of Medicine, University of Adelaide, Adelaide, Australia.
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23
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Williams KM, Inamoto Y, Im A, Hamilton B, Koreth J, Arora M, Pusic I, Mays JW, Carpenter PA, Luznik L, Reddy P, Ritz J, Greinix H, Paczesny S, Blazar BR, Pidala J, Cutler C, Wolff D, Schultz KR, Pavletic SZ, Lee SJ, Martin PJ, Socie G, Sarantopoulos S. National Institutes of Health Consensus Development Project on Criteria for Clinical Trials in Chronic Graft-versus-Host Disease: I. The 2020 Etiology and Prevention Working Group Report. Transplant Cell Ther 2021; 27:452-466. [PMID: 33877965 DOI: 10.1016/j.jtct.2021.02.035] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 02/26/2021] [Indexed: 02/06/2023]
Abstract
Preventing chronic graft-versus-host disease (GVHD) remains challenging because the unique cellular and molecular pathways that incite chronic GVHD are poorly understood. One major point of intervention for potential prevention of chronic GVHD occurs at the time of transplantation when acute donor anti-recipient immune responses first set the events in motion that result in chronic GVHD. After transplantation, additional insults causing tissue injury can incite aberrant immune responses and loss of tolerance, further contributing to chronic GVHD. Points of intervention are actively being identified so that chronic GVHD initiation pathways can be targeted without affecting immune function. The major objective in the field is to continue basic studies and to translate what is learned about etiopathology to develop targeted prevention strategies that decrease the risk of morbid chronic GVHD without increasing the risks of cancer relapse or infection. Development of strategies to predict the risk of developing debilitating or deadly chronic GVHD is a high research priority. This working group recommends further interrogation into the mechanisms underpinning chronic GVHD development, and we highlight considerations for future trial design in prevention trials.
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Affiliation(s)
- Kirsten M Williams
- Division of Blood and Marrow Transplantation, Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia
| | - Yoshihiro Inamoto
- Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Annie Im
- Division of Hematology Oncology, University of Pittsburgh, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania
| | - Betty Hamilton
- Blood and Marrow Transplant Program, Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - John Koreth
- Dana-Farber Cancer Institute, Division of Hematologic Malignancies, Harvard Medical School, Boston, Massachusetts
| | - Mukta Arora
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Iskra Pusic
- BMT and Leukemia Section, Division of Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Jacqueline W Mays
- National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland
| | - Paul A Carpenter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Leo Luznik
- Division of Hematologic Malignancies, Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Pavan Reddy
- Divsion of Hematology and Oncology, University of Michigan Rogel Cancer Center, Ann Arbor, Michigan
| | - Jerome Ritz
- Dana-Farber Cancer Institute, Division of Hematologic Malignancies, Harvard Medical School, Boston, Massachusetts
| | - Hildegard Greinix
- Clinical Division of Hematology, Medical University of Graz, Graz, Austria
| | - Sophie Paczesny
- Department of Microbiology and Immunology and Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Bruce R Blazar
- Division of Pediatric Blood and Marrow Transplantation & Cellular Therapy, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Joseph Pidala
- Blood and Marrow Transplantation and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Corey Cutler
- Dana-Farber Cancer Institute, Division of Hematologic Malignancies, Harvard Medical School, Boston, Massachusetts
| | - Daniel Wolff
- Department of Internal Medicine III, University Hospital of Regensburg, Regensburg, Germany
| | - Kirk R Schultz
- Pediatric Oncology, Hematology, and Bone Marrow Transplant, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Steven Z Pavletic
- Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Stephanie J Lee
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Medicine, University of Washington, Seattle, Washington
| | - Paul J Martin
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Medicine, University of Washington, Seattle, Washington
| | - Gerard Socie
- Hematology Transplantation, Saint Louis Hospital, AP-HP, and University of Paris, INSERM U976, Paris, France.
| | - Stefanie Sarantopoulos
- Division of Hematological Malignancies and Cellular Therapy, Department of Medicine, Duke Cancer Institute, Durham, North Carolina.
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24
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Tomaszewska A, Jagasia M, Beohou E, van der Werf S, Blaise D, Kanfer E, Milpied N, Reményi P, Ciceri F, Bourhis JH, Chevallier P, Solano C, Socié G, Bruno B, Rambaldi A, Castagna L, Kröger N, Corradini P, Afanasyev B, Ladetto M, Niederwieser D, Scheid C, Sengeloev H, Kroschinsky F, Yakoub-Agha I, Schoemans H, Koenecke C, Penack O, Perić Z, Greinix H, Duarte RF, Basak GW. Addition of Rituximab in Reduced Intensity Conditioning Regimens for B-Cell Malignancies Does Not Influence Transplant Outcomes: EBMT Registry Analyses Following Allogeneic Stem Cell Transplantation for B-Cell Malignancies. Front Immunol 2021; 11:613954. [PMID: 33603743 PMCID: PMC7884746 DOI: 10.3389/fimmu.2020.613954] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 12/16/2020] [Indexed: 11/13/2022] Open
Abstract
Rituximab (R) is increasingly incorporated in reduced intensity conditioning (RIC) regimens for allogeneic hematopoietic cell transplantation (alloHCT) in patients with B-cell malignancies, not only to improve disease control, but also to prevent graft-versus-host disease (GVHD). There are no randomized prospective data to validate this practice, although single center data and the CIBMTR analysis have shown promising results. We aimed at validation of these findings in a large registry study. We conducted a retrospective analysis using the EBMT registry of 3,803 adult patients with B-cell malignancies undergoing alloHCT (2001-2013) with either rituximab (R-RIC-9%) or non-rituximab (RIC-91%) reduced intensity regimens respectively. Median age and median follow up were 55 years (range 19.1-77.3) and 43.2 months (range 0.3-179.8), respectively. There was no difference in transplant outcomes (R-RIC vs RIC), including 1-year overall survival (69.9% vs 70.7%), 1-year disease-free survival (64.4% vs 62.2%), 1-year non-relapse mortality (21% vs 22%), and day-100 incidence of acute GVHD 2-4° (12% vs 12%). In summary, we found that addition of rituximab in RIC regimens for B-cell malignancies had no significant impact on major transplant outcome variables. Of note, data on chronic GVHD was not available, limiting the conclusions that can be drawn from the present study.
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Affiliation(s)
- Agnieszka Tomaszewska
- Department of Hematology, Transplantology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Madan Jagasia
- Division of Hematology-Oncology, Vanderbilt University Medical Center, Nashville, TN, United States
| | | | | | | | - Edward Kanfer
- Hammersmith Hospital, Imperial College Healthcare, London, United Kingdom
| | | | | | | | - Jean H Bourhis
- Gustave Roussy Institute de Cancérologie, Val de Marne, France
| | | | | | | | - Benedetto Bruno
- A.O.U. Citta della Salute e della Scienza di Torino, Universita di Torino, Turin, Italy
| | | | | | | | - Paolo Corradini
- Fondazione IRCCS Istituto Nazionale dei Tumori, University of Milano, Milan, Italy
| | - Boris Afanasyev
- First State Pavlov Medical University of St. Petersburg, St. Petersburg, Russia
| | | | | | | | | | | | | | | | | | - Olaf Penack
- Department of Hematology, Oncology, and Tumor Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - Hildegard Greinix
- Department of Hematology and Oncology, Medical University of Graz, Graz, Austria
| | - Rafael F Duarte
- Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Grzegorz W Basak
- Department of Hematology, Transplantology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
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25
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Wertheimer T, Dohse M, Afram G, Weber D, Heidenreich M, Holler B, Kattner AS, Neubauer A, Mielke S, Ljungman P, Holler E, Herr W, Edinger M, Martínez AP, Fante M, Wolff D. Abatacept as salvage therapy in chronic graft-versus-host disease-a retrospective analysis. Ann Hematol 2021; 100:779-787. [PMID: 33515310 PMCID: PMC7914235 DOI: 10.1007/s00277-021-04434-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 01/18/2021] [Indexed: 01/08/2023]
Abstract
The immunomodulatory fusion protein abatacept has recently been investigated for the treatment of steroid-refractory chronic graft-versus-host disease (cGvHD) in a phase 1 clinical trial. We analyzed the safety and efficacy of abatacept for cGvHD therapy in a retrospective study with 15 patients who underwent allogeneic hematopoietic stem cell transplantation (allo-HSCT) and received abatacept for cGvHD with a median age of 49 years. Grading was performed as part of the clinical routine according to the National Institute of Health’s (NIH) consensus criteria at initiation of abatacept and 1, 3, 6, 9 and 12 months thereafter. The median time of follow-up was 191 days (range 55–393 days). Best overall response rate (ORR) was 40%. In particular, patients with bronchiolitis obliterans syndrome showed significant clinical improvement and durable responses following abatacept treatment with a response rate of 89% based on improvement in lung severity score (n = 6) or stabilized lung function (n = 4) or both (n = 3). Infectious complications CTCAE °III or higher were observed in 3/15 patients. None of the patients relapsed from the underlying malignancy. Thus, abatacept appears to be a promising treatment option for cGvHD, in particular for patients with lung involvement. However, further evaluation within a phase 2 clinical trial is required.
