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Jeurkar C, Leiby B, Rashid S, Gergis U, Grossso D, Carabasi M, Filicko-O'Hara J, O'Hara W, Klumpp T, Porcu P, Flomenberg N, Wagner JL. A prospective study of posttransplant cyclophosphamide for unrelated donor peripheral blood stem cell transplant with special attention to graft content and the impact of a higher γδ T cell dose. Eur J Haematol 2024; 113:283-289. [PMID: 38711359 DOI: 10.1111/ejh.14221] [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: 10/15/2023] [Revised: 04/14/2024] [Accepted: 04/16/2024] [Indexed: 05/08/2024]
Abstract
Posttransplant cyclophosphamide (PtCy) has been shown to decrease post-hematopoietic stem cell transplant acute and chronic graft-versus-host disease (GVHD). In this study, PtCy was used in 44 patients along with mycophenolate and tacrolimus with HLA matched (29) and mismatched (15) unrelated donors to determine the impact of graft content on outcome; thus, all patients had flow cytometric analysis of their graft content including the number of B cells, NK cells, and various T cell subsets. Higher γδ T cell dose was associated with the development of acute GVHD (p = .0038). For PtCy, further studies of the cell product along with further graft manipulation, such as selective γδ T cell depletion, could potentially improve outcomes.
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Affiliation(s)
- Chetan Jeurkar
- Department of Medical Oncology, Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Benjamin Leiby
- Department of Pharmacology and Experimental Therapeutics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Shaik Rashid
- Department of Medical Oncology, Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Usama Gergis
- Department of Medical Oncology, Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Dolores Grossso
- Department of Medical Oncology, Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Matthew Carabasi
- Department of Medical Oncology, Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Joanne Filicko-O'Hara
- Department of Medical Oncology, Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - William O'Hara
- Department of Medical Oncology, Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Thomas Klumpp
- Department of Medical Oncology, Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Pierluigi Porcu
- Department of Medical Oncology, Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Neal Flomenberg
- Department of Medical Oncology, Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - John L Wagner
- Department of Medical Oncology, Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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2
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Montoro J, Ngoya M, Kulagin A, Giebel S, Broers AEC, Bramanti S, Halahleh K, Pérez-Simón JA, Solano C, Ozcelik T, Blaise D, Sanz J, Henriques M, Peffault de Latour R, Martino R, Scheid C, Fox L, Gromek T, Jurado M, Sakellari I, Van Gorkom G, Matteucci P, Nagler A, Koc Y, Glass B. PTCy vs CNI-based GVHD prophylaxis in HLA-matched transplants for Hodgkin lymphoma: a study of the LWP of the EBMT. Blood Adv 2024; 8:3985-3992. [PMID: 38810260 DOI: 10.1182/bloodadvances.2024013328] [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: 04/03/2024] [Revised: 05/13/2024] [Accepted: 05/19/2024] [Indexed: 05/31/2024] Open
Abstract
ABSTRACT Studies comparing the efficacy of posttransplant cyclophosphamide (PTCy) to conventional calcineurin inhibitor (CNI)-based graft-versus-host disease (GVHD) prophylaxis regimens in patients with Hodgkin lymphoma (HL) are scarce. This study aimed to compare the outcomes of patients with HL undergoing hematopoietic stem cell transplantation (HSCT) from HLA-matched donors who received GVHD prophylaxis with either PTCy- or conventional CNI-based regimens, using data reported in the European Society for Blood and Marrow Transplantation database between January 2015 and December 2022. Among the cohort, 270 recipients received conventional CNI-based prophylaxis and 176 received PTCy prophylaxis. Notably, PTCy prophylaxis was associated with delayed hematopoietic recovery but also with a lower risk of chronic (25% vs 43%; P < .001) and extensive chronic GVHD (13% vs 28%; P = .003) compared with the CNI-based cohort. The 2-year cumulative incidence of nonrelapse mortality and relapse was 11% vs 17% (P = .12) and 17% vs 30% (P = .007) for PTCy- and CNI-based, respectively. Moreover, the 2-year overall survival (OS), progression-free survival (PFS), and GVHD-free, relapse-free survival (GRFS) were all significantly better in the PTCy group compared with the CNI-based group: 85% vs 72% (P = .005), 72% vs 53% (P < .001), and 59% vs 31% (P < .001), respectively. In multivariable analysis, PTCy was associated with a lower risk of chronic and extensive chronic GVHD, reduced relapse, and better OS, PFS, and GRFS than the CNI-based platform. Our findings suggest that PTCy as GVHD prophylaxis offers more favorable outcomes than conventional CNI-based prophylaxis in adult patients with HL undergoing HSCT from HLA-matched donors.
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Affiliation(s)
- Juan Montoro
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
- Department of Hematology, Universidad Católica de Valencia, Valencia, Spain
| | - Maud Ngoya
- Department of Biostatistics, EBMT Lymphoma Working Party, Paris, France
| | - Alexander Kulagin
- RM Gorbacheva Research Institute, Pavlov University, Saint-Petersburg, Russia
| | - Sebastian Giebel
- Department of Bone Marrow Transplantation and Oncohematology, Fundacja Na Ratunek Dzieciom z Chorobą Nowotworową, Gliwice, Poland
| | - Annoek E C Broers
- Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Stefania Bramanti
- IRCCS Humanitas Research Hospital, Transplantation Unit Department of Oncology and Haematology, Milan, Italy
| | - Khalid Halahleh
- King Hussein Cancer Centre, Adult BMT Program, Amman, Jordan
| | - Jose A Pérez-Simón
- Department of Hematology. Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla, CISC, Universidad de Sevilla, Seville, Spain
| | - Carlos Solano
- Hospital Clínico Universitario-INCLIVA, University of Valencia, Valencia, Spain
| | - Tulay Ozcelik
- Demiroglu Bilim University, Istanbul Florence Nightingale Hospital, Istanbul, Turkey
| | - Didier Blaise
- Programme de Transplantation & Therapie Cellulaire, Marseille, France
| | - Jaime Sanz
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
- Departament de Medicina, Universitat de Valencia, Valencia, Spain
| | - Marta Henriques
- Department of Hematology, Unversity Hospital Sao Joao, Oporto, Portugal
| | | | - Rodrigo Martino
- Department of Hematology, Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - Christof Scheid
- Department of Internal Medicine, University of Cologne, Cologne, Germany
| | - Laura Fox
- Department of Hematology, Hospital Vall d`Hebron, Barcelona, Spain
| | - Tomasz Gromek
- Department of Hematology, Samodzielny Publiczny Szpital Kliniczny, Lublin, Poland
| | - Manuel Jurado
- Department of Hematology, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Ioanna Sakellari
- Department of Hematology, George Papanicolaou General Hospital, Thessaloniki, Greece
| | - Gwendolyn Van Gorkom
- Division of Hematology, Department of Internal Medicine, GROW School for Oncology and Development Biology, Maastricht, The Netherlands
| | - Paola Matteucci
- Department of Hematology, University of Milano, Milan, Italy
| | - Arnon Nagler
- Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - Yener Koc
- Department of Hematology, Medicana International Hospital Istanbul, Istanbul, Turkey
| | - Bertram Glass
- Department of Hematology, Oncology, and Stem Cell Transplantation, Asklepios Klinik St. Georg, Hamburg, Germany
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3
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Al-Jamaei AAH, Epstein JB, de Visscher JGAM, Spielberger RT, Nakamura R, Raber-Durlacher JE. Comparing the risk of severe oral mucositis associated with methotrexate as graft-versus host-disease prophylaxis to other immunosuppressive prophylactic agents in hematopoietic cell transplantation: a systematic review and meta-analysis. Support Care Cancer 2024; 32:519. [PMID: 39017899 PMCID: PMC11255043 DOI: 10.1007/s00520-024-08722-w] [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: 03/20/2024] [Accepted: 07/05/2024] [Indexed: 07/18/2024]
Abstract
PURPOSE This study examines the risk of severe oral mucositis (SOM) in graft-versus-host disease prophylaxis (GVHD) compared to other agents in hematopoietic cell transplantation patients. METHODS A comprehensive search of four databases, including PubMed, Embassy, Web of Science, and Scopus, was conducted to identify studies reporting frequency and severity of oral mucositis in association with GVHD prophylactic regimens. RevMan 5.4 was used to perform the meta-analysis. Risk of bias assessment was carried out using the Rob-2 tool for randomized clinical trials (RCTs) and ROBINS-I tool for observational studies. RESULTS Twenty-five papers, including 11 RCTs and 14 observational studies, met the inclusion criteria. The pooled results from eight RCTs showed a higher risk of SOM in patients receiving MTX or MTX-inclusive GVHD prophylaxis versus non-MTX alternatives (RR = 1.50, 95% CI [1.20, 1.87], I2 = 36%, P = 0.0003). Mycophenolate mofetil (MMF) and post-transplant cyclophosphamide (Pt-Cy) consistently showed lower risk of mucositis than MTX. Folinic acid (FA) rescue and mini-dosing of MTX were associated with reduced oral mucositis severity. CONCLUSION Patients receiving MTX have a higher SOM risk compared to other approaches to prevent GVHD, which should be considered in patient care. When appropriate, MMF, FA, and a mini-dose of MTX may be an alternative that is associated with less SOM. This work also underlines the scarcity of RCTs on MTX interventions to provide the best evidence-based recommendations.
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Affiliation(s)
- Aisha A H Al-Jamaei
- Department of Oral and Maxillofacial Surgery, Amsterdam UMC, Amsterdam, The Netherlands
- Department of Oral Medicine, Periodontics, Diagnostic, and Oral Radiology, Faculty of Dentistry, Sanaá University, Sanaá, Yemen
- Department of Oral Surgery and Oral Medicine, Al-Razi University, Sanaá, Yemen
| | - Joel B Epstein
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
- City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Jan G A M de Visscher
- Department of Oral and Maxillofacial Surgery, Amsterdam UMC, Amsterdam, The Netherlands
| | - Ricardo T Spielberger
- Department of BMT, Southern California Permanente Medical Group, Kaiser Permanente, Los Angeles, CA, USA
- Department of Hematology &, Center for Stem Cell Transplantation at City of Hope Comprehensive Cancer Center, Hematopoietic Cell Transplantation, Duarte, CA, USA
| | - Ryotaro Nakamura
- Department of Hematology &, Center for Stem Cell Transplantation at City of Hope Comprehensive Cancer Center, Hematopoietic Cell Transplantation, Duarte, CA, USA
| | - Judith E Raber-Durlacher
- Department of Oral and Maxillofacial Surgery, Amsterdam UMC, Amsterdam, The Netherlands.
- Department of Oral Medicine, Academic Centre for Dentistry Amsterdam, Amsterdam, The Netherlands.
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4
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Nagler A, Labopin M, Swoboda R, Schroeder T, Hamladji RM, Griskevicius L, Salmenniemi U, Rambaldi A, Mielke S, Kulagin A, Passweg J, Luft T, Gedde-Dahl T, Forcade E, Helbig G, Stelljes M, Castilla-Llorente C, Spyridonidis A, Brissot E, Ciceri F, Mohty M. Post-transplant cyclophosphamide, calcineurin inhibitor, and mycophenolate mofetil compared to anti-thymocyte globulin, calcineurin inhibitor, and methotrexate combinations as graft-versus-host disease prophylaxis post allogeneic stem cell transplantation from sibling and unrelated donors in patients with acute myeloid leukemia: a study on behalf of the Acute Leukemia Working Party of the European Society for Blood and Marrow Transplantation. Bone Marrow Transplant 2024; 59:1012-1021. [PMID: 38615143 DOI: 10.1038/s41409-024-02284-5] [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: 01/22/2024] [Revised: 04/07/2024] [Accepted: 04/08/2024] [Indexed: 04/15/2024]
Abstract
Post-transplant cyclophosphamide plus calcineurin inhibitor (CNI)(tacrolimus or cyclosporine A) plus mycophenolate mofetil (PTCy/TAC or CSA/MMF) and anti-thymocyte globulin plus CNI (tacrolimus or cyclosporine A) plus methotrexate (ATG/TAC or CSA/MTX) are common graft-versus-host disease (GVHD) prophylaxis regimens. We compared the two regimens in patients with acute myeloid leukemia (AML) undergoing allogeneic transplantation from matched siblings or unrelated donors. 402 received PTCy/TAC or CSA/MMF and 5648 received ATG/TAC or CSA/MTX. Patients in the PTCy-based group were younger (48.7 vs. 51.5 years, p = 0.024) and there was a higher frequency of patient cytomegalovirus seropositivity and female donor to male patient combination in this group (77.8% vs. 71.8%, p = 0.009 and 18.4% vs. 14.4%, p = 0.029, respectively). More patients in the PTCy-based group received reduced-intensity conditioning (51.5% vs. 41%, p < 0.0001). No differences were observed in the incidence of acute GVHD grade II-IV and III-IV (21.2% vs. 20.4%, p = 0.92 and 8.1% vs. 6%, p = 0.1) or 2-year total and extensive chronic GVHD (33.7% vs. 30%, p = 0.09 and 10.7% vs. 11.2%, p = 0.81) between the groups. In the multivariate analysis, all transplant outcomes did not differ between the groups. PTCy/CNI/MMF and ATG/CNI/MTX are alternative regimens for GVHD prophylaxis in AML patients.
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Affiliation(s)
- Arnon Nagler
- Division of Hematology, Chaim Sheba Medical Center, Tel Hashomer, Israel.
| | - Myriam Labopin
- EBMT Paris Study Office; Department of Haematology, Saint Antoine Hospital; INSERM UMR 938, Sorbonne University, Paris, France
- Department of Haematology, Saint Antoine Hospital, Sorbonne University; INSERM UMR 938, Paris, France
| | - Ryszard Swoboda
- Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Gliwice, Poland
| | | | | | | | | | - Alessandro Rambaldi
- Department of Oncology and Hematology, University of Milan and Azienda Socio-Sanitaria Territoriale, Papa Giovanni XXIII, Bergamo, Italy
| | | | - Alexander Kulagin
- RM Gorbacheva Research Institute, Pavlov University, Petersburg, Russia
| | | | - Thomas Luft
- University of Heidelberg, Heidelberg, Germany
| | | | | | | | | | | | - Alexandros Spyridonidis
- Department of Internal Medicine, Bone Marrow Transplantation Unit, University Hospital of Patras, Patras, Greece
| | - Eolia Brissot
- Department of Haematology, Saint Antoine Hospital, Sorbonne University; INSERM UMR 938, Paris, France
| | - Fabio Ciceri
- Department of Haematology and BMT, IRCCS Osspedale San Raffaele; Vita-Salute San Raffaele University, Milano, Italy
| | - Mohamad Mohty
- EBMT Paris Study Office; Department of Haematology, Saint Antoine Hospital; INSERM UMR 938, Sorbonne University, Paris, France
- Department of Haematology, Saint Antoine Hospital, Sorbonne University; INSERM UMR 938, Paris, France
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5
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Dybko J, Sobczyk-Kruszelnicka M, Sadowska-Klasa A, Piekarska A, Makuch S, Agrawal S, Dudek K, Giordano U, Giebel S, Gil L. Optimizing Outcomes in Mismatched Unrelated Donor Allogeneic Transplantation: Post-Transplant Cyclophosphamide's Dual Impact on Graft versus Host Disease Incidence and Overall Survival: Retrospective Analysis on Behalf of Polish Adult Leukemia Group. J Clin Med 2024; 13:3569. [PMID: 38930096 PMCID: PMC11204542 DOI: 10.3390/jcm13123569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 06/12/2024] [Accepted: 06/15/2024] [Indexed: 06/28/2024] Open
Abstract
Allogeneic hematopoietic cell transplantation (allo-HSCT) stands as an effective treatment method for various hematologic malignancies. However, graft-versus-host disease (GvHD), an intricate immunological phenomenon where donor immune cells target recipient tissues, remains a significant challenge, particularly in mismatched unrelated donors (MMUD). Post-transplant cyclophosphamide (PTCy) has emerged as a promising immunosuppressive strategy, revolutionizing haploidentical transplantation and demonstrating promise in MMUD settings. Background/Objectives: This study aimed to evaluate the impact of PTCy on MMUD allo-HSCT outcomes, specifically its effects on GvHD incidence and overall survival, compared to anthitymocyte globulin (ATG). Methods: One hundred seventy-four patients were classified into three groups based on the type of transplantation: PTCy-haplo (114/174; 65.5%), PTCy-MMUD (23/174; 13.2%), and ATG-MMUD (37/174; 21.2%). Results: Our findings showed that PTCy-MMUD significantly reduced acute GvHD occurrence compared to PTCy-haplo and ATG-MMUD approaches (p = 0.006). The delayed onset of acute GvHD in the PTCy-MMUD group suggests a more controlled immune reconstitution, contributing to the lower incidence. Importantly, PTCy-MMUD exhibited enhanced five-year overall survival rates, aligning with the notion that reduced GvHD correlates with improved patient outcomes (p = 0.032). Conclusions: We believe that this study contributes valuable insights into PTCy-MMUD's management, underscoring its potential to significantly reduce GvHD incidence and enhance survival outcomes. Although further investigations and clinical trials are warranted, this research underscores the promising role of PTCy-based GvHD prophylaxis in improving MMUD allo-HCT success.