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Affiliation(s)
- Tobias Wertheimer
- Department of Internal Medicine III, Hematology and Oncology, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany.
| | - Marius Dohse
- Department of Hematology, Oncology and Immunology, University Hospital Giessen and Marburg, Marburg, Germany
| | - Gabriel Afram
- Department of Cellular Therapy and Allogeneic Stem Cell Transplantation, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Daniela Weber
- Department of Internal Medicine III, Hematology and Oncology, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Martin Heidenreich
- Department of Internal Medicine III, Hematology and Oncology, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Barbara Holler
- Department of Internal Medicine III, Hematology and Oncology, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Anna-Sophia Kattner
- Department of Internal Medicine III, Hematology and Oncology, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Andreas Neubauer
- Department of Hematology, Oncology and Immunology, University Hospital Giessen and Marburg, Marburg, Germany
| | - Stephan Mielke
- Department of Cellular Therapy and Allogeneic Stem Cell Transplantation, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Per Ljungman
- Department of Cellular Therapy and Allogeneic Stem Cell Transplantation, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Ernst Holler
- Department of Internal Medicine III, Hematology and Oncology, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany.,Regensburg Center for Interventional Immunology, Regensburg, Germany
| | - Wolfgang Herr
- Department of Internal Medicine III, Hematology and Oncology, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany.,Regensburg Center for Interventional Immunology, Regensburg, Germany
| | - Matthias Edinger
- Department of Internal Medicine III, Hematology and Oncology, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany.,Regensburg Center for Interventional Immunology, Regensburg, Germany
| | - Antonio Pérez Martínez
- Pediatric Hematology, Oncology and Stem Cell Transplantation, Hospital Universitario La Paz, Universidad Autonóma de Madrid, Madrid, Spain
| | - Matthias Fante
- Department of Internal Medicine III, Hematology and Oncology, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Daniel Wolff
- Department of Internal Medicine III, Hematology and Oncology, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany.,Regensburg Center for Interventional Immunology, Regensburg, Germany
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26
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Assmann JC, Farthing DE, Saito K, Maglakelidze N, Oliver B, Warrick KA, Sourbier C, Ricketts CJ, Meyer TJ, Pavletic SZ, Linehan WM, Krishna MC, Gress RE, Buxbaum NP. Glycolytic metabolism of pathogenic T cells enables early detection of GVHD by 13C-MRI. Blood 2021; 137:126-137. [PMID: 32785680 PMCID: PMC7808015 DOI: 10.1182/blood.2020005770] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 08/01/2020] [Indexed: 02/06/2023] Open
Abstract
Graft-versus-host disease (GVHD) is a prominent barrier to allogeneic hematopoietic stem cell transplantation (AHSCT). Definitive diagnosis of GVHD is invasive, and biopsies of involved tissues pose a high risk of bleeding and infection. T cells are central to GVHD pathogenesis, and our previous studies in a chronic GVHD mouse model showed that alloreactive CD4+ T cells traffic to the target organs ahead of overt symptoms. Because increased glycolysis is an early feature of T-cell activation, we hypothesized that in vivo metabolic imaging of glycolysis would allow noninvasive detection of liver GVHD as activated CD4+ T cells traffic into the organ. Indeed, hyperpolarized 13C-pyruvate magnetic resonance imaging detected high rates of conversion of pyruvate to lactate in the liver ahead of animals becoming symptomatic, but not during subsequent overt chronic GVHD. Concomitantly, CD4+ T effector memory cells, the predominant pathogenic CD4+ T-cell subset, were confirmed to be highly glycolytic by transcriptomic, protein, metabolite, and ex vivo metabolic activity analyses. Preliminary data from single-cell sequencing of circulating T cells in patients undergoing AHSCT also suggested that increased glycolysis may be a feature of incipient acute GVHD. Metabolic imaging is being increasingly used in the clinic and may be useful in the post-AHSCT setting for noninvasive early detection of GVHD.
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Affiliation(s)
| | - Don E Farthing
- Experimental Transplantation and Immunotherapy Branch and
| | - Keita Saito
- Radiation Biology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | | | | | | | - Carole Sourbier
- Office of Biotechnology Products, Office of Pharmaceutical Quality, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD
| | | | - Thomas J Meyer
- CCR Collaborative Bioinformatics Resource, National Cancer Institute, National Institutes of Health, Bethesda, MD
- Advanced Biomedical Computational Science, Frederick National Laboratory for Cancer Research, Frederick, MD; and
| | - Steven Z Pavletic
- Immune Deficiency Cellular Therapy Program, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | | | - Murali C Krishna
- Radiation Biology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Ronald E Gress
- Experimental Transplantation and Immunotherapy Branch and
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27
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Wolff D, Fatobene G, Rocha V, Kröger N, Flowers ME. Steroid-refractory chronic graft-versus-host disease: treatment options and patient management. Bone Marrow Transplant 2021; 56:2079-2087. [PMID: 34218265 PMCID: PMC8410585 DOI: 10.1038/s41409-021-01389-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 06/14/2021] [Accepted: 06/22/2021] [Indexed: 02/05/2023]
Abstract
Chronic graft-versus-host disease (cGVHD) is one of the major causes of late mortality after allogenic hematopoietic stem cell transplantation. Moderate-to-severe cGVHD is associated with poor health-related quality of life and substantial disease burden. While corticosteroids with or without calcineurin inhibitors comprise the first-line treatment option, the prognosis for patients with steroid-refractory cGVHD (SR-cGVHD) remains poor. The mechanisms underlying steroid resistance are unclear, and there are no standard second-line treatment guidelines for patients with SR-cGVHD. In this review, we provide an overview on current treatment options of cGVHD and use a series of theoretical case studies to elucidate the rationale of choices of second- and third-line treatment options for patients with SR-cGVHD based on individual patient profiles.
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Affiliation(s)
- Daniel Wolff
- grid.411941.80000 0000 9194 7179Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany
| | - Giancarlo Fatobene
- grid.411074.70000 0001 2297 2036Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP), São Paulo, Brazil ,Vila Nova Star Hospital and IDOR, Rede D’Or, São Paulo, Brazil
| | - Vanderson Rocha
- grid.411074.70000 0001 2297 2036Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP), São Paulo, Brazil ,Vila Nova Star Hospital and IDOR, Rede D’Or, São Paulo, Brazil
| | - Nicolaus Kröger
- grid.13648.380000 0001 2180 3484Department of Stem Cell Transplantation, University Medical Center Hamburg, Hamburg, Germany
| | - Mary E. Flowers
- grid.34477.330000000122986657Clinical Research Division, Fred Hutchinson Cancer Research Center and Department of Medicine, University of Washington, Seattle, Seattle, WA USA
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28
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Velickovic VM, McIlwaine E, Zhang R, Spelman T. Adverse events in second- and third-line treatments for acute and chronic graft- versus-host disease: systematic review. Ther Adv Hematol 2020; 11:2040620720977039. [PMID: 33343855 PMCID: PMC7727084 DOI: 10.1177/2040620720977039] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 10/29/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is associated with an increased risk of graft-versus-host disease (GvHD), a strong prognostic predictor of early mortality within the first 2 years following allo-HSCT. The objective of this study was to describe the harm outcomes reported among patients receiving second- and third-line treatment as part of the management for GvHD via a systematic literature review. METHODS A total of 34 studies met the systematic review inclusion criteria, reporting adverse events (AEs) across 12 different second- and third-line therapies. RESULTS A total of 14 studies reported AEs across nine different therapies used in the treatment of acute GvHD (aGvHD), 17 studies reported AEs of eight different treatments for chronic GvHD (cGvHD) and 3 reported a mixed population. Infections were the AE reported most widely, followed by haematologic events and laboratory abnormalities. Reported infections per patient were lower under extracorporeal photopheresis (ECP) for aGvHD (0.267 infections per patient over 6 months) relative to any of the therapies studied (ranging from 0.853 infections per patient per 6 months under etanercept up to 1.998 infections per patient on inolimomab). CONCLUSION The reported incidence of infectious AEs in aGvHD and grade 3-5 AEs in cGvHD was lower on ECP compared with pharmaceutical management.