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Affiliation(s)
- Jarosław Dybko
- Department of Hematology and Cellular Transplantation, Lower Silesian Oncology Center, 53-413 Wroclaw, Poland
- Department of Oncology and Hematology, Faculty of Medicine, Wroclaw University of Science and Technology, 58-376 Wroclaw, Poland
| | - Małgorzata Sobczyk-Kruszelnicka
- Department of Bone Marrow Transplantation and Oncohematology, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, 44-102 Gliwice, Poland; (M.S.-K.); (S.G.)
| | - Alicja Sadowska-Klasa
- Department of Hematology and Transplantology, Medical University of Gdansk, 80-210 Gdansk, Poland; (A.S.-K.); (A.P.)
| | - Agnieszka Piekarska
- Department of Hematology and Transplantology, Medical University of Gdansk, 80-210 Gdansk, Poland; (A.S.-K.); (A.P.)
| | - Sebastian Makuch
- Department of Clinical and Experimental Pathology, Wroclaw Medical University, 50-368 Wroclaw, Poland;
| | - Siddarth Agrawal
- Department and Clinic of Internal Medicine, Occupational Diseases, Hypertension and Clinical Oncology, Wroclaw Medical University, 50-556 Wroclaw, Poland;
| | - Krzysztof Dudek
- Faculty of Mechanical Engineering, Wroclaw University of Science and Technology, Wybrzeze Wyspianskiego 27, 50-370 Wroclaw, Poland;
| | - Ugo Giordano
- Department and Clinic of Endocrinology, Diabetes and Isotope Therapy, 50-367 Wroclaw, Poland;
| | - Sebastian Giebel
- Department of Bone Marrow Transplantation and Oncohematology, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, 44-102 Gliwice, Poland; (M.S.-K.); (S.G.)
| | - Lidia Gil
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, 60-569 Poznan, Poland;
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Trunk AD, Guo M, Budvytyte L, Islam NS, Khera N, Hamilton BK, Amonoo HL. Hematopoietic Stem-Cell Transplantation: Exploring the Latest Advances and Gaps in Disparities, Psychosocial and Symptom Management Interventions, and Chronic Graft-Versus-Host Disease Care. Am Soc Clin Oncol Educ Book 2024; 44:e432186. [PMID: 38754066 DOI: 10.1200/edbk_432186] [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: 05/18/2024]
Abstract
Although allogeneic hematopoietic cell transplantation (HCT) offers a potential for cure for many patients with advanced hematologic malignancies and bone marrow failure or immunodeficiency syndromes, it is an intensive treatment and accompanied by short- and long-term physical and psychological symptoms requiring specialized care. With substantial advances in therapeutic approaches for HCT and supportive care, HCT survivors experience less morbidity and mortality. However, disparities in both HCT access and outcomes persist, and HCT survivors and their caregivers often lack access to much-needed psychosocial care. Additionally, more medical and psychosocial resources are needed to holistically care for HCT survivors with chronic graft-versus-host disease (GVHD). Hence, this chapter focuses on three areas pertaining to advances and gaps in HCT care: disparities in access to and outcomes of HCT, psychosocial and physical symptom management with supportive care interventions, and GVHD prevention and management.
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Affiliation(s)
- Andrew D Trunk
- Blood and Marrow Transplant Program, Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Michelle Guo
- Department of Psychiatry, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | | | | | | | - Betty K Hamilton
- Blood and Marrow Transplant Program, Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Hermioni L Amonoo
- Department of Psychiatry, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA
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7
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Salas MQ, Alfaro-Moya T, Atenafu EG, Datt Law A, Lam W, Pasic I, Novitzky-Basso I, Santos Carreira A, Chen C, Michelis FV, Gerbitz A, Howard Lipton J, Kim DDH, Kumar R, Mattsson J, Viswabandya A. Outcomes of Antithymocyte Globulin-Post-Transplantation Cyclophosphamide-Cyclosporine-Based versus Antithymocyte Globulin-Based Prophylaxis for 10/10 HLA-Matched Unrelated Donor Allogeneic Hematopoietic Cell Transplantation. Transplant Cell Ther 2024; 30:536.e1-536.e13. [PMID: 38281592 DOI: 10.1016/j.jtct.2024.01.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 01/22/2024] [Accepted: 01/23/2024] [Indexed: 01/30/2024]
Abstract
In 2015, dual T cell depletion with antithymocyte globulin (ATG) and post-transplantation cyclophosphamide (PTCy) combined with cyclosporine A (CsA) replaced our prior institutional graft-versus-host disease (GVHD) prophylaxis regimen of 4.5 mg/kg ATG, CsA, and mycophenolate mofetil (MMF) (ATG-based) in 10/10 HLA-matched unrelated donor (MUD) peripheral blood allogeneic hematopoietic stem cell transplantation (allo-HCT). The initial ATG dose of 4.5 mg/kg [ATG(4.5)/PTCy] was reduced to 2 mg/kg [ATG(2)/PTCy] in 2018. This study compares the results obtained from 444 adults undergoing MUD allo-HCT at our institution who received ATG(4.5)/PTCy (n = 127) or ATG(2)/PTCy (n = 223) with those who received ATG-based prophylaxis without PTCy (n = 84). The rates of grade II-IV and grade III-IV acute GVHD (aGVHD) at day +100 and moderate/severe chronic GVHD (cGVHD) at 1 year were 35.7%, 21.6%, and 14.7%, respectively, in patients receiving ATG-based prophylaxis without PTCy; 16.5%, 4.9%, and 4.3% in patients receiving ATG(4.5)/PTCy; and 23.3% (P = .004), 8.0% (P < .001), and 14.1% (P =.006) in patients receiving ATG(2)/PTCy. One-year overall survival (OS), nonrelapse mortality (NRM), and GVHD-free relapse-free survival (GRFS) were 69.8%, 25.3%, and 52.0%, respectively, for patients receiving ATG-based prophylaxis without PTCy; 82.7%, 17.3%, and 59.8% for patients receiving ATG(4.5)/PTCy; and 78.3% (P = .446), 14.7% (P = 101), and 56.2% (P = .448) for patients receiving ATG(2)/PTCy. On univariate analyses, the use of ATG(2)/PTCy was associated with a lower risk of NRM (hazard ratio, .54; P = .023) compared with the use of ATG-based prophylaxis without PTCy. ATG(2)/PTCy prophylaxis effectively prevents GVHD and is associated with comparable relapse risk, OS, and GRFS as seen with ATG(4.5)/PTCy and ATG-based prophylaxis without PTCy.
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Affiliation(s)
- Maria Queralt Salas
- University of Toronto, Department of Medicine, Section of Medical Oncology and Hematology, Toronto, Ontario, Canada; Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology. Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; Department of Hematology, Bone Marrow Transplantation Unit, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Tommy Alfaro-Moya
- University of Toronto, Department of Medicine, Section of Medical Oncology and Hematology, Toronto, Ontario, Canada; Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology. Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, Princes Margaret Cancer Centre, University Health Network. Toronto, Ontario, Canada
| | - Arjun Datt Law
- University of Toronto, Department of Medicine, Section of Medical Oncology and Hematology, Toronto, Ontario, Canada; Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology. Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Wilson Lam
- University of Toronto, Department of Medicine, Section of Medical Oncology and Hematology, Toronto, Ontario, Canada; Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology. Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Ivan Pasic
- University of Toronto, Department of Medicine, Section of Medical Oncology and Hematology, Toronto, Ontario, Canada; Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology. Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Igor Novitzky-Basso
- University of Toronto, Department of Medicine, Section of Medical Oncology and Hematology, Toronto, Ontario, Canada; Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology. Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Abel Santos Carreira
- University of Toronto, Department of Medicine, Section of Medical Oncology and Hematology, Toronto, Ontario, Canada; Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology. Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Carol Chen
- University of Toronto, Department of Medicine, Section of Medical Oncology and Hematology, Toronto, Ontario, Canada
| | - Fotios V Michelis
- University of Toronto, Department of Medicine, Section of Medical Oncology and Hematology, Toronto, Ontario, Canada; Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology. Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Armin Gerbitz
- University of Toronto, Department of Medicine, Section of Medical Oncology and Hematology, Toronto, Ontario, Canada; Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology. Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Jeffrey Howard Lipton
- University of Toronto, Department of Medicine, Section of Medical Oncology and Hematology, Toronto, Ontario, Canada; Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology. Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Dennis Dong Hwan Kim
- University of Toronto, Department of Medicine, Section of Medical Oncology and Hematology, Toronto, Ontario, Canada; Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology. Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Rajat Kumar
- University of Toronto, Department of Medicine, Section of Medical Oncology and Hematology, Toronto, Ontario, Canada; Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology. Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Jonas Mattsson
- University of Toronto, Department of Medicine, Section of Medical Oncology and Hematology, Toronto, Ontario, Canada; Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology. Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Auro Viswabandya
- University of Toronto, Department of Medicine, Section of Medical Oncology and Hematology, Toronto, Ontario, Canada; Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology. Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.
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8
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Paviglianiti A, Ngoya M, Peña M, Boumendil A, Gülbas Z, Ciceri F, Bonifazi F, Russo D, Fegueux N, Stolzel F, Bulabois CE, Socié G, Forcade E, Solano C, Finel H, Robinson S, Glass B, Montoto S. Graft-versus-host-disease prophylaxis with ATG or PTCY in patients with lymphoproliferative disorders undergoing reduced intensity conditioning regimen HCT from one antigen mismatched unrelated donor. Bone Marrow Transplant 2024; 59:597-603. [PMID: 38331980 PMCID: PMC11073988 DOI: 10.1038/s41409-024-02225-2] [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: 08/10/2023] [Revised: 01/13/2024] [Accepted: 01/23/2024] [Indexed: 02/10/2024]
Abstract
Post-transplant cyclophosphamide (PTCY) has been introduced as graft-versus-host disease (GvHD) prophylaxis in mismatched and matched unrelated hematopoietic cell transplant (HCT). However, data comparing outcomes of PTCY or ATG in patients undergoing a 1 antigen mismatched HCT for lymphoproliferative disease are limited. We compared PTCY versus ATG in adult patients with lymphoproliferative disease undergoing a first 9/10 MMUD HCT with a reduced intensity conditioning regimen from 2010 to 2021. Patients receiving PTCY were matched to patients receiving ATG according to: age, disease status at transplant, female to male matching, stem cell source and CMV serology. Grade II-IV acute GvHD at 100 day was 26% and 41% for the ATG and PTCY group, respectively (p = 0.08). Grade III-IV acute GvHD was not significantly different between the two groups. No differences were observed in relapse incidence, non-relapse mortality, progression-free survival, overall survival and GvHD-relapse-free survival at 1 year. The cumulative incidence of 1-year extensive chronic GvHD was 18% in the ATG and 5% in the PTCY group, respectively (p = 0.06). In patients with lymphoproliferative diseases undergoing 9/10 MMUD HCT, PTCY might be a safe option providing similar results to ATG prophylaxis. Due to the limited number of patients, prospective randomized trials are needed.
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Affiliation(s)
- Annalisa Paviglianiti
- Duran i Reynals Hospital, Catalan Institute of Oncology, Barcelona, Spain Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona, Spain.
- Department of Medicine, Unit of Endocrinology and Diabetes, Università Campus Bio-Medico di Roma, Rome, Italy.
| | - Maud Ngoya
- Lymphoma Working Party, EBMT, Paris, France
| | - Marta Peña
- Duran i Reynals Hospital, Catalan Institute of Oncology, Barcelona, Spain Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona, Spain
| | | | - Zafer Gülbas
- Bone Marrow Transplantation Department, Anadolu Medical Center Hospital, Kocaeli, Turkey
| | - Fabio Ciceri
- Hematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Domenico Russo
- Unit of Blood Diseases and Bone Marrow Transplantation, University of Brescia, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Nathalie Fegueux
- Department of Hematology and Oncology, CHU Lapeyronie, Montpellier, France
| | - Friedrich Stolzel
- University Hospital, Dresden, Medizinische Klinik und Poliklinik I, Dresden, Germany
| | - Claude Eric Bulabois
- CHU Grenoble Alpes - Université Grenoble Alpes, Service d'Hématologie, Grenoble, France
| | - Gerard Socié
- Hopital Saint Louis, Department of Hematology - BMT, Paris, France
| | | | - Carlo Solano
- Hospital Clínico de Valencia, Servicio de Hematología, University of Valencia, Valencia, Spain
| | | | | | | | - Silvia Montoto
- Department of Medicine, Unit of Endocrinology and Diabetes, Università Campus Bio-Medico di Roma, Rome, Italy
- Department of Haemato-oncology St.Bartholomew's Hospital, Barts Health NHS Trust, London, UK
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9
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Serio B, Storti G, D’Addona M, Santoro L, Frieri C, De Novellis D, Marano L, De Santis G, Guariglia R, Manfra I, Urciuoli E, Luponio S, Marotta S, Morini D, Rizzo M, Palmieri F, Cantore N, Giudice V, Risitano AM, Selleri C. Post-Transplant Cyclophosphamide versus Anti-Thymocyte Globulin in Patients with Hematological Malignancies Treated with Allogeneic Hematopoietic Stem Cell Transplantation from Haploidentical and Matched Unrelated Donors: A Real-Life Experience. Hematol Rep 2024; 16:234-243. [PMID: 38651452 PMCID: PMC11036213 DOI: 10.3390/hematolrep16020023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Revised: 01/26/2024] [Accepted: 04/01/2024] [Indexed: 04/25/2024] Open
Abstract
Background: Post-transplant cyclophosphamide (PTCY) is widely used as graft versus host disease (GvHD) prophylaxis in allogeneic hematopoietic stem cell transplant (HSCT) recipients, with reported clinical benefits in patients who underwent transplant from a matched unrelated donor (MUD). However, real-life data on clinical efficacy and safety of PTCY in haploidentical and MUD transplantations are still poor. Methods: In our real-life retrospective observational study, we included a total of 40 consecutive adult patients who underwent haploidentical or MUD HSCT for various hematological malignancies and who received PTCY (n = 24) or ATG (n = 16) as GvHD prophylaxis at Hematology Units from hospitals of Salerno and Avellino, Italy, and clinical outcomes were compared. Results: We showed protective effects of PTCY against disease relapse with the relapse rate after transplantation of 16% versus 50% in the ATG arm (p = 0.02). All-cause mortality was lower (36% vs. 75%; p = 0.02) and the 2-year overall survival was slightly superior in patients administered PTCY (61% vs. 42%; p = 0.26). Conclusions: We support the use of PTCY, even in a real-life setting; however, the optimization of this protocol should be further investigated to better balance relapse prevention and GvHD prophylaxis.
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Affiliation(s)
- Bianca Serio
- Hematology Unit, University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, 84131 Salerno, Italy; (B.S.)
| | - Gabriella Storti
- Hematology Unit, Hospital “S. Giuseppe Moscati”, 83100 Avellino, Italy (A.M.R.)
| | - Matteo D’Addona
- Hematology Unit, University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, 84131 Salerno, Italy; (B.S.)
- Department of Medicine, Surgery, and Dentistry, University of Salerno, 84081 Baronissi, Italy
| | - Lidia Santoro
- Hematology Unit, Hospital “S. Giuseppe Moscati”, 83100 Avellino, Italy (A.M.R.)
| | - Camilla Frieri
- Hematology Unit, Hospital “S. Giuseppe Moscati”, 83100 Avellino, Italy (A.M.R.)
| | - Danilo De Novellis
- Hematology Unit, University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, 84131 Salerno, Italy; (B.S.)
- Department of Medicine, Surgery, and Dentistry, University of Salerno, 84081 Baronissi, Italy
| | - Luana Marano
- Hematology Unit, Hospital “S. Giuseppe Moscati”, 83100 Avellino, Italy (A.M.R.)
| | - Giovanna De Santis
- Hematology Unit, Hospital “S. Giuseppe Moscati”, 83100 Avellino, Italy (A.M.R.)
| | - Roberto Guariglia
- Hematology Unit, University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, 84131 Salerno, Italy; (B.S.)
| | - Ilenia Manfra
- Hematology Unit, Hospital “S. Giuseppe Moscati”, 83100 Avellino, Italy (A.M.R.)
| | - Eleonora Urciuoli
- Hematology Unit, Hospital “S. Giuseppe Moscati”, 83100 Avellino, Italy (A.M.R.)
| | - Serena Luponio
- Hematology Unit, University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, 84131 Salerno, Italy; (B.S.)
| | - Serena Marotta
- Hematology Unit, Hospital “S. Giuseppe Moscati”, 83100 Avellino, Italy (A.M.R.)
| | - Denise Morini
- Hematology Unit, University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, 84131 Salerno, Italy; (B.S.)
| | - Michela Rizzo
- Hematology Unit, University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, 84131 Salerno, Italy; (B.S.)
| | - Fausto Palmieri
- Hematology Unit, Hospital “S. Giuseppe Moscati”, 83100 Avellino, Italy (A.M.R.)
| | - Nicola Cantore
- Hematology Unit, Hospital “S. Giuseppe Moscati”, 83100 Avellino, Italy (A.M.R.)
| | - Valentina Giudice
- Hematology Unit, University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, 84131 Salerno, Italy; (B.S.)
- Department of Medicine, Surgery, and Dentistry, University of Salerno, 84081 Baronissi, Italy
| | | | - Carmine Selleri
- Hematology Unit, University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, 84131 Salerno, Italy; (B.S.)