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Affiliation(s)
- Vladica M. Velickovic
- Health Economics and Evidence Synthesis Department, Synergus AB, Danderyd, Stockholm, Sweden
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Reseaech and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria
| | - Emily McIlwaine
- Health Economics and Evidence Synthesis Department, Synergus AB, Danderyd, Stockholm, Sweden
| | - Rongrong Zhang
- Health Economics and Evidence Synthesis Department, Synergus AB, Danderyd, Stockholm, Sweden
| | - Tim Spelman
- Health Economics and Evidence Synthesis Department, Synergus AB, Kevinge Strand 20, Danderyd, Stockholm 182 57, Sweden
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29
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Maas-Bauer K, Kiote-Schmidt C, Bertz H, Apostolova P, Wäsch R, Ihorst G, Finke J, Zeiser R. Ruxolitinib-ECP combination treatment for refractory severe chronic graft-versus-host disease. Bone Marrow Transplant 2020; 56:909-916. [PMID: 33203951 DOI: 10.1038/s41409-020-01122-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 09/25/2020] [Accepted: 10/29/2020] [Indexed: 02/06/2023]
Abstract
Glucocorticoid-refractory (SR) chronic (c) graft-versus-host disease (GVHD) is a multisystem immunological disease and the leading cause of non-relapse mortality (NRM) in patients surviving longer than 2 years after allogeneic hematopoietic cell transplantation. Both ruxolitinib (RUX) and extracorporeal photopheresis (ECP) have shown activity for SR-cGVHD which motivated us to treat refractory cGHVD patients with the RUX-ECP combination. In this retrospective survey, 23 patients received RUX-ECP as salvage therapy for SR-cGVHD. The best response (CR or PR) at any time point during treatment was 74% (17/23) including 9% (2/23) CR and 65% (15/23) PR. The 24-months-survival was 75% (CI 56.0-94.1). Newly diagnosed cytopenia occurred in 22% (5/23) and CMV reactivation was observed in 26% (6/23) of the patients. Serum levels of soluble interleukin-2 receptor (sIL-2R) correlated with response. Our retrospective analysis shows that the RUX-ECP combination is safe and has activity in a fraction of patients with SR-cGVHD, which needs validation in a prospective trial.
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Affiliation(s)
- Kristina Maas-Bauer
- Department of Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, Freiburg, Germany
| | - Chrissoula Kiote-Schmidt
- Department of Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, Freiburg, Germany
| | - Hartmut Bertz
- Department of Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, Freiburg, Germany
| | - Petya Apostolova
- Department of Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, Freiburg, Germany
| | - Ralph Wäsch
- Department of Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, Freiburg, Germany
| | - Gabriele Ihorst
- Clinical Trials Unit, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany
| | - Jürgen Finke
- Department of Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, Freiburg, Germany
| | - Robert Zeiser
- Department of Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, Freiburg, Germany.
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Saidu NEB, Bonini C, Dickinson A, Grce M, Inngjerdingen M, Koehl U, Toubert A, Zeiser R, Galimberti S. New Approaches for the Treatment of Chronic Graft-Versus-Host Disease: Current Status and Future Directions. Front Immunol 2020; 11:578314. [PMID: 33162993 PMCID: PMC7583636 DOI: 10.3389/fimmu.2020.578314] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 09/18/2020] [Indexed: 12/15/2022] Open
Abstract
Chronic graft-versus-host disease (cGvHD) is a severe complication of allogeneic hematopoietic stem cell transplantation that affects various organs leading to a reduced quality of life. The condition often requires enduring immunosuppressive therapy, which can also lead to the development of severe side effects. Several approaches including small molecule inhibitors, antibodies, cytokines, and cellular therapies are now being developed for the treatment of cGvHD, and some of these therapies have been or are currently tested in clinical trials. In this review, we discuss these emerging therapies with particular emphasis on tyrosine kinase inhibitors (TKIs). TKIs are a class of compounds that inhibits tyrosine kinases, thereby preventing the dissemination of growth signals and activation of key cellular proteins that are involved in cell growth and division. Because they have been shown to inhibit key kinases in both B cells and T cells that are involved in the pathophysiology of cGvHD, TKIs present new promising therapeutic approaches. Ibrutinib, a Bruton tyrosine kinase (Btk) inhibitor, has recently been approved by the Food and Drug Administration (FDA) in the United States for the treatment of adult patients with cGvHD after failure of first-line of systemic therapy. Also, Janus Associated Kinases (JAK1 and JAK2) inhibitors, such as itacitinib (JAK1) and ruxolitinib (JAK1 and 2), are promising in the treatment of cGvHD. Herein, we present the current status and future directions of the use of these new drugs with particular spotlight on their targeting of specific intracellular signal transduction cascades important for cGvHD, in order to shed some light on their possible mode of actions.
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Affiliation(s)
- Nathaniel Edward Bennett Saidu
- Division of Molecular Medicine, Ruđer Bošković Institute, Zagreb, Croatia
- Department of Pharmacology, University of Oslo and Oslo University Hospital, Oslo, Norway
| | - Chiara Bonini
- Experimental Hematology Unit, San Raffaele Scientific Institute, Milano, Italy
| | - Anne Dickinson
- Haematological Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Magdalena Grce
- Division of Molecular Medicine, Ruđer Bošković Institute, Zagreb, Croatia
| | - Marit Inngjerdingen
- Department of Pharmacology, University of Oslo and Oslo University Hospital, Oslo, Norway
| | - Ulrike Koehl
- Faculty of Medicine, Institute of Clinical Immunology, University Leipzig and Fraunhofer IZI, Leipzig, Germany
| | - Antoine Toubert
- Université de Paris, Institut de Recherche Saint Louis, EMiLy, Inserm U1160, Paris, France
- Laboratoire d'Immunologie et d`Histocompatibilité, AP-HP, Hopital Saint-Louis, Paris, France
| | - Robert Zeiser
- Department of Hematology, Oncology and Stem Cell Transplantation, Freiburg University Medical Center, Faculty of Medicine, Freiburg, Germany
| | - Sara Galimberti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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31
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Chhabra S, Visotcky A, Pasquini MC, Zhu F, Tang X, Zhang MJ, Thompson R, Abedin S, D'Souza A, Dhakal B, Drobyski WR, Fenske TS, Jerkins JH, Douglas Rizzo J, Runaas L, Saber W, Shah NN, Shaw BE, Horowitz MM, Hari PN, Hamadani M. Ixazomib for Chronic Graft-versus-Host Disease Prophylaxis following Allogeneic Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2020; 26:1876-1885. [PMID: 32653622 PMCID: PMC7571859 DOI: 10.1016/j.bbmt.2020.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 06/12/2020] [Accepted: 07/02/2020] [Indexed: 11/16/2022]
Abstract
Chronic graft-versus-host disease (cGVHD) is major cause of morbidity and mortality following allogeneic hematopoietic cell transplantation (HCT). Ixazomib is an oral, second-generation, proteasome inhibitor that has been shown in preclinical models to prevent GVHD. We conducted a phase I/II trial in 57 patients to evaluate the safety and efficacy of ixazomib administration for cGVHD prophylaxis in patients undergoing allogeneic HCT. Oral ixazomib was administered on a weekly basis for a total of 4 doses, beginning days +60 through +90, to recipients of matched related donor (MRD, n = 25) or matched unrelated donor (MUD, n = 26) allogeneic HCT in phase II portion of the study, once the recommended phase II dose of 4 mg was identified in phase I (n = 6). All patients received peripheral blood graft and standard GVHD prophylaxis of tacrolimus and methotrexate. Ixazomib administration was safe and well tolerated, with thrombocytopenia, leukopenia, gastrointestinal complaints, and fatigue the most common adverse events (>10%). In phase II (n = 51), the cumulative incidence of cGVHD at 1 year was 36% (95% confidence interval [CI], 19% to 54%) in the MRD cohort and 39% (95% CI, 21% to 56%) in the MUD cohort. One-year cumulative incidence of nonrelapse mortality (NRM) and relapse was 0% and 20% (95% CI, 8% to 36%) in the MRD cohort, respectively. In the MUD cohort, the respective NRM and relapse rates were 4% (0% to 16%) and 34% (17% to 52%). The outcomes on the study were compared post hoc with contemporaneous matched Center for International Blood and Marrow Transplant Research (CIBMTR) controls. This post hoc analysis showed no significant improvement in cGVHD rates in both the MRD (hazard ratio [HR] = 0.85, P = .64) or MUD cohorts (HR = 0.68, P = .26) on the study compared with CIBMTR controls. B cell activating factor plasma levels were significantly higher after ixazomib dosing in those who remained cGVHD free compared with those developed cGVHD. This study shows that the novel strategy of short-course oral ixazomib following allogeneic HCT is safe but did not demonstrate significant improvement in cGVHD incidence in recipients of MRD and MUD transplantation compared with matched CIBMTR controls. This study is registered at www.clinicaltrials.gov as NCT02250300.