- Department of Medicine, Surgery, and Dentistry, University of Salerno, 84081 Baronissi, Italy
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10
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Copsel SN, Garrido VT, Barreras H, Bader CS, Pfeiffer B, Mateo-Victoriano B, Wolf D, Gallardo M, Paczesny S, Komanduri KV, Benjamin CL, Villarino AV, Saluja AK, Levy RB. Minnelide suppresses GVHD and enhances survival while maintaining GVT responses. JCI Insight 2024; 9:e165936. [PMID: 38602775 PMCID: PMC11141936 DOI: 10.1172/jci.insight.165936] [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: 10/04/2022] [Accepted: 04/03/2024] [Indexed: 04/13/2024] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (aHSCT) can cure patients with otherwise fatal leukemias and lymphomas. However, the benefits of aHSCT are limited by graft-versus-host disease (GVHD). Minnelide, a water-soluble analog of triptolide, has demonstrated potent antiinflammatory and antitumor activity in several preclinical models and has proven both safe and efficacious in clinical trials for advanced gastrointestinal malignancies. Here, we tested the effectiveness of Minnelide in preventing acute GVHD as compared with posttransplant cyclophosphamide (PTCy). Strikingly, we found Minnelide improved survival, weight loss, and clinical scores in an MHC-mismatched model of aHSCT. These benefits were also apparent in minor MHC-matched aHSCT and xenogeneic HSCT models. Minnelide was comparable to PTCy in terms of survival, GVHD clinical score, and colonic length. Notably, in addition to decreased donor T cell infiltration early after aHSCT, several regulatory cell populations, including Tregs, ILC2s, and myeloid-derived stem cells in the colon were increased, which together may account for Minnelide's GVHD suppression after aHSCT. Importantly, Minnelide's GVHD prevention was accompanied by preservation of graft-versus-tumor activity. As Minnelide possesses anti-acute myeloid leukemia (anti-AML) activity and is being applied in clinical trials, together with the present findings, we conclude that this compound might provide a new approach for patients with AML undergoing aHSCT.
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Affiliation(s)
| | | | | | | | - Brent Pfeiffer
- Department of Pediatrics, University of Miami, Miller School of Medicine, Miami, Florida, USA
| | | | | | | | - Sophie Paczesny
- Department of Microbiology and Immunology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Krishna V. Komanduri
- Department of Microbiology and Immunology
- Sylvester Comprehensive Cancer Center
- Department of Medicine, and
| | - Cara L. Benjamin
- Sylvester Comprehensive Cancer Center
- Department of Medicine, and
| | | | - Ashok K. Saluja
- Department of Surgery, and
- Sylvester Comprehensive Cancer Center
| | - Robert B. Levy
- Department of Microbiology and Immunology
- Sylvester Comprehensive Cancer Center
- Department of Ophthalmology, University of Miami, Miller School of Medicine, Miami, Florida, USA
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11
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Mina A, Greenberg PL, Deeg HJ. How I reduce and treat posttransplant relapse of MDS. Blood 2024; 143:1344-1354. [PMID: 38306658 DOI: 10.1182/blood.2023023005] [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: 10/23/2023] [Revised: 01/12/2024] [Accepted: 01/28/2024] [Indexed: 02/04/2024] Open
Abstract
ABSTRACT Allogeneic hematopoietic stem cell transplantation (HSCT) is the only potentially curative option for patients with high-risk myelodysplastic syndromes (MDS). Advances in conditioning regimens and supportive measures have reduced treatment-related mortality and increased the role of transplantation, leading to more patients undergoing HSCT. However, posttransplant relapse of MDS remains a leading cause of morbidity and mortality for this procedure, necessitating expert management and ongoing results analysis. In this article, we review treatment options and our institutional approaches to managing MDS relapse after HSCT, using illustrative clinical cases that exemplify different clinical manifestations and management of relapse. We address areas of controversy relating to conditioning regimen intensity, chemotherapeutic bridging, and donor selection. In addition, we discuss future directions for advancing the field, including (1) the need for prospective clinical trials separating MDS from acute myeloid leukemia and focusing on posttransplant relapse, as well as (2) the validation of measurable residual disease methodologies to guide timely interventions.
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Affiliation(s)
- Alain Mina
- Myeloid Malignancies Program, Center for Cancer Research, National Cancer Institute, Bethesda, MD
| | - Peter L Greenberg
- Department of Medicine, Division of Hematology, Stanford University School of Medicine, Stanford, CA
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12
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Velardi A, Mancusi A, Ruggeri L, Pierini A. How adoptive transfer of components of the donor immune system boosts GvL and prevents GvHD in HLA-haploidentical hematopoietic transplantation for acute leukemia. Bone Marrow Transplant 2024; 59:301-305. [PMID: 38212671 DOI: 10.1038/s41409-024-02199-1] [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: 11/14/2023] [Revised: 12/29/2023] [Accepted: 01/04/2024] [Indexed: 01/13/2024]
Abstract
Why a new Perspective in allogeneic hematopoietic transplantation? A summary. Nowadays, for high-risk acute leukemia patients without an HLA-matched donor (sibling or volunteer), hematopoietic transplants that use HLA-haploidentical grafts combined with enhanced post transplant immune suppression (i.e., high-dose cyclophosphamide) are widely used. They are associated with low TRM rates. However, they are also associated with significant chronic GvHD while they only partially abrogate leukemia relapse rates. One may speculate that post-transplant immune suppression, required for GvHD prophylaxis, weakens the anti-leukemic potential of the graft. Historically, haploidentical transplants became feasible for the first time through transplantation of T cell-depleted peripheral blood hematopoietic progenitor cells. Lack of post-transplant immune suppression allowed the emergence of donor-versus-recipient NK-cell alloreactions that eradicated AML. In an attempt to improve these results we recently combined an age-adapted, irradiation-based conditioning regimen with transplant of T-cell-depleted grafts and infusion of regulatory and conventional T cells, without any post transplant immune suppression. With the obvious limitations of a single center experience, this protocol resulted in extremely low relapse and chronic GvHD rates and, consequently, in a remarkable 75% chronic GvHD/relapse-free survival in over 50 AML patients up to the age of 65 many of whom at high risk of relapse.
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Affiliation(s)
- Andrea Velardi
- Department of Medicine and Surgery, Division of Hematology and Clinical Immunology, University of Perugia, Perugia, Italy.
| | - Antonella Mancusi
- Department of Medicine and Surgery, Division of Hematology and Clinical Immunology, University of Perugia, Perugia, Italy
| | - Loredana Ruggeri
- Department of Medicine and Surgery, Division of Hematology and Clinical Immunology, University of Perugia, Perugia, Italy
| | - Antonio Pierini
- Department of Medicine and Surgery, Division of Hematology and Clinical Immunology, University of Perugia, Perugia, Italy
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13
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Montoro J, Boumendil A, Finel H, Bramanti S, Castagna L, Blaise D, Dominietto A, Kulagin A, Yakoub-Agha I, Tbakhi A, Solano C, Giebel S, Gulbas Z, López Corral L, Pérez-Simón JA, Díez Martín JL, Sanz J, Farina L, Koc Y, Socié G, Arat M, Jurado M, Bermudez A, Labussière-Wallet H, Villalba M, Ciceri F, Martinez C, Nagler A, Sureda A, Glass B. Post-Transplantation Cyclophosphamide-Based Graft-versus-Host Disease Prophylaxis in HLA-Matched and Haploidentical Donor Transplantation for Patients with Hodgkin Lymphoma: A Comparative Study of the Lymphoma Working Party of the European Society for Blood and Marrow Transplantation. Transplant Cell Ther 2024; 30:210.e1-210.e14. [PMID: 38043802 DOI: 10.1016/j.jtct.2023.11.021] [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: 10/10/2023] [Revised: 11/15/2023] [Accepted: 11/25/2023] [Indexed: 12/05/2023]
Abstract
Post-transplantation cyclophosphamide (PTCy) has emerged as a promising approach for preventing graft-versus-host disease (GVHD) in allogeneic hematopoietic stem cell transplantation (allo-HSCT). However, there is a lack of studies examining the impact of this GVHD prophylaxis when different donor types are used in patients with Hodgkin lymphoma (HL). This study compared the outcomes of patients with HL undergoing HSCT from HLA-matched donors, including matched sibling donors (MSDs) and matched unrelated donors (MUDs), and haploidentical donors, using PTCy as the GVHD prophylaxis approach in all cohorts. We retrospectively compared outcomes of allo-HSCT from 166 HLA-matched donors (96 sibling and 70 unrelated donors) and 694 haploidentical donors using PTCy-based GVHD prophylaxis in patients with HL registered in the European Society for Blood and Marrow Transplantation database from 2010 to 2020. Compared to HLA-matched HSCT, haploidentical donor HSCT was associated with a significantly lower rate of platelet engraftment (86% versus 94%; P < .001) and a higher rate of grade II-IV acute GVHD (34% versus 24%; P = .01). The 2-year cumulative incidence of nonrelapse mortality (NRM) was significantly lower in the HLA-matched cohort compared to the haploidentical cohort (10% versus 18%; P = .02), resulting in a higher overall survival (OS) rate (82% versus 70%; P = .002). There were no significant differences between the 2 cohorts in terms of relapse, progression-free survival, or GVHD-free relapse-free survival. In multivariable analysis, haploidentical HSCT was associated with an increased risk of grade II-IV acute GVHD and NRM and worse OS compared to HLA-matched HSCT. Our findings suggest that in the context of PTCy-based GVHD prophylaxis, transplantation from HLA-matched donors appears to be a more favorable option compared to haploidentical HSCT.
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Affiliation(s)
- Juan Montoro
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain; Universidad Católica de Valencia, Spain.
| | - Ariane Boumendil
- European Society for Blood and Marrow Transplantation Lymphoma Working Party, Paris, France
| | - Hervé Finel
- European Society for Blood and Marrow Transplantation Lymphoma Working Party, Paris, France
| | - Stefania Bramanti
- Department of Oncology/Hematology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Luca Castagna
- Department of Oncology/Hematology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Didier Blaise
- Programme de Transplantation and Therapie Cellulaire, Marseille, France
| | - Alida Dominietto
- UO Ematologia e Terapie Cellulari, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Aleksandr Kulagin
- RM Gorbacheva Research Institute, Pavlov University, Saint Petersburg, Russia
| | | | | | - Carlos Solano
- Hematology Department, Hospital Clínico Universitario-INCLIVA, Valencia, Spain
| | - Sebastian Giebel
- The Department of Bone Marrow Transplantation and Onco-Hematology, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Gliwice, Poland
| | - Zafer Gulbas
- Anadolu Health Center Avliated John Hopkins, Kocaeli, Gebze, Turkey
| | | | - José A Pérez-Simón
- Servicio de Hematología, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla (IBIS), CSIC, Universidad de Sevilla, Spain
| | | | - Jaime Sanz
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Lucia Farina
- University of Milan. Hematology Division, Fondazione IRCCS Istituto. Nazionale dei Tumori di Milano, Milan, Italy
| | - Yener Koc
- Medical Park Hospitals, Beylikduzu, Istanbul, Turkey
| | - Gerard Socié
- Department of Hematology - BMT, Hematology Transplantation, Paris, France
| | - Mutlu Arat
- Demiroglu Bilim University Istanbul Florence Nightingale Hospital, Hematopoietic SCT Unit, Istanbul, Turkey
| | | | | | | | - Marta Villalba
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Fabio Ciceri
- Hematology and Bone Marrow Transplantation Unit, Milano, Italy
| | - Carmen Martinez
- Hematopoietic Stem Cell Transplantation Unit, Hospital Clínic de Barcelona, Institute of Cancer and Blood Diseases, Barcelona, Spain
| | - Arnon Nagler
- Hematology Division, Chaim Sheba Medical Center, Tel-Hashomer, Ramat-Gan, Israel
| | - Anna Sureda
- Hematology Department. Institut Català d'Oncologia, Hospital Duran i Reynals. Institut d'Investigació Biomèdica de Bellvitge, Universitat de Barcelona, Barcelona, Spain
| | - Bertram Glass
- Department of Hematology, Oncology and Stem Cell Transplantation, Asklepios Klinik St. Georg, Hamburg, Germany
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14
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Salas MQ, Pedraza A, Charry P, Suárez-Lledó M, Rodríguez-Lobato LG, Brusosa M, Solano MT, Serrahima A, Nomdedeu M, Cid J, Lozano M, Arcarons J, de Llobet N, Rosiñol L, Esteve J, Urbano-Ispizua Á, Carreras E, Fernández-Avilés F, Rovira M, Martinez C. Post-Transplantation Cyclophosphamide and Tacrolimus for Graft-versus-Host Disease Prevention after Allogeneic Hematopoietic Cell Transplantation from HLA-Matched Donors Has More Advantages Than Limitations. Transplant Cell Ther 2024; 30:213.e1-213.e12. [PMID: 38042256 DOI: 10.1016/j.jtct.2023.11.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 11/26/2023] [Accepted: 11/27/2023] [Indexed: 12/04/2023]
Abstract
This study compared the efficacy of graft-versus-host disease (GVHD) prophylaxis with post-transplantation cyclophosphamide (PTCy) and tacrolimus (Tac) versus other regimens in 272 adults undergoing peripheral blood (PB) allogeneic hematopoietic cell transplantation (allo-HCT) from HLA-matched donors. Of these 272 patients, 95 (34.9%) received PTCy/Tac. The times to neutrophil and platelet engraftment were longer in the PTCy/Tac group (20 days versus 16 days for neutrophils and 19 days versus 12 days for platelets). The day +30 cumulative incidence (CuI) of bacterial bloodstream infection was higher in the PTCy/Tac group (43.2% versus 13.0%; P < .001). The CuIs of grade II-IV and grade III-IV acute GVHD (aGVHD) at day +180 were 14.7% and 4.2%, and the CuI of moderate/severe cGVHD at 2 years was 2.4% in the PTCy/Tac group and 41.8% (hazard ratio [HR], .29; P < .001), 15.8%, (HR, .24; P = .007), and 47.0% (HR, .05; P < .001), respectively, in the no-PTCy group. The duration of immunosuppression was shorter in patients receiving PTCy/Tac (6.2 months versus 9.0 months; P < .001). PTCy/Tac patients had higher OS (2 years: 74.3% versus 60.9%; HR, .54; P = .012), lower NRM (2 years: 8.6% versus 15.8%; HR, .54; P = .11), comparable CuI of relapse (2 years: 26.0% versus 24.4%; HR, 1.03; P = .89), and higher GRFS (2 years: 59.1% versus 16.7%; HR, .32; P < .001). Using PTCy/Tac in HLA-matched PB allo-HCT improved transplantation outcomes at out institution compared with previous prophylactic regimens, including a higher probability of survival despite more delayed engraftment and a higher rate of bacterial infection.
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Affiliation(s)
- María Queralt Salas
- Hematopoietic Transplantation Unit, Hematology Department, Clinical Institute of Hematology and Oncology, Hospital Clínic de Barcelona, Barcelona, Spain; Apheresis and Cellular Therapy Unit, Hemotherapy and Hemostasis Department, Clinical Institute of Hematology and Oncology, Hospital Clínic de Barcelona, Barcelona, Spain.
| | - Alexandra Pedraza
- Hematopoietic Transplantation Unit, Hematology Department, Clinical Institute of Hematology and Oncology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Paola Charry
- Hematopoietic Transplantation Unit, Hematology Department, Clinical Institute of Hematology and Oncology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - María Suárez-Lledó
- Hematopoietic Transplantation Unit, Hematology Department, Clinical Institute of Hematology and Oncology, Hospital Clínic de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Luis Gerardo Rodríguez-Lobato
- Hematopoietic Transplantation Unit, Hematology Department, Clinical Institute of Hematology and Oncology, Hospital Clínic de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | | | - María Teresa Solano
- Hematopoietic Transplantation Unit, Hematology Department, Clinical Institute of Hematology and Oncology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Anna Serrahima
- Hematopoietic Transplantation Unit, Hematology Department, Clinical Institute of Hematology and Oncology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Meritxell Nomdedeu
- Hematopoietic Transplantation Unit, Hematology Department, Clinical Institute of Hematology and Oncology, Hospital Clínic de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain; University of Barcelona, Barcelona, Spain
| | - Joan Cid
- Apheresis and Cellular Therapy Unit, Hemotherapy and Hemostasis Department, Clinical Institute of Hematology and Oncology, Hospital Clínic de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain; University of Barcelona, Barcelona, Spain
| | - Miquel Lozano
- Apheresis and Cellular Therapy Unit, Hemotherapy and Hemostasis Department, Clinical Institute of Hematology and Oncology, Hospital Clínic de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain; University of Barcelona, Barcelona, Spain
| | - Jordi Arcarons
- Hematopoietic Transplantation Unit, Hematology Department, Clinical Institute of Hematology and Oncology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Noemi de Llobet
- Hematopoietic Transplantation Unit, Hematology Department, Clinical Institute of Hematology and Oncology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Laura Rosiñol
- Hematopoietic Transplantation Unit, Hematology Department, Clinical Institute of Hematology and Oncology, Hospital Clínic de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain; University of Barcelona, Barcelona, Spain
| | - Jordi Esteve
- Hematopoietic Transplantation Unit, Hematology Department, Clinical Institute of Hematology and Oncology, Hospital Clínic de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain; University of Barcelona, Barcelona, Spain
| | - Álvaro Urbano-Ispizua
- Hematopoietic Transplantation Unit, Hematology Department, Clinical Institute of Hematology and Oncology, Hospital Clínic de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain; University of Barcelona, Barcelona, Spain
| | - Enric Carreras
- Fundació Josep Carreras Contra la Leucèmia, Barcelona, Spain
| | - Francesc Fernández-Avilés
- Hematopoietic Transplantation Unit, Hematology Department, Clinical Institute of Hematology and Oncology, Hospital Clínic de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain; University of Barcelona, Barcelona, Spain
| | - Montserrat Rovira
- Hematopoietic Transplantation Unit, Hematology Department, Clinical Institute of Hematology and Oncology, Hospital Clínic de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain; University of Barcelona, Barcelona, Spain
| | - Carmen Martinez
- Hematopoietic Transplantation Unit, Hematology Department, Clinical Institute of Hematology and Oncology, Hospital Clínic de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain; University of Barcelona, Barcelona, Spain
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15
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Borovkova AS, Paina OV, Semenova EV, Bykova TA, Osipova AA, Slesarchuk OA, Kozhokar PV, Tsvetkova LA, Rakhmanova ZZ, Kozlov AV, Chukhlovin AB, Kazantsev IV, Estrina MA, Goloshchapov OV, Bondarenko SN, Moiseev IS, Kulagin AD, Zubarovskaya LS. Post-transplant сyclophosphamide after matched donor hematopoietic stem cell transplantation in children with acute leukemia. Clin Transplant 2024; 38:e15181. [PMID: 37922213 DOI: 10.1111/ctr.15181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 10/19/2023] [Accepted: 10/24/2023] [Indexed: 11/05/2023]
Abstract
INTRODUCTION The data on post-transplant cyclophosphamide (PTCy) in pediatric acute leukemia after matched allo-HSCT are limited to case series. The present study aimed to assess the results of PTCy-based GVHD prophylaxis in a large cohort of children with acute leukemia after matched allo-HSCT. METHODS A retrospective analysis of 190 pediatric patients with acute leukemia who had a first allograft between 2008 and 2020 from a matched sibling donor (MSD) or matched unrelated donor (MUD) was carried out. In the MSD setting, GVHD prophylaxis consisted of PTCy alone (n = 28) for the study group, and calcineurin inhibitor (CNI) ± antimetabolite (n = 30) for the control group. In MUD setting, most patients in the study group received GVHD prophylaxis with PTCy+CNI+mycophenolate mofetil (n = 42, 66.7%) or PTCy+CNI+sirolimus (n = 12, 19%). All patients (n = 69) in the control group received ATG+CNI+antimetabolite. RESULTS After MUD allo-HSCT, the incidences of acute GVHD grade III-IV and moderate/severe chronic GVHD were significantly lower in the PTCy group compared to control (6.6% vs. 35.0% and 12.7% vs. 47.1%, respectively, p < .0001). Five-year GVHD-free, relapse-free survival (GRFS) after MUD allo-HSCT was higher in the PTCy group compared to control (35.1% vs. 7.3%, p < .0001). At the same time, there was no significant difference between both groups after MSD allo-HSCT. CONCLUSIONS In pediatric acute leukemia, PTCy-based GVHD prophylaxis for MUD allo-HSCT is a feasible and effective option that results in a low incidence of GVHD. Compared to the ATG-based approach, PTCy provides better control of GVHD in children. In pediatric allo-HSCT from MSD, PTCy demonstrates comparable effectiveness to conventional GVHD prophylaxis.