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Affiliation(s)
- Saurabh Chhabra
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Blood and Marrow Transplant & Cellular Therapy Program, Froedtert & Medical College of Wisconsin, Milwaukee, Wisconsin; Center for International Blood and Marrow Transplant Research, Milwaukee Campus, Milwaukee, Wisconsin
| | - Alexis Visotcky
- Department of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Marcelo C Pasquini
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Blood and Marrow Transplant & Cellular Therapy Program, Froedtert & Medical College of Wisconsin, Milwaukee, Wisconsin; Center for International Blood and Marrow Transplant Research, Milwaukee Campus, Milwaukee, Wisconsin
| | - Fenlu Zhu
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Blood and Marrow Transplant & Cellular Therapy Program, Froedtert & Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Xiaoying Tang
- Center for International Blood and Marrow Transplant Research, Milwaukee Campus, Milwaukee, Wisconsin; Department of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Mei-Jie Zhang
- Center for International Blood and Marrow Transplant Research, Milwaukee Campus, Milwaukee, Wisconsin; Department of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Robert Thompson
- Center for International Blood and Marrow Transplant Research, Milwaukee Campus, Milwaukee, Wisconsin
| | - Sameem Abedin
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Blood and Marrow Transplant & Cellular Therapy Program, Froedtert & Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Anita D'Souza
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Blood and Marrow Transplant & Cellular Therapy Program, Froedtert & Medical College of Wisconsin, Milwaukee, Wisconsin; Center for International Blood and Marrow Transplant Research, Milwaukee Campus, Milwaukee, Wisconsin
| | - Binod Dhakal
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Blood and Marrow Transplant & Cellular Therapy Program, Froedtert & Medical College of Wisconsin, Milwaukee, Wisconsin
| | - William R Drobyski
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Blood and Marrow Transplant & Cellular Therapy Program, Froedtert & Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Timothy S Fenske
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Blood and Marrow Transplant & Cellular Therapy Program, Froedtert & Medical College of Wisconsin, Milwaukee, Wisconsin
| | - James H Jerkins
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Blood and Marrow Transplant & Cellular Therapy Program, Froedtert & Medical College of Wisconsin, Milwaukee, Wisconsin
| | - J Douglas Rizzo
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Blood and Marrow Transplant & Cellular Therapy Program, Froedtert & Medical College of Wisconsin, Milwaukee, Wisconsin; Center for International Blood and Marrow Transplant Research, Milwaukee Campus, Milwaukee, Wisconsin
| | - Lyndsey Runaas
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Blood and Marrow Transplant & Cellular Therapy Program, Froedtert & Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Wael Saber
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Blood and Marrow Transplant & Cellular Therapy Program, Froedtert & Medical College of Wisconsin, Milwaukee, Wisconsin; Center for International Blood and Marrow Transplant Research, Milwaukee Campus, Milwaukee, Wisconsin
| | - Nirav N Shah
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Blood and Marrow Transplant & Cellular Therapy Program, Froedtert & Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Bronwen E Shaw
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Blood and Marrow Transplant & Cellular Therapy Program, Froedtert & Medical College of Wisconsin, Milwaukee, Wisconsin; Center for International Blood and Marrow Transplant Research, Milwaukee Campus, Milwaukee, Wisconsin
| | - Mary M Horowitz
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Blood and Marrow Transplant & Cellular Therapy Program, Froedtert & Medical College of Wisconsin, Milwaukee, Wisconsin; Center for International Blood and Marrow Transplant Research, Milwaukee Campus, Milwaukee, Wisconsin
| | - Parameswaran N Hari
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Blood and Marrow Transplant & Cellular Therapy Program, Froedtert & Medical College of Wisconsin, Milwaukee, Wisconsin; Center for International Blood and Marrow Transplant Research, Milwaukee Campus, Milwaukee, Wisconsin
| | - Mehdi Hamadani
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Blood and Marrow Transplant & Cellular Therapy Program, Froedtert & Medical College of Wisconsin, Milwaukee, Wisconsin; Center for International Blood and Marrow Transplant Research, Milwaukee Campus, Milwaukee, Wisconsin.
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32
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Yang K, Chen Y, Qi H, Ye Y, Fan Z, Huang F, Zhang H, Suo Y, Liu Q, Jin H. Anti-Ro52 Autoantibodies Are Related to Chronic Graft-vs.-Host Disease After Allogeneic Hematopoietic Stem Cell Transplantation. Front Immunol 2020; 11:1505. [PMID: 32849514 PMCID: PMC7399095 DOI: 10.3389/fimmu.2020.01505] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 06/09/2020] [Indexed: 01/14/2023] Open
Abstract
Chronic graft-vs.-host disease (cGVHD) remains a major cause of morbidity and mortality after allogeneic hematopoietic stem cell transplantation (allo-HSCT). Previous studies have shown that autoantibodies play an important role in the development of cGVHD. Anti-nuclear autoantibodies (ANA) is the most frequently detected autoantibodies in patients with cGVHD, but the role of anti-Ro52 autoantibodies (anti-Ro52) in cGVHD remains largely unknown. In this study, we analyzed autoantibodies from 84 patients after allo-HSCT, including 42 with active cGVHD and 42 without cGVHD. Autoantibodies were found in 36 (42.9%) patients. Among these autoantibody-positive patients, 28 (77.8%) patients had active cGVHD. The most frequent autoantibodies in patients with active cGVHD were ANA (50.0%), anti-Ro52 (28.6%) and anti-mitochondrial autoantibodies type 2 (4.8%). We further explored the association between anti-Ro52 and cGVHD. Patients with active cGVHD had higher anti-Ro52 levels than patients without cGVHD (P < 0.05). The increases of anti-Ro52 levels were more significant in patients with moderate/severe cGVHD compared to those of patients without cGVHD (P < 0.05). Stratified and multivariable logistic regression analysis demonstrated that moderate/severe cGVHD was an independent risk factor for the levels of anti-Ro52 (P < 0.01). ROC analysis confirmed anti-Ro52 as a risk factor for progression of skin cGVHD. Moreover, the anti-Ro52 levels were highly correlated with the levels of B cell-activating factor (BAFF) and IgG1 antibodies. Our study demonstrates that anti-Ro52 is associated with cGVHD. The increased levels of anti-Ro52 were associated with higher levels of BAFF and IgG1 antibodies, suggesting a mechanistic link between elevated anti-Ro52 levels and aberrant B cell homeostasis.
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Affiliation(s)
- Kaibo Yang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yanqiu Chen
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Hanzhou Qi
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yiling Ye
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhiping Fan
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Fen Huang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Haiyan Zhang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yuan Suo
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qifa Liu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Construction and Detection in Tissue Engineering, Southern Medical University, Guangdong, China
| | - Hua Jin
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
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Fante MA, Holler B, Weber D, Angstwurm K, Bergler T, Holler E, Edinger M, Herr W, Wertheimer T, Wolff D. Cyclophosphamide for salvage therapy of chronic graft-versus-host disease: a retrospective analysis. Ann Hematol 2020; 99:2181-2190. [PMID: 32715339 PMCID: PMC7419371 DOI: 10.1007/s00277-020-04193-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 07/20/2020] [Indexed: 12/16/2022]
Abstract
We retrospectively analyzed the safety and efficacy of cyclophosphamide (cyclo) for salvage treatment of chronic graft-versus-host disease (cGvHD) and cGvHD-associated (glomerulo-)nephritis at our center between 01/2010 and 11/2019. We identified 13 patients (pts) receiving cyclo for treatment of moderate (3/13) and severe (6/13) steroid-refractory cGvHD, cGvHD-associated (glomerulo-)nephritis (3/13), or vasculitis-like CNS manifestation of cGvHD (1/13). Cyclo was started on median day 509 (range 42-8193) after cGvHD onset; the median duration of application was 153 days (range 14-486) with 2/13 currently continuing treatment. The National Institute of Health organ grading and the intensity of immunosuppression (IS) were assessed at cyclo start and repeated after 3, 6, and 12 months. Response assessment was stopped at the start of any additional new IS. The median time of follow up was 407 days (range 86-1534). Best response was 1/13 CR, 6/13 PR, 4/13 SD, 1/13 MR, and 1/13 PD (ORR 54%). Significant and durable response was observed especially in cGvHD-associated (glomerulo-)nephritis (3/3). Infectious complications > CTCAE grade III were observed in 3/12 pts. During cyclo therapy, none of the pts suffered from recurrence of underlying malignancy. Overall, cyclo was relatively well tolerated and showed responses in heavily pretreated patients but requires further evaluation within clinical trials.
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Affiliation(s)
- Matthias A Fante
- Department of Hematology and Oncology, Internal Medicine III, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany.
| | - Barbara Holler
- Department of Hematology and Oncology, Internal Medicine III, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Daniela Weber
- Department of Hematology and Oncology, Internal Medicine III, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Klemens Angstwurm
- Department of Neurology, University Hospital Regensburg, Regensburg, Germany
| | - Tobias Bergler
- Department of Nephrology, University Hospital Regensburg, Regensburg, Germany
| | - Ernst Holler
- Department of Hematology and Oncology, Internal Medicine III, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Matthias Edinger
- Department of Hematology and Oncology, Internal Medicine III, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Wolfgang Herr
- Department of Hematology and Oncology, Internal Medicine III, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Tobias Wertheimer
- Department of Hematology and Oncology, Internal Medicine III, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Daniel Wolff
- Department of Hematology and Oncology, Internal Medicine III, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
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Impact of Rituximab and Host/Donor Fc Receptor Polymorphisms after Allogeneic Hematopoietic Cell Transplantation for CD20 + B Cell Malignancies. Biol Blood Marrow Transplant 2020; 26:1811-1818. [PMID: 32693210 DOI: 10.1016/j.bbmt.2020.07.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/11/2020] [Accepted: 07/13/2020] [Indexed: 11/22/2022]
Abstract
We previously reported a 24% 1-year relapse rate in 93 older or medically unfit patients with CD20+ B cell malignancies after allogeneic hematopoietic cell transplantation (HCT) with low-intensity conditioning. The current prospective study tested the hypothesis that disease relapse could be reduced and overall survival (OS) improved by peritransplantation administration of rituximab (RTX). Sixty-three patients received RTX (375 mg/m2/day) on days -3, +10, +24, and +38 along with 2 to 3 Gy total body irradiation with or without fludarabine (30 mg/m2 for 3 days). Median RTX levels of >25 μg/mL were achieved through day +84 after transplantation, but RTX level was not correlated with relapse or graft-versus-host disease (GVHD). HCT recipients with F/F and V/F FCγRIIIa polymorphisms showed a trend toward a higher relapse rate compared with those with V/V polymorphism (P= .15). No difference in outcome was found based on V/V donor pairing. Five-year relapse rates were similar between RTX-treated patients and historical controls (32% versus 28%; P = .94). RTX-treated patients had greater 5-year OS (47% versus 38%; P = .13) and progression-free survival (41% versus 32%; P = .12) compared with historical controls who underwent HCT without RTX, although the difference was not statistically significant. The incidence of acute GVHD was similar in the 2 groups (grade II-IV, 57% versus 56%; grade III-IV, 13% versus 17%), but the 5-year incidence of chronic GVHD was higher among RTX-treated patients (62% versus 47%). In patients with relapsed or refractory non-Hodgkin lymphoma, peritransplantation RTX neither reduced relapse nor improved GVHD. The role of donor-recipient pairing by FCγRIIIa polymorphisms in outcomes remains to be determined.
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Gonzalez RM, Pidala J. Evolving Therapeutic Options for Chronic Graft‐versus‐Host Disease. Pharmacotherapy 2020; 40:756-772. [DOI: 10.1002/phar.2427] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 04/04/2020] [Accepted: 04/13/2020] [Indexed: 12/17/2022]
Affiliation(s)
- Rebecca M. Gonzalez
- Department of Blood & Marrow Transplant and Cellular Immunotherapy (BMT CI) Moffitt Cancer Center Tampa Florida USA
- Department of Pharmacy Moffitt Cancer Center Tampa Florida USA
| | - Joseph Pidala
- Department of Blood & Marrow Transplant and Cellular Immunotherapy (BMT CI) Moffitt Cancer Center Tampa Florida USA
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36
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Dissecting the biology of allogeneic HSCT to enhance the GvT effect whilst minimizing GvHD. Nat Rev Clin Oncol 2020; 17:475-492. [PMID: 32313224 DOI: 10.1038/s41571-020-0356-4] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2020] [Indexed: 12/12/2022]
Abstract
Allogeneic haematopoietic stem cell transplantation (allo-HSCT) was the first successful therapy for patients with haematological malignancies, predominantly owing to graft-versus-tumour (GvT) effects. Dramatic methodological changes, designed to expand eligibility for allo-HSCT to older patients and/or those with comorbidities, have led to the use of reduced-intensity conditioning regimens, in parallel with more aggressive immunosuppression to better control graft-versus-host disease (GvHD). Consequently, disease relapse has become the major cause of death following allo-HSCT. Hence, the prevention and treatment of relapse has come to the forefront and remains an unmet medical need. Despite >60 years of preclinical and clinical studies, the immunological requirements necessary to achieve GvT effects without promoting GvHD have not been fully established. Herein, we review learnings from preclinical modelling and clinical studies relating to the GvT effect, focusing on mechanisms of relapse and on immunomodulatory strategies that are being developed to overcome disease recurrence after both allo-HSCT and autologous HSCT. Emphasis is placed on discussing current knowledge and approaches predicated on the use of cell therapies, cytokines to augment immune responses and dual-purpose antibody therapies or other pharmacological agents that can control GvHD whilst simultaneously targeting cancer cells.