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16
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Ustun C, Chen M, Kim S, Auletta JJ, Batista MV, Battiwalla M, Cerny J, Gowda L, Hill JA, Liu H, Munshi PN, Nathan S, Seftel MD, Wingard JR, Chemaly RF, Dandoy CE, Perales MA, Riches M, Papanicolaou GA. Post-transplantation cyclophosphamide is associated with increased bacterial infections. Bone Marrow Transplant 2024; 59:76-84. [PMID: 37903992 PMCID: PMC11164622 DOI: 10.1038/s41409-023-02131-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 10/05/2023] [Accepted: 10/13/2023] [Indexed: 11/01/2023]
Abstract
Post-transplant cyclophosphamide (PTCy) is increasingly used to reduce graft-versus-host disease after hematopoietic cell transplantation (HCT); however, it might be associated with more infections. All patients who were ≥2 years old, receiving haploidentical or matched sibling donor (Sib) HCT for acute leukemias or myelodysplastic syndrome, and either calcineurin inhibitor (CNI)- or PTCy-based GVHD prophylaxis [Haploidentical HCT with PTCy (HaploCy), 757; Sibling with PTCy (SibCy), 403; Sibling with CNI-based (SibCNI), 1605] were included. Most bacterial infections occurred within the first 100 days; 953 patients (34.5%) had at least 1 infection and 352 patients (13%) had ≥2 infections. Patients receiving PTCy had a greater incidence of bacterial infections by day 180 [HaploCy 46%; SibCy 48%; SibCNI 35%; p < 0.001]. Compared with the SibCNI without infection cohort, 1.99-fold, 3.33-fold, 2.78-fold, and 2.53-fold increased TRM was seen for the HaploCy cohort without infection and HaploCy, SibCy, and SibCNI cohorts with infection, respectively. Bacterial infections increased mortality [HaploCy (HR1.84, 99% CI: 1.45-2.33, p < 0.0001), SibCy cohort (HR,1.68, 99% CI: 1.30-2.19, p < 0.0001), and SibCNI cohort (HR,1.76, 99% CI: 1.43-2.16, p < 0.0001). PTCy was associated with increased bacterial infections regardless of donor, and bacterial infections were associated with increased mortality irrespective of GVHD prophylaxis. Patients receiving PTCy should be monitored carefully for bacterial infections following PTCy.
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Affiliation(s)
- Celalettin Ustun
- Division of Hematology/Oncology/Cell Therapy, Rush University, Chicago, IL, USA.
| | - Min Chen
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Soyoung Kim
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jeffery J Auletta
- CIBMTR® (Center for International Blood and Marrow Transplant Research), National Marrow Donor Program/Be The Match, Minneapolis, MN, USA
- Hematology/Oncology/BMT and Infectious Diseases, Nationwide Children's Hospital, Columbus, OH, USA
| | | | - Minoo Battiwalla
- Sarah Cannon Transplant and Cell Therapy Network, Nashville, TN, USA
| | - Jan Cerny
- Division of Hematology/Oncology, Department of Medicine, University of Massachusetts Chan Medical School and Medical Center, Worcester, MA, USA
| | - Lohith Gowda
- Yale Cancer Center and Yale School of Medicine, New Haven, CT, USA
| | - Joshua A Hill
- Fred Hutchinson Cancer Center, Seattle, WA, USA
- University of Washington School of Medicine, Seattle, WA, USA
| | - Hongtao Liu
- Section of Hematology/Oncology, University of Chicago Medicine, Chicago, IL, USA
| | - Pashna N Munshi
- Stem Cell Transplant and Cellular Immunotherapy Program, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Sunita Nathan
- Division of Hematology/Oncology/Cell Therapy, Rush University, Chicago, IL, USA
| | - Matthew D Seftel
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - John R Wingard
- Division of Hematology & Oncology, Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Roy F Chemaly
- The University of Texas, M.D. Anderson Cancer Center, Houston, TX, USA
| | - Christopher E Dandoy
- Cincinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Marcie Riches
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Genovefa A Papanicolaou
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
- Infectious Diseases Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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17
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Dybko J, Giordano U, Pilch J, Mizera J, Borkowski A, Dereń-Wagemann I. Evaluating the Impact of Post-Transplant Cyclophosphamide and Anti-Thymocyte Globulin on CMV Reactivation Following Allogeneic Hematopoietic Stem Cell Transplantation: A Systematic Literature Review. J Clin Med 2023; 12:7765. [PMID: 38137835 PMCID: PMC10743888 DOI: 10.3390/jcm12247765] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 12/08/2023] [Accepted: 12/15/2023] [Indexed: 12/24/2023] Open
Abstract
Anti-thymocyte globulin (ATG) and post-transplantation cyclophosphamide (PTCy) are two frequently utilised strategies in graft-versus-host disease (GvHD) prophylaxis following allogeneic hematopoietic cell transplantation (allo-HCT), currently approved for different recipient-donor settings. In addition, being efficacious in preventing GvHD owing to their T-cell depleting capacity, the employment of these two agents increases the risk of infections, including CMV reactivation, which stands as one of the most common and serious infections following allo-HCT. We performed a systematic literature review of articles published until 1 September 2023, through PubMed, MEDLINE, and Scopus, with the main endpoint being CMV reactivation after PTCy or ATG allo-HCT. The majority of the studies included in the analysis provide supporting evidence for a reduced risk of CMV reactivations following the use of PTCy compared to ATG, although not all findings reached statistical significance. Additionally, it appears that utilising a haploidentical donor leads to a higher incidence of CMV infections and clinically significant CMV infections (CS-CMVis) compared to other donor settings in PTCy allo-HCT. This study aims to compare the risk of CMV infections following allo-HCT in patients who have received either ATG or PTCy as GvHD prophylaxis and discuss other factors that could influence the infectious outcomes of patients who have undergone allo-HCT.
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Affiliation(s)
- Jarosław Dybko
- Lower Silesia Centre for Oncology, Pulmonology and Hematology in Wrocław, 53-439 Wroclaw, Poland; (J.D.); (I.D.-W.)
- Department of Oncology and Hematology, Faculty of Medicine, Wroclaw University of Science and Technology, 50-370 Wroclaw, Poland
| | - Ugo Giordano
- Department and Clinic of Endocrinology, Diabetes and Isotope Therapy, Wroclaw Medical University, Wybrzeże Pasteura 4, 50-367 Wroclaw, Poland
- Faculty of Medicine, Wroclaw Medical University, 50-367 Wroclaw, Poland; (J.P.); (J.M.)
| | - Justyna Pilch
- Faculty of Medicine, Wroclaw Medical University, 50-367 Wroclaw, Poland; (J.P.); (J.M.)
| | - Jakub Mizera
- Faculty of Medicine, Wroclaw Medical University, 50-367 Wroclaw, Poland; (J.P.); (J.M.)
| | - Artur Borkowski
- Department of Nuclear Medicine and Endocrine Oncology, M. Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, 44-102 Gliwice, Poland;
| | - Izabela Dereń-Wagemann
- Lower Silesia Centre for Oncology, Pulmonology and Hematology in Wrocław, 53-439 Wroclaw, Poland; (J.D.); (I.D.-W.)
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18
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Duléry R, Brissot E, Mohty M. Combining post-transplant cyclophosphamide with antithymocyte globulin for graft-versus-host disease prophylaxis in hematological malignancies. Blood Rev 2023; 62:101080. [PMID: 37085459 DOI: 10.1016/j.blre.2023.101080] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 04/10/2023] [Indexed: 04/23/2023]
Abstract
In search of an ideal partner or alternative to conventional immunosuppressive agents, rabbit anti-thymocyte globulin (ATG) and, more recently, post-transplant cyclophosphamide (PT-Cy) have both emerged as valid and efficient options for preventing graft-versus-host disease (GvHD). To further reduce the risk of GvHD, strategies combining ATG and PT-Cy have recently been investigated. In a haploidentical setting, retrospective studies suggest that combining PT-Cy and ATG may result in a lower incidence of chronic GvHD without increasing the risks of infection or relapse, when compared to PT-Cy without ATG. In haploidentical or unrelated donor settings, adding reduced doses of PT-Cy to ATG may reduce the risk of acute and chronic GvHD and improve survival, particularly GvHD-free, relapse-free survival (GRFS), when compared to ATG without PT-Cy. Overall, the combination of PT-Cy and ATG is a safe and promising approach for patients with hematological malignancies undergoing allogeneic hematopoietic stem cell transplantation (HSCT).
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Affiliation(s)
- Rémy Duléry
- Sorbonne University, Department of Clinical Hematology and Cellular Therapy, Saint Antoine Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France; INSERM, UMRs 938, Centre de recherche Saint Antoine (CRSA), Paris, France
| | - Eolia Brissot
- Sorbonne University, Department of Clinical Hematology and Cellular Therapy, Saint Antoine Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France; INSERM, UMRs 938, Centre de recherche Saint Antoine (CRSA), Paris, France
| | - Mohamad Mohty
- Sorbonne University, Department of Clinical Hematology and Cellular Therapy, Saint Antoine Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France; INSERM, UMRs 938, Centre de recherche Saint Antoine (CRSA), Paris, France.
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19
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Jurdi NE, Hoover A, O'Leary D, Cao Q, Gupta A, Ebens C, Maakaron JE, Betts BC, Rashidi A, Juckett MB, Lund T, Bachanova V, MacMillan ML, Miller JS, Orchard PJ, Wagner JE, Vercellotti G, Weisdorf DJ, Dusenbery K, Terezakis S, Holtan SG. Phase II Study of Myeloablative 7-8/8-Matched Allotransplantation with Post-Transplantation Cyclophosphamide, Tacrolimus, and Mycophenolate Mofetil. Transplant Cell Ther 2023; 29:576.e1-576.e5. [PMID: 37311510 PMCID: PMC10530433 DOI: 10.1016/j.jtct.2023.06.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 06/05/2023] [Accepted: 06/06/2023] [Indexed: 06/15/2023]
Abstract
Graft-versus-host disease (GVHD) is the major toxicity of allogeneic hematopoietic cell transplantation (HCT). We hypothesized that a GVHD prophylaxis regimen of post-transplantation cyclophosphamide (PTCy), tacrolimus (Tac), and mycophenolate mofetil (MMF) would be associated with incidences of acute and chronic GVHD in patients receiving a matched or single antigen mismatched HCT. This Phase II study was conducted at the University of Minnesota using a myeloablative regimen of either total body irradiation (TBI) at a total dose of 1320 cGy, administered in 165-cGy fractions, twice daily from day -4 to day -1, or busulfan (Bu) 3.2 mg/kg daily (cumulative area under the curve, 19,000 to 21,000 μmol/min/L) plus fludarabine (Flu) 40 mg/m2 once daily on days -5 to -2, followed by a GVHD prophylaxis regimen of PTCy 50 mg/kg on days +3 and +4, Tac, and MMF beginning on day +5. The primary endpoint was the cumulative incidence of chronic GVHD necessitating systemic immunosuppression (IST) at 1 year post-transplantation. Between March 2018 and May 2022, we enrolled 125 pediatric and adult patients, with a median follow-up of 813 days. The incidence of chronic GVHD necessitating systemic IST at 1 year was 5.5%. The rate of grade II-IV acute GVHD was 17.1%, and that of grade III-IV acute GVHD was 5.5%. Two-year overall survival was 73.7%, and 2-year graft-versus-host disease-free, relapse-free survival was 52.2%. The 2-year cumulative incidence of nonrelapse mortality was 10.2%, and the rate of relapse was 39.1%. There was no statistically significant difference in survival outcomes between recipients of matched donor transplants versus recipients of 7/8 matched donor transplants. Our data show that myeloablative HCT with PTCy/Tac/MMF results in an extremely low incidence of severe acute and chronic GVHD in well-matched allogeneic HCT.
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Affiliation(s)
- Najla El Jurdi
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Alex Hoover
- Division of Pediatric Hematology/Oncology, University of Minnesota, Minneapolis, Minnesota
| | - Daniel O'Leary
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Qing Cao
- Biostatistics Core, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Ashish Gupta
- Division of Pediatric Blood and Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, Minnesota
| | - Christen Ebens
- Division of Pediatric Blood and Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, Minnesota
| | - Joseph E Maakaron
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Brian C Betts
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Armin Rashidi
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Mark B Juckett
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Troy Lund
- Division of Pediatric Blood and Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, Minnesota
| | - Veronika Bachanova
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Margaret L MacMillan
- Division of Pediatric Blood and Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, Minnesota
| | - Jeffrey S Miller
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Paul J Orchard
- Division of Pediatric Blood and Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, Minnesota
| | - John E Wagner
- Division of Pediatric Blood and Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, Minnesota
| | - Gregory Vercellotti
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Daniel J Weisdorf
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Kathryn Dusenbery
- Department of Radiation Oncology, University of Minnesota, Minneapolis, Minnesota
| | - Stephanie Terezakis
- Department of Radiation Oncology, University of Minnesota, Minneapolis, Minnesota
| | - Shernan G Holtan
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota.
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20
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Kachur E, Patel JN, Morse AL, Moore DC, Arnall JR. Post-Transplant Cyclophosphamide for the Prevention of Graft-vs.-Host Disease in Allogeneic Hematopoietic Cell Transplantation: A Guide to Management for the Advanced Practitioner. J Adv Pract Oncol 2023; 14:520-532. [PMID: 37808076 PMCID: PMC10558021 DOI: 10.6004/jadpro.2023.14.6.5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023] Open
Abstract
Cyclophosphamide remains a critical component to haploidentical transplant conditioning regimens. Post-transplant cyclophosphamide (PTCy) emerged as an effective component of graft-vs.-host disease (GVHD) prophylaxis in the nonmyeloablative haploidentical bone marrow transplant setting. The relative ease of administration compared with ex vivo manipulations and efficacy in reducing GVHD has led to increasing PTCy use in transplant centers around the world. The role of PTCy has expanded to haploidentical transplantation with myeloablative conditioning regimens and peripheral blood progenitor cells as the donor source. Moreover, encouraging results in GVHD management have been shown with the use of PTCy alone or in combination with other immunosuppressives in the human leukocyte antigen-matched donor setting. The toxicity profile of cyclophosphamide varies extensively depending on dose, duration, overall drug exposure, and, potentially, pharmacogenetics. This review highlights the pharmacology, pharmacokinetics, and toxic effects of cyclophosphamide and offers practical guidance for clinical application in the post-transplant setting. We summarize data on the management of high-dose cyclophosphamide toxicities and provide insights into the pharmacogenetic implications on drug efficacy and safety data.
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Affiliation(s)
- Ekaterina Kachur
- From Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Jai N Patel
- From Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Allison L Morse
- From Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Donald C Moore
- From Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Justin R Arnall
- From Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
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21
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Ibikunle S, Grosso D, Gergis U. The two-step approach to allogeneic hematopoietic stem cell transplantation. Front Immunol 2023; 14:1237782. [PMID: 37720225 PMCID: PMC10502717 DOI: 10.3389/fimmu.2023.1237782] [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: 06/10/2023] [Accepted: 08/01/2023] [Indexed: 09/19/2023] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) provides the only potentially curative option for multiple hematological conditions. However, allogeneic HSCT outcomes rely on an optimal balance of effective immune recovery, minimal graft-versus-host disease (GVHD), and lasting control of disease. The quest to attain this balance has proven challenging over the past few decades. The two-step approach to HSCT was conceptualized and pioneered at Thomas Jefferson University in 2005 and remains the main platform for allografting at our institution. Following administration of the transplant conditioning regimen, patients receive a fixed dose of donor CD3+ cells (HSCT step one-DLI) as the lymphoid portion of the graft on day -6 with the aim of optimizing and controlling T cell dosing. Cyclophosphamide (CY) is administered after the DLI (days -3 and -2) to induce donor-recipient bidirectional tolerance. On day 0, a CD34-selected stem cell graft is given as the myeloid portion of the graft (step two). In this two-step approach, the stem cell graft is infused after CY tolerization, which avoids exposure of the stem cells to an alkylating agent, allowing rapid count recovery. Here, the two-step platform is described with a focus on key results from studies over the past two decades. Finally, this review details lessons learned and current strategies to optimize the graft-versus-tumor effect and limit transplant-related toxicities.