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Shaw BE. Graft Versus Host Disease Clinical Trials: Is it Time for Patients Centered Outcomes to Be the Primary Objective? Curr Hematol Malig Rep 2020; 14:22-30. [PMID: 30637541 DOI: 10.1007/s11899-019-0494-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW Graft versus host disease (GVHD) is a common complication following hematopoietic cell transplant and is associated with a high symptom burden, reduced functional status, and impaired quality of life (QOL). QOL is best assessed by patient-reported outcomes (PRO). Numerous clinical trials for the prevention and treatment of GVHD are available. This review aims to understand the landscape of PRO inclusion in clinical trials for GVHD over the last decade. RECENT FINDINGS Consensus bodies, including experts in GVHD, PRO, and clinical trials have made recommendations for a standardized approach for the inclusion of PRO in clinical trials including as primary outcomes, however, these have yet to be implemented in a consistent manner in practice. Consistently applying consensus recommendation in chronic GVHD will ensure that PROs are appropriately included in clinical trials. Development of validated measures in acute GVHD and composite outcomes for all GVHD trials are required.
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Affiliation(s)
- Bronwen E Shaw
- CIBMTR (Center for International Blood and Marrow Transplant Research)/Froedtert, Department of Medicine, Medical College of Wisconsin, 9200 W. Wisconsin Ave., Suite C5500, Milwaukee, WI, 53226, USA.
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39
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Wang JY, Tabata MM, Pugliese S, Phillips D, Kim J, Weng W, Kwong BY. Pityriasis rubra pilaris-like graft-vs-host disease following allogeneic stem cell transplant in two patients. Clin Case Rep 2019; 7:2491-2494. [PMID: 31893086 PMCID: PMC6935619 DOI: 10.1002/ccr3.2458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 08/22/2019] [Indexed: 11/09/2022] Open
Abstract
Chronic cutaneous graft-vs-host disease (GVHD) has several atypical variants. We describe two cases of GVHD with clinical and histopathologic features of pityriasis rubra pilaris (PRP), which responded to additional immunosuppression. Recognition of this newly described PRP-like clinical presentation of GVHD may prompt early consideration of additional steroid-sparing therapies.
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Affiliation(s)
- Jennifer Y. Wang
- Department of DermatologyStanford University Medical CenterStanfordCalifornia
| | - Mika M. Tabata
- Department of DermatologyStanford University Medical CenterStanfordCalifornia
| | - Silvina Pugliese
- Department of DermatologyStanford University Medical CenterStanfordCalifornia
| | - Darci Phillips
- Department of DermatologyStanford University Medical CenterStanfordCalifornia
| | - Jinah Kim
- Department of DermatologyStanford University Medical CenterStanfordCalifornia
- Department of PathologyStanford University Medical CenterStanfordCalifornia
- Department of DermatopathologyPalo Alto Medical FoundationPalo AltoCalifornia
| | - Wen‐Kai Weng
- Division of Blood and Marrow TransplantationDepartment of MedicineStanford University Medical CenterStanfordCalifornia
| | - Bernice Y. Kwong
- Department of DermatologyStanford University Medical CenterStanfordCalifornia
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40
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Escamilla Gómez V, García-Gutiérrez V, López Corral L, García Cadenas I, Pérez Martínez A, Márquez Malaver FJ, Caballero-Velázquez T, González Sierra PA, Viguria Alegría MC, Parra Salinas IM, Calderón Cabrera C, González Vicent M, Rodríguez Torres N, Parody Porras R, Ferra Coll C, Orti G, Valcárcel Ferreiras D, De la Cámara LLanzá R, Molés P, Velázquez-Kennedy K, João Mende M, Caballero Barrigón D, Pérez E, Martino Bofarull R, Saavedra Gerosa S, Sierra J, Poch M, Zudaire Ripa MT, Díaz Pérez MA, Molina Angulo B, Sánchez Ortega I, Sanz Caballer J, Montoro Gómez J, Espigado Tocino I, Pérez-Simón JA. Ruxolitinib in refractory acute and chronic graft-versus-host disease: a multicenter survey study. Bone Marrow Transplant 2019; 55:641-648. [PMID: 31700138 PMCID: PMC7051903 DOI: 10.1038/s41409-019-0731-x] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 10/13/2019] [Accepted: 10/17/2019] [Indexed: 01/22/2023]
Abstract
Graft-versus-host disease is the main cause of morbidity and mortality after allogeneic hematopoietic stem cell transplantation. First-line treatment is based on the use of high doses of corticosteroids. Unfortunately, second-line treatment for both acute and chronic graft-versus-host disease, remains a challenge. Ruxolitinib has been shown as an effective and safe treatment option for these patients. Seventy-nine patients received ruxolitinib and were evaluated in this retrospective and multicenter study. Twenty-three patients received ruxolitinib for refractory acute graft-versus-host disease after a median of 3 (range 1–5) previous lines of therapy. Overall response rate was 69.5% (16/23) which was obtained after a median of 2 weeks of treatment, and 21.7% (5/23) reached complete remission. Fifty-six patients were evaluated for refractory chronic graft-versus-host disease. The median number of previous lines of therapy was 3 (range 1–10). Overall response rate was 57.1% (32/56) with 3.5% (2/56) obtaining complete remission after a median of 4 weeks. Tapering of corticosteroids was possible in both acute (17/23, 73%) and chronic graft-versus-host disease (32/56, 57.1%) groups. Overall survival was 47% (CI: 23–67%) at 6 months for patients with aGVHD (62 vs 28% in responders vs non-responders) and 81% (CI: 63–89%) at 1 year for patients with cGVHD (83 vs 76% in responders vs non-responders). Ruxolitinib in the real life setting is an effective and safe treatment option for GVHD, with an ORR of 69.5% and 57.1% for refractory acute and chronic graft-versus-host disease, respectively, in heavily pretreated patients.
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Affiliation(s)
- Virginia Escamilla Gómez
- Department of Hematology of the University Hospital Virgen del Rocío, Instituto de Biomedicina (IBIS/CSIC/CIBERONC, CB16/12/00480), Universidad de Sevilla, Seville, Spain
| | | | - Lucía López Corral
- Complejo Asistencial Universitario de Salamanca-IBSAL, Centro de Investigación del Cáncer-IBMCC, Salamanca, Spain
| | | | | | - Francisco J Márquez Malaver
- Department of Hematology of the University Hospital Virgen del Rocío, Instituto de Biomedicina (IBIS/CSIC/CIBERONC, CB16/12/00480), Universidad de Sevilla, Seville, Spain
| | - Teresa Caballero-Velázquez
- Department of Hematology of the University Hospital Virgen del Rocío, Instituto de Biomedicina (IBIS/CSIC/CIBERONC, CB16/12/00480), Universidad de Sevilla, Seville, Spain
| | | | | | | | - Cristina Calderón Cabrera
- Department of Hematology of the University Hospital Virgen del Rocío, Instituto de Biomedicina (IBIS/CSIC/CIBERONC, CB16/12/00480), Universidad de Sevilla, Seville, Spain
| | | | - Nancy Rodríguez Torres
- Department of Hematology of the University Hospital Virgen del Rocío, Instituto de Biomedicina (IBIS/CSIC/CIBERONC, CB16/12/00480), Universidad de Sevilla, Seville, Spain
| | | | | | | | | | | | | | | | - María João Mende
- Complejo Asistencial Universitario de Salamanca-IBSAL, Centro de Investigación del Cáncer-IBMCC, Salamanca, Spain
| | - Dolores Caballero Barrigón
- Complejo Asistencial Universitario de Salamanca-IBSAL, Centro de Investigación del Cáncer-IBMCC, Salamanca, Spain
| | - Estefanía Pérez
- Complejo Asistencial Universitario de Salamanca-IBSAL, Centro de Investigación del Cáncer-IBMCC, Salamanca, Spain
| | | | | | - Jorge Sierra
- Hospital Santa Creu I Sant Pau, Barcelona, Spain
| | - Marc Poch
- Clinic University Hospital of Valencia, Valencia, Spain
| | | | | | | | | | | | | | - Ildefonso Espigado Tocino
- Department of Hematology of the University Hospital Virgen del Rocío, Instituto de Biomedicina (IBIS/CSIC/CIBERONC, CB16/12/00480), Universidad de Sevilla, Seville, Spain
| | - José A Pérez-Simón
- Department of Hematology of the University Hospital Virgen del Rocío, Instituto de Biomedicina (IBIS/CSIC/CIBERONC, CB16/12/00480), Universidad de Sevilla, Seville, Spain.
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41
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Stocker N, Labopin M, Boussen I, Paccoud O, Bonnin A, Malard F, Amiel C, Gozlan J, Battipaglia G, Duléry R, Giannotti F, Ruggeri A, Gaugler B, Mohty M, Brissot E. Pre-emptive rituximab treatment for Epstein–Barr virus reactivation after allogeneic hematopoietic stem cell transplantation is a worthwhile strategy in high-risk recipients: a comparative study for immune recovery and clinical outcomes. Bone Marrow Transplant 2019; 55:586-594. [DOI: 10.1038/s41409-019-0699-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 08/03/2019] [Accepted: 08/10/2019] [Indexed: 12/13/2022]
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Muhsen IN, Hashmi SK, Niederwieser D, Kroeger N, Agrawal S, Pasquini MC, Atsuta Y, Ballen KK, Seber A, Saber W, Kharfan-Dabaja MA, Rasheed W, Okamoto S, Khera N, Wood WA, Koh MBC, Greinix H, Kodera Y, Szer J, Horowitz MM, Weisdorf D, Aljurf M. Worldwide Network for Blood and Marrow Transplantation (WBMT) perspective: the role of biosimilars in hematopoietic cell transplant: current opportunities and challenges in low- and lower-middle income countries. Bone Marrow Transplant 2019; 55:698-707. [PMID: 31484992 DOI: 10.1038/s41409-019-0658-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 06/28/2019] [Accepted: 07/05/2019] [Indexed: 12/18/2022]
Abstract
Health care costs attributed to biologics have increased exponentially in the recent years, thus biosimilars offer a possible solution to limit costs while maintaining safety and efficacy. Reducing expenditure is vital to health care especially in developing countries where affordability and access to health care is a major challenge. We discuss the opportunities and the challenges of biosimilars in the field of hematopoietic cell transplantation (HCT) in low- and lower-middle income countries. Developing countries can potentially invest in the forecasted costs reduction by utilizing biosimilars. This can be used to decrease the costs of procedures such as HCT, which is a rapidly growing field in many developing regions. The introduction of biosimilars in the developing regions faces many challenges which include, but are not limited to: legal and regulatory issues, lack of research infrastructure, and the presence of educational barriers. Thus, collaborative efforts are needed to ensure an effective and safe introduction of biosimilars into low- and lower-middle income countries.
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Affiliation(s)
- Ibrahim N Muhsen
- Department of Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - Shahrukh K Hashmi
- Hematology Department, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia. .,Department of Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Dietger Niederwieser
- Department of Hematology and Medical Oncology, University of Leipzig, Leipzig, Germany
| | - Nicolaus Kroeger
- Department of Stem Cell Transplantation, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Samir Agrawal
- Division of Haemato-Oncology, Bart's Health NHS Trust and Blizard Institute, Queen Mary University of London, London, UK
| | - Marcelo C Pasquini
- Center for International Blood and Marrow Transplant Research (CIBMTR), Milwaukee, WI, USA
| | - Yoshiko Atsuta
- Japanese Data Center for Hematopoietic Cell Transplantation, Nagoya, Japan
| | - Karen K Ballen
- Division of Hematology/Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | | | - Wael Saber
- Center for International Blood and Marrow Transplant Research (CIBMTR), Milwaukee, WI, USA
| | - Mohamed A Kharfan-Dabaja
- Department of Medicine, Division of Hematology-Oncology and Blood and Marrow Transplantation program, Mayo Clinic, Jacksonville, FL, USA
| | - Walid Rasheed
- Hematology Department, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | | | - Nandita Khera
- Department of Medicine, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - William A Wood
- Lineberger Comprehensive Cancer Center, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
| | | | | | - Yoshihisa Kodera
- Center for Hematopoietic Stem Cell Transplantation, Aichi Medical University Hospital, Nagakute, Japan
| | - Jeff Szer
- Department of Clinical Haematology, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Mary M Horowitz
- Center for International Blood and Marrow Transplant Research (CIBMTR), Milwaukee, WI, USA
| | | | - Mahmoud Aljurf
- Hematology Department, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
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43
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Klobuch S, Weber D, Holler B, Edinger M, Herr W, Holler E, Wolff D. Long-term follow-up of rituximab in treatment of chronic graft-versus-host disease-single center experience. Ann Hematol 2019; 98:2399-2405. [PMID: 31375860 DOI: 10.1007/s00277-019-03768-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Accepted: 07/25/2019] [Indexed: 12/19/2022]
Abstract
Rituximab was recently described also as first-line therapy of chronic graft-versus-host disease (cGvHD). We retrospectively analyzed the efficacy and safety of all patients receiving rituximab for treatment of cGvHD between 2005 and 2016 at the Regensburg University transplant center with a median follow-up after rituximab therapy of 2.8 years. Responses of 29 allogeneic stem cell-transplanted patients (median age 49) with previous failure of response to steroids including one patient after donor lymphocyte infusion were assessed. Three months after rituximab application, the overall response rate was 31% (7% complete (n = 2) and 24% partial remission (n = 7)). At 12 months, overall survival was 72% (n = 21) and failure-free survival was 24% (n = 7). We further analyzed associations of rituximab response with clinical characteristics showing a higher response rate in steroid-dependent cGvHD patients (89% of 9 responding compared to steroid refractory patients (11% responding)). However, this difference was not statistically significant. Seven patients (24%) (including four lethal infectious complications) developed serious infections requiring hospitalization within 1-9 months after rituximab therapy exclusively in patients failing to respond to rituximab. In conclusion, rituximab appears to be an effective treatment of cGvHD especially in steroid dependent patients, but identification of biomarker predicting response will be crucial to avoid long-term infectious morbidity and mortality in non-responders.
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Affiliation(s)
- Sebastian Klobuch
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany.
| | - Daniela Weber
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany.,Regensburg Center for Interventional Immunology, University Hospital Regensburg, Regensburg, Germany
| | - Barbara Holler
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany
| | - Matthias Edinger
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany.,Regensburg Center for Interventional Immunology, University Hospital Regensburg, Regensburg, Germany
| | - Wolfgang Herr
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany.,Regensburg Center for Interventional Immunology, University Hospital Regensburg, Regensburg, Germany
| | - Ernst Holler
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany.,Regensburg Center for Interventional Immunology, University Hospital Regensburg, Regensburg, Germany
| | - Daniel Wolff
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany.,Regensburg Center for Interventional Immunology, University Hospital Regensburg, Regensburg, Germany
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44
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Progress of cGVHD pathogenesis from the perspective of B cells. BLOOD SCIENCE 2019; 1:84-87. [PMID: 35402796 PMCID: PMC8974942 DOI: 10.1097/bs9.0000000000000021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 07/19/2019] [Indexed: 11/26/2022] Open
Abstract
An increasing number of physicians realize that chronic graft-versus-host disease (cGVHD) is not just dominated by T cells and that B cells also play a vital role in cGVHD development. It has been reported that altered B cell subsets, aberrant B cell signaling pathways, antibody deposition, and abnormal T-B interactions can be observed in many cGVHD patients. Studies of B cells in cGVHD development are now mainly focused on B cell subsets and GC destruction. These two aspects describe the process of B cell evolution in cGVHD patients and are associated with some original treatments. In this review, we summarize recent literature and discuss mechanisms and novel ideas of therapeutic strategies regarding the two aspects mentioned above.
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45
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Abstract
Graft-versus-host disease (GVHD) is an adverse immunologic phenomenon following allogenic hematopoietic stem cell transplant. Cutaneous manifestations are the earliest and most common presentation of the disease. This article describes the pathophysiology, clinical presentation, diagnosis, and treatment options available for acute and chronic GVHD. Acute and chronic GVHD result from an initial insult triggering an exaggerated inflammatory cascade. Clinical presentation for cutaneous acute GVHD is limited to maculopapular rash and oral mucosal lesions, whereas chronic GVHD can also include nail, scalp, and genitalia changes. Diagnosis is often made clinically and supported by biopsy, laboratory and radiology findings.