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Affiliation(s)
- Sikemi Ibikunle
- Department of Medical Oncology, Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, United States
| | | | - Usama Gergis
- Department of Medical Oncology, Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, United States
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22
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Ai J. Take a spin: Apheresis in the care of adult leukaemia patients. Best Pract Res Clin Haematol 2023; 36:101467. [PMID: 37353291 DOI: 10.1016/j.beha.2023.101467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 04/11/2023] [Indexed: 06/25/2023]
Abstract
Apheresis is an automated process to separate the whole blood of a patient or a donor, collect or remove specific blood components, and return the remaining back to the individual. Apheresis is an integral part of blood and marrow transplantation and has been increasingly utilized in novel cellular therapies for a variety of blood disorders. This review uses clinical cases to highlight the multiple roles of apheresis in the care of adult leukaemia patients, including therapeutic leukapheresis in hyperleukocytosis, mobilized peripheral blood hematopoietic progenitor cell collection in donors, mononucleated cell collection in preparation of donor lymphocyte infusion or chimeric antigen receptor T cells manufacture, and extracorporeal photopheresis in the treatment of graft versus host diseases.
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Affiliation(s)
- Jing Ai
- Transplant and Cellular Therapy Program, Levine Cancer Institute, Atrium Health, 1021 Morehead Medical Drive, LCI 2, Charlotte, NC, 28204, USA.
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23
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Sharaf El-Deen MO, Soliman MM, Al-Azab G, Samra M, Shams MEE. Cyclophosphamide with cyclosporine A for graft-versus-host disease prophylaxis in adult patients with acute myeloid leukemia undergoing allogeneic hematopoietic stem cell transplantation from human leucocyte antigen-matched donors. Int Immunopharmacol 2023; 120:110374. [PMID: 37235962 DOI: 10.1016/j.intimp.2023.110374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 05/07/2023] [Accepted: 05/19/2023] [Indexed: 05/28/2023]
Abstract
BACKGROUND Graft-versus-host disease (GVHD) is one of the most severe complications in patients with acute myeloid leukemia (AML) who underwent allogenic hematopoietic stem cell transplantation (HSCT). This study addressed the effectiveness and safety outcomes of high dose post-transplant cyclophosphamide (PT-CY) followed by cyclosporine A (CSA) as a GVHD prophylaxis protocol. PATIENTS AND METHODS From January 2019 to March 2021, AML patients who underwent HSCT, and received high-dose PT-CY followed by CSA were prospectively recruited, assessed, and followed up for one-year post-transplantation (PT). The cumulative incidences of both acute GVHD (aGVHD) at 100 days PT, and chronic GVHD (cGVHD) at one-year PT were assessed. RESULTS This study included 52 patients. The cumulative incidence (95% CIs) of aGVHD was 2.3% (0.3 - 15.4%), while the cumulative incidence of cGVHD was 23.2% (12.2-41.5%). The cumulative incidence of relapse and non-relapse mortality were 15.6%, and 7.9%, respectively. The median duration to reach neutrophil and platelet engraftment was 17 and 13 days, respectively. The overall, progression-free, and GVHD-free/relapse-free survival rates (95% CIs) were 89.6% (76.6 - 95.6%), 77.7% (62.1-87.5%), and 58.2% (41.6 - 71.7%) respectively. The cumulative incidences of the main transplant-related complications were; neutropenic sepsis (48.3%), cytomegalovirus reactivation (21.7%), pneumonia (13.8%), hemorrhagic cystitis (17.8%), septic shock (4.9%), and CSA toxicity (48.9%). CONCLUSION PT-CY followed by CSA was associated with low cumulative incidences of both aGVHD and cGVHD without increase in either the relapse or transplant-related complications; so, considered as a promising protocol to be widely applied in the settings of HLA-matched donors.
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Affiliation(s)
- Mustafa O Sharaf El-Deen
- Clinical Pharmacy and Pharmacy Practice Department, Faculty of Pharmacy, Mansoura University, Mansoura, Egypt
| | - Moetaza M Soliman
- Clinical Pharmacy and Pharmacy Practice Department, Faculty of Pharmacy, Mansoura University, Mansoura, Egypt.
| | - Gamal Al-Azab
- Clinical Pharmacy Department, Faculty of Pharmacy, Tanta University, Tanta, Egypt
| | - Mohamed Samra
- Medical Oncology and Hematology Department, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Mohammad E E Shams
- Clinical Pharmacy and Pharmacy Practice Department, Faculty of Pharmacy, Mansoura University, Mansoura, Egypt
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24
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Tamaki M, Akahoshi Y, Ashizawa M, Misaki Y, Koi S, Kim SW, Ozawa Y, Fujiwara SI, Kako S, Matsuoka KI, Sawa M, Katayama Y, Onizuka M, Kanda Y, Fukuda T, Atsuta Y, Yakushijin K, Nakasone H. Impact of anti-thymocyte globulin on survival outcomes in female-to-male allogeneic hematopoietic stem cell transplantation. Sci Rep 2023; 13:7166. [PMID: 37138004 PMCID: PMC10156723 DOI: 10.1038/s41598-023-34442-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 04/30/2023] [Indexed: 05/05/2023] Open
Abstract
Allogeneic hematopoietic cell transplantation between female donors and male recipients (female-to-male allo-HCT) is a well-established risk factor for inferior survival outcomes due to a higher incidence of graft-versus-host disease (GVHD). However, a clinical significance of anti-thymocyte globulin (ATG) in the female-to-male allo-HCT has not been elucidated. In this study, we retrospectively evaluated male patients who underwent allo-HCT between 2012 and 2019 in Japan. In the female-to-male allo-HCT cohort (n = 828), the use of ATG was not associated with a decreased risk of GVHD (HR of acute GVHD 0.691 [95% CI: 0.461-1.04], P = 0.074; HR of chronic GVHD 1.06 [95% CI: 0.738-1.52], P = 0.76), but was associated with favorable overall survival (OS) and a decreased risk of non-relapse mortality (NRM) (HR of OS 0.603 [95% CI: 0.400-0.909], P = 0.016; HR of NRM 0.506 [95% CI: 0.300-0.856], P = 0.011). The use of ATG in female-to-male allo-HCT resulted in survival outcomes that were almost equivalent to those in the male-to-male allo-HCT group. Therefore, GVHD prophylaxis with ATG might overcome the inferiority of survival outcomes in female-to-male allo-HCT.
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Affiliation(s)
- Masaharu Tamaki
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan.
| | - Yu Akahoshi
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, USA
| | | | - Yukiko Misaki
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
| | - Satoshi Koi
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Disease Center, Komagome Hospital, Tokyo, Japan
| | - Sung-Won Kim
- Hematopoietic Stem Cell Transplantation Division, National Cancer Center Hospital, Tokyo, Japan
| | - Yukiyasu Ozawa
- Department of Hematology, Japanese Red Cross Aichi Medical Center Nagoya Daiichi Hospital, Nagoya, Japan
| | | | - Shinichi Kako
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
| | - Ken-Ichi Matsuoka
- Department of Hematology and Oncology, Okayama University Hospital, Okayama, Japan
| | - Masashi Sawa
- Department of Hematology and Oncology, Anjo Kosei Hospital, Anjo, Japan
| | - Yuta Katayama
- Department of Hematology, Hiroshima Red Cross Hospital & Atomic-Bomb Survivors Hospital, Hiroshima, Japan
| | - Makoto Onizuka
- Department of Hematology/Oncology, Tokai University School of Medicine, Isehara, Japan
| | - Yoshinobu Kanda
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
- Division of Hematology, Jichi Medical University, Shimotsuke, Japan
| | - Takahiro Fukuda
- Hematopoietic Stem Cell Transplantation Division, National Cancer Center Hospital, Tokyo, Japan
| | - Yoshiko Atsuta
- Japanese Data Center for Hematopoietic Cell Transplantation, Nagakute, Japan
- Department of Registry Science for Transplantation and Cellular Therapy, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Kimikazu Yakushijin
- Department of Medical Oncology and Hematology, Kobe University Hospital, Kobe, Japan
| | - Hideki Nakasone
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan.
- Division of Stem Cell Regulation, Center for Molecular Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, 329-0498, Japan.
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25
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Ueda Oshima M, Xie H, Zamora D, Flowers ME, Hill GR, Mielcarek MB, Sandmaier BM, Gooley TA, Boeckh MJ. Impact of GVHD prophylaxis on CMV reactivation and disease after HLA-matched peripheral blood stem cell transplantation. Blood Adv 2023; 7:1394-1403. [PMID: 36595478 PMCID: PMC10139935 DOI: 10.1182/bloodadvances.2022009112] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 12/28/2022] [Indexed: 01/04/2023] Open
Abstract
The kinetics of early and late cytomegalovirus (CMV) reactivation after hematopoietic cell transplantation using various methods of graft-versus-host-disease (GVHD) prophylaxis are poorly defined. We retrospectively compared CMV reactivation and disease among 780 seropositive patients given HLA-matched peripheral blood stem cell (PBSC) grafts and calcineurin inhibitor plus posttransplantation cyclophosphamide (PTCy; n = 44), mycophenolate mofetil (MMF; n = 414), or methotrexate (MTX; n = 322). Transplantation occurred between 2007 and 2018; CMV monitoring/management followed uniform standard practice. Hazards of CMV reactivation at various thresholds were compared. Spline curves were fit over average daily viral load and areas under the curve (AUC) within 1 year were calculated. PTCy and MMF were associated with an increased risk of early (day ≤100) CMV reactivation ≥250 IU/mL after multivariate adjustment. The viral load AUC at 1 year was highest with MMF (mean difference = 0.125 units vs MTX group) and similar between PTCy and MTX (mean difference = 0.016 units vs MTX group). CMV disease risk was similar across groups. There was no interaction between GVHD prophylaxis and CMV reactivation on chronic GVHD risk. Despite PTCy-associated increased risk of early CMV reactivation, the CMV disease risk by 1 year was low in HLA-matched PBSC transplant recipients. In contrast, MMF was associated with higher overall CMV viral burden in the 1 year posttransplant. Although different mechanisms of immunosuppressive agents may affect CMV reactivation risk, effective prevention of GVHD may reduce corticosteroid exposure and mitigate infection risk over time.
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Affiliation(s)
- Masumi Ueda Oshima
- Fred Hutchinson Cancer Center, Seattle, WA
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA
| | - Hu Xie
- Fred Hutchinson Cancer Center, Seattle, WA
| | - Danniel Zamora
- Fred Hutchinson Cancer Center, Seattle, WA
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA
| | - Mary E. Flowers
- Fred Hutchinson Cancer Center, Seattle, WA
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA
| | - Geoffrey R. Hill
- Fred Hutchinson Cancer Center, Seattle, WA
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA
| | - Marco B. Mielcarek
- Fred Hutchinson Cancer Center, Seattle, WA
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA
| | - Brenda M. Sandmaier
- Fred Hutchinson Cancer Center, Seattle, WA
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA
| | | | - Michael J. Boeckh
- Fred Hutchinson Cancer Center, Seattle, WA
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA
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26
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García-Cadenas I, Redondo S, Esquirol A, Portos JM, Novelli S, Saavedra S, Moreno C, Garrido A, Oñate G, López J, Ana-Carolina C, Miqueleiz S, Arguello-Tomas M, Briones J, Sierra J, Martino R. Successful Outcome in Patients with Myelofibrosis Undergoing Allogeneic Donor Hematopoietic Cell Transplantation Using Reduced-Doses of Post-Transplant Cyclophosphamide: challenges and review of the literature. Transplant Cell Ther 2023:S2666-6367(23)01239-3. [PMID: 37086849 DOI: 10.1016/j.jtct.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/05/2023] [Accepted: 04/10/2023] [Indexed: 04/24/2023]
Abstract
BACKGROUND Engraftment and non-relapse mortality (NRM) greatly depend upon the transplant platform in patients with Myelofibrosis (MF). OBJECTIVE We report outcomes of 14 consecutive MF patients who received reduced doses of post-transplant Cyclophosphamide (PTCy) (60 mg/kg total dose) and tacrolimus as graft versus host disease (GVHD) prophylaxis as part of a new standardized allogeneic hematopoietic-cell transplantation (allo-HCT) protocol. STUDY DESIGN Median age at HCT was 59 years (range: 41-67), and median interval from diagnosis to HCT was 19 months (range: 2-114). All cases received ruxolitinib before HCT and 71% had no response. Most patients (78%) had symptomatic splenomegaly at HCT. Eighty-six percent received reduced-intensity conditioning (RIC) and most of them (64%) from an unrelated donor. RESULTS There were not graft failures and neutrophil and platelet recovery occurred at a median of 21 and 31 days. The cumulative incidence of grade II-IV and III-IV acute GVHD was 28.6% and 7%. The 2-year incidence of overall and moderate-severe chronic GVHD was 36% and 14%. Only 1 patient relapsed after transplant, and NRM at 100 days and 2-years was 7% and 14%. GVHD-free/relapse-free and immunosuppression free incidence at 1 year was 41%. With a median follow-up for survivors of 28 months (range:8-55), the 2-year overall survival and progression-free survival are 86% and 69%. CONCLUSION Reduced doses of PTCy as GVHD prophylaxis for high risk MF patients shows promising results by reducing GVHD incidence without cases of graft failure.
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Affiliation(s)
- Irene García-Cadenas
- Hematology Department, Hospital de la Santa Creu i Sant Pau. IIB-Sant Pau and José Carreras Leukemia Research Institutes. Departamento de Medicina, Universidad Autónoma de Barcelona, Spain
| | - Sara Redondo
- Hematology Department, Hospital de la Santa Creu i Sant Pau. IIB-Sant Pau and José Carreras Leukemia Research Institutes. Departamento de Medicina, Universidad Autónoma de Barcelona, Spain..
| | - Albert Esquirol
- Hematology Department, Hospital de la Santa Creu i Sant Pau. IIB-Sant Pau and José Carreras Leukemia Research Institutes. Departamento de Medicina, Universidad Autónoma de Barcelona, Spain
| | - J M Portos
- Hematology Department, Hospital de la Santa Creu i Sant Pau. IIB-Sant Pau and José Carreras Leukemia Research Institutes. Departamento de Medicina, Universidad Autónoma de Barcelona, Spain
| | - Silvana Novelli
- Hematology Department, Hospital de la Santa Creu i Sant Pau. IIB-Sant Pau and José Carreras Leukemia Research Institutes. Departamento de Medicina, Universidad Autónoma de Barcelona, Spain
| | - Silvana Saavedra
- Hematology Department, Hospital de la Santa Creu i Sant Pau. IIB-Sant Pau and José Carreras Leukemia Research Institutes. Departamento de Medicina, Universidad Autónoma de Barcelona, Spain
| | - Carol Moreno
- Hematology Department, Hospital de la Santa Creu i Sant Pau. IIB-Sant Pau and José Carreras Leukemia Research Institutes. Departamento de Medicina, Universidad Autónoma de Barcelona, Spain
| | - Ana Garrido
- Hematology Department, Hospital de la Santa Creu i Sant Pau. IIB-Sant Pau and José Carreras Leukemia Research Institutes. Departamento de Medicina, Universidad Autónoma de Barcelona, Spain
| | - Guadalupe Oñate
- Hematology Department, Hospital de la Santa Creu i Sant Pau. IIB-Sant Pau and José Carreras Leukemia Research Institutes. Departamento de Medicina, Universidad Autónoma de Barcelona, Spain
| | - Jordi López
- Hematology Department, Hospital de la Santa Creu i Sant Pau. IIB-Sant Pau and José Carreras Leukemia Research Institutes. Departamento de Medicina, Universidad Autónoma de Barcelona, Spain
| | - Caballero Ana-Carolina
- Hematology Department, Hospital de la Santa Creu i Sant Pau. IIB-Sant Pau and José Carreras Leukemia Research Institutes. Departamento de Medicina, Universidad Autónoma de Barcelona, Spain
| | - Sara Miqueleiz
- Hematology Department, Hospital de la Santa Creu i Sant Pau. IIB-Sant Pau and José Carreras Leukemia Research Institutes. Departamento de Medicina, Universidad Autónoma de Barcelona, Spain
| | - Miguel Arguello-Tomas
- Hematology Department, Hospital de la Santa Creu i Sant Pau. IIB-Sant Pau and José Carreras Leukemia Research Institutes. Departamento de Medicina, Universidad Autónoma de Barcelona, Spain
| | - Javier Briones
- Hematology Department, Hospital de la Santa Creu i Sant Pau. IIB-Sant Pau and José Carreras Leukemia Research Institutes. Departamento de Medicina, Universidad Autónoma de Barcelona, Spain
| | - Jorge Sierra
- Hematology Department, Hospital de la Santa Creu i Sant Pau. IIB-Sant Pau and José Carreras Leukemia Research Institutes. Departamento de Medicina, Universidad Autónoma de Barcelona, Spain
| | - Rodrigo Martino
- Hematology Department, Hospital de la Santa Creu i Sant Pau. IIB-Sant Pau and José Carreras Leukemia Research Institutes. Departamento de Medicina, Universidad Autónoma de Barcelona, Spain
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27
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Hoff FW, Chung SS, Patel PA, Premnath N, Khatib J, Tadic-Ovcina M, AhmedRabie A, Helton D, Yohannes S, Shahan J, Patel H, Geethakumari PR, Vusirikala M, Collins RH, Madanat YF. Post-transplant cyclophosphamide and early mixed donor Chimerism in myeloid malignancies; a single-center experience. Transpl Immunol 2023; 77:101808. [PMID: 36842566 DOI: 10.1016/j.trim.2023.101808] [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: 12/22/2022] [Accepted: 02/21/2023] [Indexed: 02/28/2023]
Abstract
BACKGROUND Allogeneic hematopoietic stem cell transplantation (allo-HSCT) remains the only curative option for high-risk myeloid malignancies. Post-transplant cyclophosphamide (PT-Cy) has proven to be effective for graft versus host disease (GVHD) prophylaxis. Given that graft-versus-tumor (GVT) effect plays a major role in reducing the risk of disease relapse, the application of PT-Cy must balance the risk of relapse. Mixed chimerism (MC) refers to a state of concurrent presence of recipient and donor cells post allo-HSCT which may precede relapse disease. OBJECTIVE We investigated the impact of PT-Cy on early MC (EMC) and disease relapse in patients with a myeloid malignancy post allo-HSCT. STUDY DESIGN This retrospective single-center study included patients that underwent allo-HSCT between 2015 and 2021. Patient and disease characteristics were collected from the electronic health records. EMC was defined as <95% donor cells at day 90-120 post allo-HSCT. RESULTS A total of 144 patient that received an allo-HSCT were included in the study. One hundred and eight (75%) patients received PT-Cy as part of the GVHD prophylaxis regimen. The majority underwent allo-HSCT for acute myeloid leukemia (62%) or myelodysplastic syndrome (31%). Sixty-five percent received allo-HSCT from a matched unrelated donor transplant and 65% received a myeloablative conditioning regimen. A lower rate of chronic GVHD (p = 0.03) and a higher rate of EMC (p = 0.04) were observed in patients that received PT-Cy. PT-Cy was not associated with overall survival (OS) and relapse-free survival (RFS). Multivariable analysis identified measurable residual disease status (p = 0.003), hematopoietic cell transplantation-specific comorbidity index (p = 0.012) and chronic GVHD (p = 0.006) as independent prognostic variables for OS. AML-adverse risk (p = 0.004) and EMC (p = 0.018) were independently prognostic for RFS. While EMC overall was not significantly associated with higher risk of relapse, EMC was associated with shorter RFS within adverse-risk AML patients. CONCLUSION Our study shows that PT-Cy was associated with an increased risk of EMC. The predictive value of EMC for relapse remains unclear and may depend on the underlying disease, which should be validated in a larger cohort.
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Affiliation(s)
- Fieke W Hoff
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, United States of America
| | - Stephen S Chung
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, United States of America
| | - Prapti A Patel
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, United States of America
| | - Naveen Premnath
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, United States of America
| | - Jude Khatib
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, United States of America
| | - Mirjana Tadic-Ovcina
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, United States of America
| | - Abeer AhmedRabie
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, United States of America
| | - Debra Helton
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, United States of America
| | - Selamawit Yohannes
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, United States of America
| | - Jaime Shahan
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, United States of America
| | - Hetalkumari Patel
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, United States of America
| | | | - Madhuri Vusirikala
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, United States of America
| | - Robert H Collins
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, United States of America
| | - Yazan F Madanat
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, United States of America.
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28
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Perchetti GA, Biernacki MA, Xie H, Castor J, Joncas-Schronce L, Ueda Oshima M, Kim Y, Jerome KR, Sandmaier BM, Martin PJ, Boeckh M, Greninger AL, Zamora D. Cytomegalovirus breakthrough and resistance during letermovir prophylaxis. Bone Marrow Transplant 2023; 58:430-436. [PMID: 36693927 DOI: 10.1038/s41409-023-01920-w] [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: 05/26/2022] [Revised: 01/08/2023] [Accepted: 01/12/2023] [Indexed: 01/26/2023]
Abstract
Letermovir is a relatively new antiviral for prophylaxis against cytomegalovirus (CMV) after allogeneic hematopoietic cell transplantation (HCT). CMV-seropositive HCT recipients who received letermovir prophylaxis from 2018 to 2020 at our center were evaluated for letermovir resistance and breakthrough CMV reactivation. Two-hundred twenty-six letermovir recipients were identified and 7/15 (47%) with CMV DNAemia ≥200 IU/mL were successfully genotyped for UL56 resistance. A single C325Y resistance mutation was identified in an umbilical cord blood recipient. Ninety-five (42%), 43 (19%), and 15 (7%) patients had breakthrough CMV at any level, ≥150 IU/mL, and ≥500 IU/mL, respectively. Risk factors for breakthrough CMV reactivation at each viral threshold were examined. Cumulative steroid exposure was the strongest risk factor for CMV at all evaluated viral thresholds. Graft-versus-host disease prophylaxis with post-transplantation cyclophosphamide (aHR 2.34, 95% CI 1.28-4.28, p = 0.001) or calcineurin inhibitors plus mycophenolate (aHR 2.24, 95% CI 1.30-3.86, p = 0.004) were also associated with an increased risk of CMV reactivation at any level. De novo letermovir resistance is rare and can be successfully treated using other antivirals. Letermovir effectively prevents clinically significant CMV, however, subclinical CMV reactivation occurs frequently at our center.
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Affiliation(s)
- Garrett A Perchetti
- Department of Laboratory Medicine and Pathology, University of Washington, School of Medicine, Seattle, WA, USA
| | - Melinda A Biernacki
- Department of Medicine, University of Washington, School of Medicine, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Hu Xie
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Jared Castor
- Department of Laboratory Medicine and Pathology, University of Washington, School of Medicine, Seattle, WA, USA
| | - Laurel Joncas-Schronce
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Masumi Ueda Oshima
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Division of Medical Oncology, Department of Medicine, University of Washington, School of Medicine, Seattle, WA, USA
| | - YoungJun Kim
- Department of Pathology, University of Virginia, School of Medicine, Charlottesville, VA, USA
| | - Keith R Jerome
- Department of Laboratory Medicine and Pathology, University of Washington, School of Medicine, Seattle, WA, USA
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Brenda M Sandmaier
- Division of Medical Oncology, Department of Medicine, University of Washington, School of Medicine, Seattle, WA, USA
- Translational Science and Therapeutics Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Paul J Martin
- Department of Medicine, University of Washington, School of Medicine, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Michael Boeckh
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Alexander L Greninger
- Department of Laboratory Medicine and Pathology, University of Washington, School of Medicine, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Danniel Zamora
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA.
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA, USA.
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29
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Gao WH, Zhu JY, Wang LN, Wan M, Wang L, Devillier R, Jiang JL, Blaise D, Hu J. Post-transplantation cyclophosphamide combined with tacrolimus and low-dose post-engraftment anti-thymoglobulin as GVHD prophylaxis for patients undergoing peripheral blood stem cell transplantation from haploidentical family donor: A single center analysis. Front Med (Lausanne) 2023; 10:1140217. [PMID: 37064033 PMCID: PMC10103611 DOI: 10.3389/fmed.2023.1140217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 03/13/2023] [Indexed: 04/03/2023] Open
Abstract
IntroductionPost-transplantation cyclophosphamide (PT-Cy) use is a recent graft-versus-host disease (GVHD) prophylaxis strategy for patients undergoing allogeneic stem cell transplantation (allo-HSCT). PT-Cy combined with two immunosuppressants is now widely used after haplo-identical (haplo) and HLA-matched peripheral blood stem cell (PBSC) transplantations with promising GVHD and relapsefree survival (GRFS) probabilities. Although appealing, these results may benefit from improvement notably outside matched sibling donor transplantation, and should be investigated in various ethnic populations.MethodsTherefore, we report our experience of GVHD prophylaxis regimen combining PT-Cy and tacrolimus with addition of post-engraftment low-dose anti-thymocyte globulin (ATG) in allogeneic stem cell transplantation from haplo-identical donors (Haplo). Sixtyseven patients were included in the analysis. All patients received myeloablative or intensified sequential conditioning regimen.ResultsThe median follow-up was 521 (range, 10~991) days. The cumulative incidences of 100-day grade II-IV acute GVHD was 14.9±4.4%, and no case of grade III-IV acute GVHD was documented. The cumulative incidences of 2-yearchronic GVHD and moderate-to-severe chronic GVHD were 25.4±5.4% and 11.9±4%, respectively. The non-relapse mortality at day+100 and 2year were 7.5±3.2% and 9.0±3.5%, respectively. The cumulative incidence of relapse at 2year was 16±6.4%. The 2-year probability of DFS and OS were 73.8% (95%CI, 61.5~88.4%) and 72.5% (95% CI, 57.1~92.1%), respectively. The 2-year GRFS was estimated as 63.6% (95%CI, 50.6~80%).DiscussionOur results suggested that a combination of PT-Cy, tacrolimus, and low-dose post-engraftment ATG was a promising GVHD prophylaxis with low incidence of acute GVHD in the haplo-transplantation setting.
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Affiliation(s)
- Wen-hui Gao
- Shanghai Institute of Hematology, Blood and Marrow Transplantation Center, Department of Hematology, Collaborative Innovation Center of Hematology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jia-yan Zhu
- Shanghai Institute of Hematology, Blood and Marrow Transplantation Center, Department of Hematology, Collaborative Innovation Center of Hematology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Li-ning Wang
- Shanghai Institute of Hematology, Blood and Marrow Transplantation Center, Department of Hematology, Collaborative Innovation Center of Hematology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ming Wan
- Shanghai Clinical Research Center (SCRC), Fenglin International Centre, Shanghai, China
| | - Ling Wang
- Shanghai Institute of Hematology, Blood and Marrow Transplantation Center, Department of Hematology, Collaborative Innovation Center of Hematology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Raynier Devillier
- Department of Hematology, Program of Transplantation and Cell Therapy, Program of Leukemia, Centre de Recherche en Cancérologie de Marseille (CRCM), Institut Paoli-Calmettes, Aix Marseille University, Marseille, France
| | - Jie-ling Jiang
- Shanghai Institute of Hematology, Blood and Marrow Transplantation Center, Department of Hematology, Collaborative Innovation Center of Hematology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- *Correspondence: Jie-ling Jiang,
| | - Didier Blaise
- Department of Hematology, Program of Transplantation and Cell Therapy, Program of Leukemia, Centre de Recherche en Cancérologie de Marseille (CRCM), Institut Paoli-Calmettes, Aix Marseille University, Marseille, France
- Didier Blaise,
| | - Jiong Hu
- Shanghai Institute of Hematology, Blood and Marrow Transplantation Center, Department of Hematology, Collaborative Innovation Center of Hematology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Jiong Hu,
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30
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El Jurdi N, Hoover A, O'Leary D, Cao Q, Gupta A, Ebens C, Maakaron J, Betts BC, Rashidi A, Juckett M, Lund T, Bachanova V, MacMillan M, Miller J, Orchard P, Wagner J, Vercellotti G, Weisdorf D, Dusenbery K, Terezakis S, Holtan S. Phase II Study of Myeloablative 8/8- or 7/8-Matched Allotransplantation with Post-Transplant Cyclophosphamide, Tacrolimus, and Mycophenolate Mofetil: Marked Reduction in GVHD Risk Without Increased Relapse Risk Compared to Historical Cyclosporine/Methotrexate. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.03.24.23287521. [PMID: 37034603 PMCID: PMC10081397 DOI: 10.1101/2023.03.24.23287521] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
Introduction Graft-versus host disease (GVHD) is a major limitation to the success of allogeneic hematopoietic cell transplant (HCT). We hypothesized that the GVHD prophylaxis regimen of post-transplant cyclophosphamide (PTCy), tacrolimus (Tac) and mycophenolate mofetil (MMF) would reduce the incidence of GVHD in patients receiving a matched or single antigen mismatched HCT without an increase in risk of malignant relapse. Methods This is a phase II study conducted at the University of Minnesota using a myeloablative regimen of either: (A) total body irradiation (TBI, total dose 1320 cGy, administered in 165 cGy fractions, twice a day from days -4 to -1) or (B) Busulfan 3.2mg/kg daily (cumulative AUC 19,000 - 21,000 μmol/min/L) plus fludarabine 160mg/m2 days -5 to -2, followed by a GVHD prophylaxis regimen of PTCy (50mg/kg days +3 and +4), Tac and MMF (beginning day +5). The primary endpoint is cumulative incidence of chronic GVHD requiring systemic immunosuppression at 1-year post-transplant. We compared results to our previous myeloablative protocol for matched donors utilizing cyclosporine/methotrexate (CSA/MTX) GVHD prophylaxis. Results From March 2018 - June 2022, we enrolled and treated 125 pediatric and adult patients with a median follow up of 472 days. Grade II-IV acute GVHD occurred in 16% (95% confidence interval (CI): 9-23%); Grade III-IV acute GVHD was 4% (CI: 0-8%). No patients experienced grade IV GVHD, and there were no deaths due to GVHD before day 100. Only 3 developed chronic GVHD requiring immune suppression, (4%, CI: 0-8%). Two-year overall survival (OS) was 80% (CI: 69-87%), and (graft-versus-host disease-free, relapse-free survival) GRFS 57% (CI: 45-67%), both higher than historical CSA/MTX. The incidence of grade II-IV aGVHD, cGVHD, and NRM were all lower with PTCy/Tac/MMF compared to historical CSA/MTX. One-quarter (25%) experienced relapse (CI: 15-36%) similar to historical CSA/MTX. There was no statistically significant difference in survival outcomes between recipients of matched versus 7/8 donors. Conclusion Myeloablative HCT with PTCy/Tac/MMF results in extremely low incidence of severe acute or chronic GVHD, the primary endpoint of this clinical trial. Relapse risk is not increased compared to our historical CSA/MTX cohort.
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Affiliation(s)
- Najla El Jurdi
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
| | - Alex Hoover
- Division of Pediatric Hematology/Oncology, University of Minnesota, Minneapolis, MN, USA
| | - Daniel O'Leary
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
| | - Qing Cao
- Biostatistics Core, Masonic Cancer Center, University of Minnesota, Minneapolis, MN
| | - Ashish Gupta
- Division of Pediatric Blood and Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, MN, USA
| | - Christen Ebens
- Division of Pediatric Blood and Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, MN, USA
| | - Joseph Maakaron
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
| | - Brian C Betts
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
| | - Armin Rashidi
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
| | - Mark Juckett
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
| | - Troy Lund
- Division of Pediatric Blood and Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, MN, USA
| | - Veronika Bachanova
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
| | - Margaret MacMillan
- Division of Pediatric Blood and Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, MN, USA
| | - Jeffrey Miller
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
| | - Paul Orchard
- Division of Pediatric Blood and Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, MN, USA
| | - John Wagner
- Division of Pediatric Blood and Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, MN, USA
| | - Gregory Vercellotti
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
| | - Daniel Weisdorf
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
| | - Kathryn Dusenbery
- Department of Radiation Oncology, University of Minnesota, Minneapolis, MN
| | | | - Shernan Holtan
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
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Dybko J, Sobczyk-Kruszelnicka M, Makuch S, Agrawal S, Dudek K, Giebel S, Gil L. The Benefits of the Post-Transplant Cyclophosphamide in Both Haploidentical and Mismatched Unrelated Donor Setting in Allogeneic Stem Cells Transplantation. Int J Mol Sci 2023; 24:ijms24065764. [PMID: 36982839 PMCID: PMC10051342 DOI: 10.3390/ijms24065764] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 03/03/2023] [Accepted: 03/14/2023] [Indexed: 03/30/2023] Open
Abstract
Allogeneic hematopoietic cell transplantation (alloHSCT) is a standard therapeutic approach for acute leukemias and many other hematologic malignancies. The proper choice of immunosuppressants applicable to different types of transplantations still requires strict and careful consideration, and data in this regard are divergent. For this reason, in this single-centered, retrospective study, we aimed to compare the outcome of 145 patients who received post-transplant cyclophosphamide (PTCy) for MMUD and haplo-HSCT or GvHD prophylaxis for MMUD-HSCT alone. We attempted to verify if PTCy is an optimal strategy in MMUD setting. Ninety-three recipients (93/145; 64.1%) underwent haplo-HSCT while 52 (52/145; 35.9%) underwent MMUD-HSCT. There were 110 patients who received PTCy (93 in haplo and 17 in MMUD group) and 35 patients received conventional GvHD prophylaxis based on antithymocyte globulin (ATG), cyclosporine (CsA), and methotrexate (Mtx) in the MMUD group only. Our study revealed that patients receiving post-transplant cyclophosphamide (PTCy) show decreased acute GvHD rates and CMV reactivation as well as a statistically lower number of CMV copies before and after antiviral treatment compared to the CsA + Mtx + ATG group. Taking into account chronic GvHD, the main predictors are donor age, ≥40 years, and haplo-HSCT administration. Furthermore, the survival rate of patients following MMUD-HSCT and receiving PTCy with tacrolimus and mycophenolate mofetil was more than eight times greater in comparison to patients receiving CsA + Mtx + ATG (OR = 8.31, p = 0.003). These data taken together suggest that the use of PTCy displays more benefits in terms of survival rate compared to ATG regardless of the type of transplantation performed. Nevertheless, more studies with a larger sample size are required to confirm the conflicting results in the literature studies.