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Affiliation(s)
| | - Sree S Kolli
- Department of Dermatology, Wake Forest School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC 27157-1071, USA.
| | - Lindsay C Strowd
- Department of Dermatology, Wake Forest School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC 27157-1071, USA
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46
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How ibrutinib, a B-cell malignancy drug, became an FDA-approved second-line therapy for steroid-resistant chronic GVHD. Blood Adv 2019; 2:2012-2019. [PMID: 30108109 DOI: 10.1182/bloodadvances.2018013060] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 07/22/2018] [Indexed: 12/11/2022] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-SCT) is potentially curative for a number of hematologic conditions, both malignant and nonmalignant. However, its success can be limited by the development of acute and chronic graft-versus-host disease (GVHD). Chronic GVHD (cGVHD) is the most common long-term complication following allo-SCT, and patients who develop this condition have significantly higher morbidity and mortality and significantly lower quality of life than patients who do not. Until recently, there were no US Food and Drug Administration (FDA)-approved therapies for cGVHD treatment. In this review article, we describe how ibrutinib was identified as potential cGVHD therapy based on preclinical cGVHD models and clinical studies in B-cell malignancies and elucidation of its mechanisms of action in cGVHD. Results from a phase 2 clinical trial that was designed based on National Institutes of Health Criteria for the grading and staging of cGVHD culminated in the FDA-approval of ibrutinib as second line therapy of steroid-refractory or steroid-resistant cGVHD. Results of ibrutinib studies in phase 3 randomized studies, for cGVHD prophylaxis and as first -line testing along with steroids will be especially important in selecting the preferred indications for ibrutinib in patients at risk for or who have developed cGVHD.
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Allogeneic Transplantation after Myeloablative Rituximab/BEAM ± Bortezomib for Patients with Relapsed/Refractory Lymphoid Malignancies: 5-Year Follow-Up Results. Biol Blood Marrow Transplant 2019; 25:1347-1354. [PMID: 30826465 DOI: 10.1016/j.bbmt.2019.02.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 02/19/2019] [Indexed: 12/16/2022]
Abstract
Although bortezomib and rituximab have synergistic activity in patients with lymphoma and both can attenuate graft-versus-host disease (GVHD), the drugs have not been used together in patients undergoing allogeneic stem cell transplantation (alloSCT). In this phase I/II trial, we assessed the safety and activity of bortezomib added to the rituximab (R) plus BEAM (carmustine, etoposide, cytarabine, melphalan) regimen in patients with relapsed lymphoma undergoing alloSCT. Primary GVHD prophylaxis consisted of tacrolimus and methotrexate. Bortezomib (1 to 1.3 mg/m2 per dose) was administered i.v. on days -13, -6, -1, and +2. We performed inverse probability weighting analysis to compare GVHD and survival results with an historical control group that received R-BEAM without bortezomib. Thirty-nine patients were assessable for toxic effects and response. The median age was 54 years. The most common diagnosis was diffuse large B cell lymphoma (41%). Twenty-two patients (56%) and 17 patients (44%) received their transplants from matched related and matched unrelated donors, respectively. The maximum tolerated bortezomib dose was 1 mg/m2. The weighted cumulative incidences of grades II to IV and III or IV acute GVHD were 50% and 34%, respectively; these incidences and survival rates were not significantly different from those of the control group. Median survival was not reached in patients age ≤ 50 years and with a long follow-up time of 60.7 months. The R-BEAM regimen has a survival benefit in lymphoma patients age ≤ 50 years undergoing alloSCT. The addition of bortezomib has no impact on survival or incidence of GVHD.
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48
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How I treat refractory chronic graft-versus-host disease. Blood 2019; 133:1191-1200. [PMID: 30674472 PMCID: PMC6418480 DOI: 10.1182/blood-2018-04-785899] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 01/20/2019] [Indexed: 02/07/2023] Open
Abstract
Approximately 35% to 50% of patients otherwise cured of hematologic malignancies after allogeneic hematopoietic stem cell transplantation will develop the pleomorphic autoimmune-like syndrome known as chronic graft-versus-host disease (cGVHD). Since in 2005, National Institutes of Health (NIH) consensus panels have proposed definitions and classifications of disease to standardize treatment trials. Recently, the first agent was approved by the US Food and Drug Administration for steroid-refractory cGVHD. Despite these advances, most individuals do not achieve durable resolution of disease activity with initial treatment. Moreover, standardized recommendations on how to best implement existing and novel immunomodulatory agents and taper salvage agents are often lacking. Given the potential life-threatening nature of cGVHD, we employ in our practice patient assessment templates at each clinic visit to elucidate known prognostic indicators and red flags. We find NIH scoring templates practical for ongoing assessments of these complex patient cases and determination of when changes in immunosuppressive therapy are warranted. Patients not eligible or suitable for clinical trials have systemic and organ-directed adjunctive treatments crafted in a multidisciplinary clinic. Herein, we review these treatment options and offer a management and monitoring scaffold for representative patients with cGVHD not responding to initial therapy.
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49
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Hillhouse EE, Thiant S, Moutuou MM, Lombard-Vadnais F, Parat R, Delisle JS, Ahmad I, Roy DC, Guimond M, Roy J, Lesage S. Double-Negative T Cell Levels Correlate with Chronic Graft-versus-Host Disease Severity. Biol Blood Marrow Transplant 2019; 25:19-25. [DOI: 10.1016/j.bbmt.2018.09.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 09/06/2018] [Indexed: 02/07/2023]
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50
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Solomon SR, Sizemore CA, Ridgeway M, Zhang X, Brown S, Holland HK, Morris LE, Solh M, Bashey A. Safety and efficacy of rituximab-based first line treatment of chronic GVHD. Bone Marrow Transplant 2018; 54:1218-1226. [PMID: 30518977 DOI: 10.1038/s41409-018-0399-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 09/22/2018] [Accepted: 11/08/2018] [Indexed: 11/09/2022]
Abstract
Initial therapy of chronic GVHD (cGvHD) has not changed for over three decades, despite limited efficacy and long-term toxicity. We have previously shown in a small pilot study the feasibility of rituximab-based first-line therapy of cGVHD. To better assess safety and efficacy, we now evaluate 69 patients that received rituximab as part of their initial treatment. Median follow-up for surviving patients was 47 (11-81) months. Resolution of cGVHD occurred in 49 patients with median time to IST discontinuation of 349 (138-920) days. The cumulative incidence (CI) of cGHVD resolution was 41%, 69 and 77% at 1-, 2- and 3-years, respectively. No systemic corticosteroids were used in 27 patients, and 67% received ≤ 10 mg/kg cumulative exposure. Overall survival (OS) at 1-, 2- and 3-years following cGVHD diagnosis was 87, 79 and 77% respectively; corresponding rates of non-relapse mortality (NRM) were 10%, 16 and 19%. The probability of being alive and free of cGVHD at 1-, 2-, and 3-years was 36, 55, and 57% respectively. This study demonstrates the feasibility and efficacy of rituximab-based first-line cGVHD treatment. This approach demonstrates significant activity and avoids long courses of corticosteroids in most patients.
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Affiliation(s)
- Scott R Solomon
- The Blood and Marrow Transplant Program at Northside Hospital, Atlanta, GA, USA.
| | - Connie A Sizemore
- The Blood and Marrow Transplant Program at Northside Hospital, Atlanta, GA, USA
| | - Michelle Ridgeway
- The Blood and Marrow Transplant Program at Northside Hospital, Atlanta, GA, USA
| | - Xu Zhang
- The University of Texas, Health Science Center at Houston, Houston, TX, USA
| | - Stacey Brown
- The Blood and Marrow Transplant Program at Northside Hospital, Atlanta, GA, USA
| | - H Kent Holland
- The Blood and Marrow Transplant Program at Northside Hospital, Atlanta, GA, USA
| | - Lawrence E Morris
- The Blood and Marrow Transplant Program at Northside Hospital, Atlanta, GA, USA
| | - Melhem Solh
- The Blood and Marrow Transplant Program at Northside Hospital, Atlanta, GA, USA
| | - Asad Bashey
- The Blood and Marrow Transplant Program at Northside Hospital, Atlanta, GA, USA
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