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Affiliation(s)
- Jarosław Dybko
- Department of Hematology and Cellular Transplantation, Lower Silesian Oncology Center, 53-413 Wroclaw, Poland
| | - Małgorzata Sobczyk-Kruszelnicka
- Department of Bone Marrow Transplantation and Oncohematology, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, 44-102 Gliwice, Poland
| | - Sebastian Makuch
- Department of Clinical and Experimental Pathology, Wroclaw Medical University, 50-368 Wrocław, Poland
| | - Siddarth Agrawal
- Department and Clinic of Internal Medicine, Occupational Diseases, Hypertension and Clinical Oncology, Wroclaw Medical University, 50-556 Wrocław, Poland
| | - Krzysztof Dudek
- Statistical Analysis Center, Wroclaw Medical University, 50-368 Wroclaw, Poland
| | - Sebatian Giebel
- Department of Bone Marrow Transplantation and Oncohematology, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, 44-102 Gliwice, Poland
| | - Lidia Gil
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, 60-569 Poznań, Poland
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32
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Donor HLA mismatch promotes full donor T-cell chimerism in the allogeneic stem cell transplant with reduced-intensity conditioning and post-transplant cyclophosphamide GVHD prophylaxis. Ann Hematol 2023; 102:613-620. [PMID: 36527460 DOI: 10.1007/s00277-022-05077-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 12/02/2022] [Indexed: 12/23/2022]
Abstract
Full donor T-cell chimerism (FDTCC) after allogeneic stem cell transplant (allo-SCT) has been associated with improved outcomes in hematologic malignancy. We studied if donor human leukocyte antigen (HLA) mismatch improves achievement of FDTCC because mismatched HLA promotes donor T-cell proliferation where recipient T-cells had been impaired by previous treatment. Patients (N = 138) received allo-SCT with reduced-intensity conditioning (RIC) from 39 HLA mismatched donors (16 unrelated; 23 haploidentical) with post-transplant cyclophosphamide (PTCy) or 99 matched donors (21 siblings; 78 unrelated) with PTCy (N = 18) or non-PTCy (N = 81). Achievement of FDTCC by day 100 was higher with HLA mismatched donors than matched donors (82.1% vs. 27.3%, p < 00,001), which was further improved with 200 cGy total body irradiation (87.9%) or lymphoid (versus myeloid) malignancy (93.8%). Since all mismatched transplants used PTCy, FDTCC was higher with PTCy than non-PTCy (68.4% vs. 25.7%, p < 0.00001), but not in the matched transplant with PTCy (38.9%), negating PTCy as the primary driver. Lymphocyte recovery was delayed with PTCy than without (median on day + 30: 100 vs. 630/µL, p < 0.0001). The benefit of FDTCC was not translated into survival outcomes, especially in myeloid malignancies, possibly due to the insufficient graft-versus-tumor effects from the delayed lymphocyte recovery. Further studies are necessary to improve lymphocyte count recovery in PTCy transplants.
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33
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Prediction of Nonrelapse Mortality in Patients With Acute Myeloid Leukemia and Acute Lymphoblastic Leukemia Receiving Allogeneic Stem Cell Transplantation With Posttransplantation Cyclophosphamide-based Graft Versus Host Disease Prophylaxis. Hemasphere 2023; 7:e846. [PMID: 36844179 PMCID: PMC9946411 DOI: 10.1097/hs9.0000000000000846] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 01/09/2023] [Indexed: 02/23/2023] Open
Abstract
Graft versus host disease (GVHD) prophylaxis with posttransplantation cyclophosphamide (PTCY) has been established to reduce severe GVHD, and thereby potentially reducing nonrelapse mortality (NRM) after allogeneic stem cell transplantation (alloSCT). We evaluated the predictive capacity of established NRM-risk scores in patients receiving PTCY-based GVHD prophylaxis, and subsequently developed and validated a novel PTCY-specific NRM-risk model. Adult patients (n = 1861) with AML or ALL in first complete remission who received alloSCT with PTCY-based GVHD prophylaxis were included. The PTCY-risk score was developed using multivariable Fine and Gray regression, selecting parameters from the hematopoietic cell transplantation-comorbidity index (HCT-CI) and European Group for Blood and Marrow Transplantation (EBMT) score with a subdistribution hazard ratio (SHR) of ≥1.2 for 2-year NRM in the training set (70% split), which was validated in the test set (30%). The performance of the EBMT score, HCT-CI, and integrated EBMT score was relatively poor for discriminating 2-year NRM (c-statistic 51.7%, 56.6%, and 59.2%, respectively). The PTCY-risk score included 10 variables which were collapsed in 3 risk groups estimating 2-year NRM of 11% ± 2%, 19% ± 2%, and 36% ± 3% (training set, c-statistic 64%), and 11% ± 2%, 18% ± 3%, and 31% ± 5% (test set, c-statistic 63%), which also translated into different overall survival. Collectively, we developed an NRM-risk score for acute leukemia patients receiving PTCY that better predicted 2-year NRM compared with existing models, which might be applicable to the specific toxicities of high-dose cyclophosphamide.
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Iqbal M, Nieto FAM, Brannick KM, Li Z, Murthy H, Foran J, Roy V, Kharfan-Dabaja MA, Ayala E. A Calcineurin Inhibitor Free Graft Versus Host Disease Prophylaxis for Patients Undergoing Matched Related and Matched Unrelated Donor Allogeneic Hematopoietic Cell Transplant. Transplant Cell Ther 2023; 29:327.e1-327.e9. [PMID: 36758832 DOI: 10.1016/j.jtct.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 02/01/2023] [Accepted: 02/01/2023] [Indexed: 02/10/2023]
Abstract
Post-transplantation cyclophosphamide (PTCy) and calcineurin inhibitor (CNI)-based graft versus host disease (GVHD) prophylaxis has been associated with lower rates of acute and chronic GVHD compared with the traditional prophylaxis of CNI and methotrexate (MTX) in matched related donor (MRD) and matched unrelated donor (MUD) allogeneic hematopoietic cell transplantation (allo-HCT). The combination of PTCy with sirolimus (PTCy-Siro) as CNI-free GVHD prophylaxis has shown promising results, with cumulative rates of grade II-IV acute and chronic GVHD in the range of 15% to 27% and 20% to 27%, respectively, in patients undergoing MRD, MUD, and haploidentical allo-HCT. We report a single-center, nonrandomized comparison of patients undergoing matched donor allo-HCT receiving PTCy-Siro with those receiving the standard GVHD prophylaxis of tacrolimus and methotrexate (Tac-MTX). One hundred and sixteen consecutive patients who had undergone an MRD or MUD allo-HCT between January 2018 and January 2021 and received either PTCy-Siro (n = 29) or Tac-MTX (n = 87) as GVHD prophylaxis regimens were eligible for inclusion. Patients receiving PTCy-Siro had a significantly shorter median time to immunosuppression withdrawal than patients receiving Tac-MTX (138 days [range, 37 to 312 days] versus 232 days [range, 66 to 1120 days]; P < .001). There was no significant difference between the 2 arms in the incidence of grade II-IV acute GVHD, grade III-IV acute GVHD, steroid-refractory acute GVHD, or clinical infections. At a median follow-up of 1.1 years (range, 0 to 1.8 years), patients receiving PTCy-Siro were significantly less likely to have chronic GVHD, with 2-year freedom from GVHD of 75% (95% confidence interval [CI], 58% to 98%) versus 20% (95% CI, 10% to 40%) for those receiving Tac-MTX (P = .005).
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Affiliation(s)
- Madiha Iqbal
- Department of Hematology-Oncology, Mayo Clinic, Jacksonville, Florida.
| | | | | | - Zhuo Li
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, Florida
| | - Hemant Murthy
- Department of Hematology-Oncology, Mayo Clinic, Jacksonville, Florida
| | - James Foran
- Department of Hematology-Oncology, Mayo Clinic, Jacksonville, Florida
| | - Vivek Roy
- Department of Hematology-Oncology, Mayo Clinic, Jacksonville, Florida
| | | | - Ernesto Ayala
- Department of Hematology-Oncology, Mayo Clinic, Jacksonville, Florida
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35
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Takeuchi Y, Miyao K, Negishi S, Ohara F, Motegi K, Wakabayashi H, Yokota H, Kuwano S, Sawa H, Inagaki Y, Sawa M. Clinical Benefit of Low-Dose Antithymocyte Globulin-Thymoglobulin as Graft-versus-Host Disease Prophylaxis in Patients Receiving Allogeneic Peripheral Blood Stem Cell Transplantation from HLA-Identical Donors. Transplant Cell Ther 2023; 29:325.e1-325.e10. [PMID: 36736783 DOI: 10.1016/j.jtct.2023.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 01/05/2023] [Accepted: 01/23/2023] [Indexed: 02/05/2023]
Abstract
Graft-versus-host disease (GVHD) is a major complication of allogeneic peripheral blood stem cell transplantation (PBSCT). Previous randomized studies have already shown that the use of several types of antihuman T lymphocyte immune globulin (ATG) as GVHD prophylaxis can reduce the incidence of acute GVHD and chronic GVHD. However, the efficacy and safety of PBSCT from HLA-identical donors with low-dose ATG remain unclear. This study aimed to clarify the efficacy and safety of PBSCT from HLA-identical donors with low-dose ATG compared with PBSCT from HLA-identical donors without ATG. To do so, we retrospectively analyzed the outcomes of patients who underwent allogeneic PBSCT from HLA-identical donors with low-dose ATG-thymoglobulin (ATG-T; 2.5 mg/kg) versus those who did not receive ATG-T. Patient data were collected retrospectively from the medical records of Anjo Kosei Hospital. This study was conducted from 2009 to the final follow-up in October 2022. Forty-seven of 91 patients received ATG-T between January 2009 and March 2020. ATG-T reduced the incidence rates of moderate-to-severe chronic GVHD (hazard ratio [HR], .15; 95% confidence interval [CI], .057 to .41; P < .0010) and nonrelapse mortality (HR, .21; 95% CI, .0058 to.75, P = .016) without increasing the risk of relapse. Overall survival did not differ significantly between the 2 groups; however, the low-dose ATG-T group had better moderate-to-severe chronic GVHD-free, relapse-free survival rates (HR, .47; 95% CI, .27 to .80, P = .0054) than the non-ATG-T group. In addition, multistate analysis revealed that the low-dose ATG-T group had better current GVHD-free, relapse-free survival at 24 months after transplantation (45% [95% CI, 29% to 63%)] versus 21% [95% CI, 9.1% to 34%]; P = .015). Low-dose ATG-T was not associated with increased incidence of infections or adverse events. Our findings suggest that low-dose ATG-T can be beneficial for patients receiving PBSCT from HLA-identical donors. © 2023 American Society for Transplantation and Cellular Therapy. Published by Elsevier Inc.
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Affiliation(s)
- Yuki Takeuchi
- Department of Hematology and Oncology, Anjo Kosei Hospital, Anjo, Japan.
| | - Kotaro Miyao
- Department of Hematology and Oncology, Anjo Kosei Hospital, Anjo, Japan
| | - Shuto Negishi
- Department of Hematology and Oncology, Anjo Kosei Hospital, Anjo, Japan
| | - Fumiya Ohara
- Department of Hematology and Oncology, Anjo Kosei Hospital, Anjo, Japan
| | - Kenta Motegi
- Department of Hematology and Oncology, Anjo Kosei Hospital, Anjo, Japan
| | | | - Hirofumi Yokota
- Department of Hematology and Oncology, Anjo Kosei Hospital, Anjo, Japan
| | - Shihomi Kuwano
- Department of Hematology and Oncology, Anjo Kosei Hospital, Anjo, Japan
| | - Hitomi Sawa
- Department of Hematology and Oncology, Anjo Kosei Hospital, Anjo, Japan
| | - Yuichiro Inagaki
- Department of Hematology and Oncology, Anjo Kosei Hospital, Anjo, Japan
| | - Masashi Sawa
- Department of Hematology and Oncology, Anjo Kosei Hospital, Anjo, Japan
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36
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Palmieri R, Montgomery RB, Doney K. Allogeneic stem cell transplantation in patients with a prior history of prostate cancer. Ann Hematol 2023; 102:407-412. [PMID: 36394580 DOI: 10.1007/s00277-022-05041-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 11/08/2022] [Indexed: 11/18/2022]
Abstract
A retrospective analysis of 25 patients with a history of prostate cancer (PC) who subsequently underwent allogeneic hematopoietic cell transplantation (HCT) for treatment of a hematologic malignancy was performed. Median patient age was 66.7 years. Median duration from the diagnosis of PC to HCT was 4.2 years. Twenty-three patients had Gleason group 1 or 2 disease. Therapy included prostatectomy (n = 13) and external beam or brachytherapy (n = 9). Hematologic diagnoses included both myeloid (n = 15) and lymphoid neoplasms (n = 10). Twenty-four patients received either a nonmyeloablative or reduced intensity conditioning regimen. GVHD prophylaxis included a calcineurin inhibitor and mycophenolate mofetil ± sirolimus. Twenty patients had HLA-matched sibling or HLA-matched unrelated donors; five patients had HLA-mismatched donors. Eleven patients are alive, and 14 have died. Median survival was 2.5 years (range, .02-12.6 years). The major cause of death was hematologic relapse. Only one patient had evidence of recurrent PC, occurring 1.5 years posttransplant. In carefully selected patients with a prior history of PC, there was no evidence of rapid recurrence of the solid tumor (ST) after HCT. PC patients who are in remission from their ST or have control of their disease on therapy should be considered eligible for HCT.
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Affiliation(s)
- Raffaele Palmieri
- Clinical Research Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave. N., D5-280, PO Box 19024, Seattle, WA, 98109-1024, USA.,Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Robert B Montgomery
- Department of Medicine, Division of Oncology, University of Washington Medical Center, Seattle, WA, USA.,VA Puget Sound, Seattle, WA, USA
| | - Kristine Doney
- Clinical Research Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave. N., D5-280, PO Box 19024, Seattle, WA, 98109-1024, USA. .,Department of Medicine, Division of Oncology, University of Washington Medical Center, Seattle, WA, USA.
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37
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How I prevent GVHD in high-risk patients: posttransplant cyclophosphamide and beyond. Blood 2023; 141:49-59. [PMID: 35405017 DOI: 10.1182/blood.2021015129] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 03/09/2022] [Accepted: 03/21/2022] [Indexed: 01/10/2023] Open
Abstract
Advances in conditioning, graft-versus-host disease (GVHD) prophylaxis and antimicrobial prophylaxis have improved the safety of allogeneic hematopoietic cell transplantation (HCT), leading to a substantial increase in the number of patients transplanted each year. This influx of patients along with progress in remission-inducing and posttransplant maintenance strategies for hematologic malignancies has led to new GVHD risk factors and high-risk groups: HLA-mismatched related (haplo) and unrelated (MMUD) donors; older recipient age; posttransplant maintenance; prior checkpoint inhibitor and autologous HCT exposure; and patients with benign hematologic disorders. Along with the changing transplant population, the field of HCT has dramatically shifted in the past decade because of the widespread adoption of posttransplantation cyclophosphamide (PTCy), which has increased the use of HLA-mismatched related donors to levels comparable to HLA-matched related donors. Its success has led investigators to explore PTCy's utility for HLA-matched HCT, where we predict it will be embraced as well. Additionally, combinations of promising new agents for GVHD prophylaxis such as abatacept and JAK inhibitors with PTCy inspire hope for an even safer transplant platform. Using 3 illustrative cases, we review our current approach to transplantation of patients at high risk of GVHD using our modern armamentarium.
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38
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Tang L, Liu Z, Li T, Dong T, Wu Q, Niu T, Liu T, Ji J. Post-transplant cyclophosphamide versus anti-thymocyte globulin in allogeneic hematopoietic stem cell transplantation from unrelated donors: A systematic review and meta-analysis. Front Oncol 2023; 13:1071268. [PMID: 36874098 PMCID: PMC9978173 DOI: 10.3389/fonc.2023.1071268] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 02/01/2023] [Indexed: 02/18/2023] Open
Abstract
Background Post-transplant cyclophosphamide (PTCy) and anti-thymocyte globulin (ATG) are both common graft-versus-host disease (GVHD) prophylaxis strategies in allo-HSCT from unrelated donors. However, no consensus has reached on which regimen is optimal. Although several studies concerning this topic exist, the outcomes of different studies still conflict with each other. Therefore, an overall comparison of the two regimens is urgently needed to help make informed clinical decisions. Methods Studies comparing PTCy and ATG regimens in unrelated donor (UD) allo-HSCT were searched in four critical medical databases from inception to April 17, 2022. The primary outcome was grade II-IV aGVHD, grade III-IV aGVHD and chronic GVHD (cGVHD), and the secondary outcomes included overall survival (OS), relapse incidence (RI), non-relapse mortality (NRM), and several severe infectious complications. The quality of articles was assessed by the Newcastle-Ottawa scale (NOS), and data were extracted by two independent investigators and then analyzed by RevMan 5.4. Results Six out of 1091 articles were eligible for this meta-analysis. Compared with the ATG regimen, prophylaxis based on PTCy achieved a lower incidence of grade II-IV aGVHD incidence (RR=0.68, 95% CI 0.50-0.93, P=0.010, I 2 = 67%), grade III-IV aGVHD (RR=0.32, 95% CI 0.14-0.76, P=0.001, I 2 = 75%), NRM (RR=0.67, 95% CI 0.53-0.84, P=0.17, I 2 = 36%), EBV-related PTLD (RR=0.23, 95% CI 0.09-0.58, P=0.85, I 2 = 0%) and better OS (RR=1.29, 95% CI 1.03-1.62, P=0.0001, I 2 = 80%). The cGVHD, RI, CMV reactivation and BKV-related HC showed no significant difference between the two groups (RR=0.66, 95% CI 0.35-1.26, P<0.00001, I 2 = 86%; RR=0.95, 95% CI 0.78-1.16, P=0.37, I 2 = 7%; RR=0.89, 95% CI 0.63-1.24, P=0.07, I 2 = 57%; RR=0.88, 95% CI 0.76-1.03, P=0.44, I 2 = 0%). Conclusion In the setting of unrelated donor allo-HSCT, prophylaxis based on PTCy can lower the incidence of grade II-IV aGVHD, grade III-IV aGVHD, NRM and EBV-related complication, achieve better OS compared to ATG-based regimen. And cGVHD, RI, CMV reactivation and BKV-related HC were comparable in the two groups.
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Affiliation(s)
- Lu Tang
- West China Hospital, Sichuan University, Chengdu, China
| | - Zhigang Liu
- Department of Hematology, West China Hospital, Sichuan University, Chengdu, China.,Clinical Trial Center, West China Hospital, Sichuan University, Chengdu, China
| | - Tao Li
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Tian Dong
- Department of Hematology, West China Hospital, Sichuan University, Chengdu, China
| | - Qiuhui Wu
- Department of Hematology, West China Hospital, Sichuan University, Chengdu, China.,Clinical Trial Center, West China Hospital, Sichuan University, Chengdu, China
| | - Ting Niu
- Department of Hematology, West China Hospital, Sichuan University, Chengdu, China
| | - Ting Liu
- Department of Hematology, West China Hospital, Sichuan University, Chengdu, China
| | - Jie Ji
- Department of Hematology, West China Hospital, Sichuan University, Chengdu, China.,Clinical Trial Center, West China Hospital, Sichuan University, Chengdu, China
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39
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Niederwieser C, Kröger N. Transplantation in CML in the TKI era: who, when, and how? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:114-122. [PMID: 36485123 PMCID: PMC9820642 DOI: 10.1182/hematology.2022000329] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Molecular therapy with tyrosine kinase inhibitors (TKIs) has significantly reduced the indication for allogeneic hematopoietic stem cell transplantation (allo-HSCT) in chronic myeloid leukemia (CML). Treatment-free remission can be obtained in about 50% of patients with an optimal response. However, cure rates up to 90% are restricted to patients receiving HSCT. Timing is essential since HSCT in the early stages of the disease has the best outcome. Patients in a more advanced phase (AdP) than chronic-phase (chP) CML undergo HSCT with suboptimal outcomes, and the gap between chP and AdP disease is widening. First-line therapy should start with first- or second-generation (G) TKIs. Patients failing treatment (BCR-ABL1 transcripts of greater than 10% at 3 and 6 months and greater than 1% at 12 months) should be switched to second-line TKIs, and HSCT should be considered. Patients not responding to 2G-TKI therapy as well as patients in an accelerated phase (AP) or blast crisis (BC) are candidates for HSCT. Therapy resistant BCR-ABL1 mutations, high-risk additional cytogenetic abnormalities, and molecular signs of leukemia progression should trigger the indication for HSCT. Patients who, despite dose adjustments, do not tolerate or develop severe adverse events, including vascular events, to multiple TKIs are also candidates for HSCT. In AdP CML, TKIs do not show long-lasting results, and the outcome of HSCT is less optimal without pretransplant therapy. In these patients the induction of chP2 with TKIs, either alone (AP) or in combination with intensive chemotherapy (BC), followed by HSCT should be pursued.
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Affiliation(s)
- Christian Niederwieser
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Germany
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Germany
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Watkins B, Williams KM. Controversies and expectations for the prevention of GVHD: A biological and clinical perspective. Front Immunol 2022; 13:1057694. [PMID: 36505500 PMCID: PMC9726707 DOI: 10.3389/fimmu.2022.1057694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 11/03/2022] [Indexed: 11/24/2022] Open
Abstract
Severe acute and chronic graft versus host disease (GVHD) remains a major cause of morbidity and mortality after allogeneic hematopoietic cell transplantation. Historically, cord blood and matched sibling transplantation has been associated with the lowest rates of GVHD. Newer methods have modified the lymphocyte components to minimize alloimmunity, including: anti-thymocyte globulin, post-transplant cyclophosphamide, alpha/beta T cell depletion, and abatacept. These agents have shown promise in reducing severe GVHD, however, can be associated with increased risks of relapse, graft failure, infections, and delayed immune reconstitution. Nonetheless, these GVHD prophylaxis strategies have permitted expansion of donor sources, especially critical for those of non-Caucasian decent who previously lacked transplant options. This review will focus on the biologic mechanisms driving GVHD, the method by which each agent impacts these activated pathways, and the clinical consequences of these modern prophylaxis approaches. In addition, emerging novel targeted strategies will be described. These GVHD prophylaxis approaches have revolutionized our ability to increase access to transplant and have provided important insights into the biology of GVHD and immune reconstitution.
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Saliba RM, Alousi AM, Pidala J, Arora M, Spellman SR, Hemmer MT, Wang T, Abboud C, Ahmed S, Antin JH, Beitinjaneh A, Buchbinder D, Byrne M, Cahn JY, Choe H, Hanna R, Hematti P, Kamble RT, Kitko CL, Laughlin M, Lekakis L, MacMillan ML, Martino R, Mehta PA, Nishihori T, Patel SS, Perales MA, Rangarajan HG, Ringdén O, Rosenthal J, Savani BN, Schultz KR, Seo S, Teshima T, van der Poel M, Verdonck LF, Weisdorf D, Wirk B, Yared JA, Schriber J, Champlin RE, Ciurea SO. Characteristics of Graft-Versus-Host Disease (GvHD) After Post-Transplantation Cyclophosphamide Versus Conventional GvHD Prophylaxis. Transplant Cell Ther 2022; 28:681-693. [PMID: 35853610 PMCID: PMC10141544 DOI: 10.1016/j.jtct.2022.07.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 06/23/2022] [Accepted: 07/12/2022] [Indexed: 02/02/2023]
Abstract
Post-transplantation cyclophosphamide (PTCy) has been shown to effectively control graft-versus-host disease (GvHD) in haploidentical (Haplo) transplantations. In this retrospective registry study, we compared GvHD organ distribution, severity, and outcomes in patients with GvHD occurring after Haplo transplantation with PTCy GvHD prophylaxis (Haplo/PTCy) versus HLA-matched unrelated donor transplantation with conventional prophylaxis (MUD/conventional). We evaluated 2 cohorts: patients with grade 2 to 4 acute GvHD (aGvHD) including 264 and 1163 recipients of Haplo and MUD transplants; and patients with any chronic GvHD (cGvHD) including 206 and 1018 recipients of Haplo and MUD transplants, respectively. In comparison with MUD/conventional transplantation ± antithymocyte globulin (ATG), grade 3-4 aGvHD (28% versus 39%, P = .001), stage 3-4 lower gastrointestinal (GI) tract aGvHD (14% versus 21%, P = .01), and chronic GI GvHD (21% versus 31%, P = .006) were less common after Haplo/PTCy transplantation. In patients with grade 2-4 aGvHD, cGvHD rate after Haplo/PTCY was also lower (hazard ratio [HR] = .4, P < .001) in comparison with MUD/conventional transplantation without ATG in the nonmyeloablative conditioning setting. Irrespective of the use of ATG, non-relapse mortality rate was lower (HR = .6, P = .01) after Haplo/PTCy transplantation, except for transplants that were from a female donor into a male recipient. In patients with cGvHD, irrespective of ATG use, Haplo/PTCy transplantation had lower non-relapse mortality rates (HR = .6, P = .04). Mortality rate was higher (HR = 1.6, P = .03) during, but not after (HR = .9, P = .6) the first 6 months after cGvHD diagnosis. Our results suggest that PTCy-based GvHD prophylaxis mitigates the development of GI GvHD and may translate into lower GvHD-related non-relapse mortality rate.
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Affiliation(s)
- Rima M Saliba
- Department of Stem Cell Transplantation and Cellular Therapy, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas.
| | - Amin M Alousi
- Department of Stem Cell Transplantation and Cellular Therapy, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Joseph Pidala
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Mukta Arora
- CIBMTR® (Center for International Blood and Marrow Transplant Research), National Marrow Donor Program/Be the Match, Minneapolis, Minnesota; Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Stephen R Spellman
- CIBMTR® (Center for International Blood and Marrow Transplant Research), National Marrow Donor Program/Be the Match, Minneapolis, Minnesota
| | - Michael T Hemmer
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Tao Wang
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Divsion of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Camille Abboud
- Washington University in St. Louis School of Medicine, Division of Oncology, Section of BMT and Leukemia, St. Louis, Missouri
| | - Sairah Ahmed
- Department of Lymphoma-Myeloma, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Joseph H Antin
- Division of Hematologic Malignancies, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Amer Beitinjaneh
- Division of Transplantation and Cellular Therapy, University of Miami Hospital and Clinics, Sylvester Comprehensive Cancer Center, Miami, Florida
| | - David Buchbinder
- Division of Pediatric Hematology, Children's Hospital of Orange County, Orange, California
| | - Michael Byrne
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jean-Yves Cahn
- Department of Hematology, CHU Grenoble Alpes, Université Grenoble Alpes, Grenoble, France
| | - Hannah Choe
- The Ohio State University Wexner Medical Center, James Comprehensive Cancer Center, Columbus, Ohio
| | | | - Peiman Hematti
- Division of Hematology/Oncology/Bone Marrow Transplantation, Department of Medicine, University of Wisconsin, Madison, Wisconsin
| | - Rammurti T Kamble
- Division of Hematology and Oncology, Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, Texas
| | - Carrie L Kitko
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mary Laughlin
- Medical Director, Cleveland Cord Blood Center, Cleveland, Ohio
| | - Lazaros Lekakis
- Division of Transplantation and Cellular Therapy, University of Miami Hospital and Clinics, Sylvester Comprehensive Cancer Center, Miami, Florida
| | - Margaret L MacMillan
- Blood and Marrow Transplant Program, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Rodrigo Martino
- Division of Clinical Hematology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Parinda A Mehta
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Taiga Nishihori
- Department of Blood & Marrow Transplant and Cellular Immunotherapy (BMT CI), Moffitt Cancer Center, Tampa, Florida
| | - Sagar S Patel
- Blood and Marrow Transplant Program, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Hemalatha G Rangarajan
- Department of Pediatric Hematology, Oncology, Blood and Marrow Transplantation, Nationwide Children's Hospital, Columbus, Ohio
| | - Olov Ringdén
- Translational Cell Therapy Group, CLINTEC (Clinical Science, Intervention and Technology), Karolinska Institutet, Stockholm, Sweden
| | | | - Bipin N Savani
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kirk R Schultz
- Department of Pediatric Hematology, Oncology and Bone Marrow Transplant, British Columbia's Children's Hospital, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Sachiko Seo
- Department of Hematology and Oncology, Dokkyo Medical University, Tochigi, Japan
| | - Takanori Teshima
- Department of Hematology, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Marjolein van der Poel
- Department of Internal Medicine, Division of Hematology, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Leo F Verdonck
- Department of Hematology/Oncology, Isala Clinic, Zwolle, The Netherlands
| | - Daniel Weisdorf
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minnesota
| | - Baldeep Wirk
- Bone Marrow Transplant Program, Penn State Cancer Institute, Hershey, Pennsylvania
| | - Jean A Yared
- Transplantation & Cellular Therapy Program, Division of Hematology/Oncology, Department of Medicine, Greenebaum Comprehensive Cancer Center, University of Maryland, Baltimore, Maryland
| | - Jeffrey Schriber
- Cancer Treatment Centers of America Comprehensive Care and Research Center, Phoenix, Arizona
| | - Richard E Champlin
- Department of Stem Cell Transplantation and Cellular Therapy, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Stefan O Ciurea
- Hematopoietic Stem Cell Transplantation and Cellular Therapy Program, University of California, Irvine, Orange, California
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Rossi F, Tortora C, Paoletta M, Marrapodi MM, Argenziano M, Di Paola A, Pota E, Di Pinto D, Di Martino M, Iolascon G. Osteoporosis in Childhood Cancer Survivors: Physiopathology, Prevention, Therapy and Future Perspectives. Cancers (Basel) 2022; 14:cancers14184349. [PMID: 36139510 PMCID: PMC9496695 DOI: 10.3390/cancers14184349] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 09/01/2022] [Accepted: 09/06/2022] [Indexed: 11/29/2022] Open
Abstract
Simple Summary Anti-cancer treatments induced an increase in the childhood cancer survival rate. However, they are responsible for several long-term side effects in childhood cancer survivors, including osteoporosis. Cancer itself, a sedentary lifestyle, and an unhealthy diet might adversely affect bone health. Early identification and adequate management of bone fragility in childhood cancer survivors could be useful to prevent osteoporosis onset and consequently fragility fractures. Abstract The improvement of chemotherapy, radiotherapy, and surgical interventions, together with hematopoietic stem cell transplantation, increased childhood cancer survival rate in the last decades, reaching 80% in Europe. Nevertheless, anti-cancer treatments are mainly responsible for the onset of long-term side effects in childhood cancer survivors (CCS), including alterations of the endocrine system function and activity. In particular, the most frequent dysfunction in CCS is a metabolic bone disorder characterized by low bone mineral density (BMD) with increased skeletal fragility. BMD loss is also a consequence of a sedentary lifestyle, malnutrition, and cancer itself could affect BMD, thus inducing osteopenia and osteoporosis. In this paper, we provide an overview of possible causes of bone impairment in CCS in order to propose management strategies for early identification and treatment of skeletal fragility in this population.
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Affiliation(s)
- Francesca Rossi
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, Via L. De Crecchio 4, 80138 Napoli, Italy
- Correspondence: ; Tel.: +39-081-566-5423
| | - Chiara Tortora
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, Via L. De Crecchio 4, 80138 Napoli, Italy
| | - Marco Paoletta
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy
| | - Maria Maddalena Marrapodi
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, Via L. De Crecchio 4, 80138 Napoli, Italy
| | - Maura Argenziano
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, Via L. De Crecchio 4, 80138 Napoli, Italy
| | - Alessandra Di Paola
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, Via L. De Crecchio 4, 80138 Napoli, Italy
| | - Elvira Pota
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, Via L. De Crecchio 4, 80138 Napoli, Italy
| | - Daniela Di Pinto
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, Via L. De Crecchio 4, 80138 Napoli, Italy
| | - Martina Di Martino
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, Via L. De Crecchio 4, 80138 Napoli, Italy
| | - Giovanni Iolascon
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy
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Post-Transplant Cyclophosphamide after Matched Sibling and Unrelated Donor Hematopoietic Stem Cell Transplantation in Pediatric Patients with Acute Myeloid Leukemia. Int J Mol Sci 2022; 23:ijms23158748. [PMID: 35955881 PMCID: PMC9368975 DOI: 10.3390/ijms23158748] [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: 07/13/2022] [Revised: 07/31/2022] [Accepted: 08/05/2022] [Indexed: 11/18/2022] Open
Abstract
Non-relapse mortality due to GVHD and infections represents a major source of morbidity and mortality in pediatric HSCT recipients. Post-transplant cyclophosphamide (PTCy) has emerged as an effective and safe GVHD prophylaxis strategy, with improved GVHD and relapse-free survival in matched (related and unrelated) and mismatched haploidentical HSCT adult recipients. However, there are no published data in pediatric patients with acute myeloid leukemia who received matched-donor HSCT with PTCy. We demonstrate, in this case series, that the use of PTCy in this population is potentially safe, effective in preventing acute GVHD, does not impair engraftment, is associated with reduced non-relapse mortality, and does not hinder immune reconstitution post HSCT.
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Nakamae H. Systematic overview of HLA-matched allogeneic hematopoietic cell transplantation with post-transplantation cyclophosphamide. Int J Hematol 2022; 116:465-481. [PMID: 35930118 DOI: 10.1007/s12185-022-03428-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 07/21/2022] [Accepted: 07/21/2022] [Indexed: 10/16/2022]
Abstract
The successful application of post-transplantation cyclophosphamide (PTCy) as graft-versus-host disease (GVHD) prophylaxis in HLA-haploidentical allogeneic hematopoietic cell transplantation (allo-HCT) led to the expansion of its application to HLA-matched related and unrelated allo-HCT. Notably, single-agent PTCy was found to be feasible for GVHD prevention in HLA-matched bone marrow transplantation. Single-agent PTCy prophylaxis was later attempted to control GVHD in HLA-matched peripheral blood stem cell transplantation (PBSCT), but this approach was inadequate to alleviate GVHD as evidenced by the high incidence of severe GVHD and/or non-relapse mortality. Therefore, various combinations of immunosuppressants with PTCy have been explored to identify the optimal drug combination that would efficiently prevent GVHD in HLA-matched PBSCT. A recent murine study helped clarify the putative mechanism underlying the activity of PTCy, demonstrating that PTCy impairs the proliferation and function of alloreactive T cells from the donor, but does not eliminate alloreactive T cells altogether. In addition, imbalanced reconstitution of NK cell as well as T cells has been observed in HLA-haploidentical allo-HCT. Therefore, it remains unclear whether or not PTCy-containing GVHD prophylaxis should replace the classical GVHD prophylaxis regimen in the HLA-matched setting, and convincing evidence supporting the benefits of PTCy is needed.
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Affiliation(s)
- Hirohisa Nakamae
- Hematology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan.
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Zu Y, Li Z, Gui R, Liu Y, Zhang Y, Yu F, Zhao H, Fu Y, Zhan X, Wang Z, Xing P, Wang X, Wang H, Zhou J, Song Y. Low-dose post-transplant cyclophosphamide with low-dose antithymocyte globulin for prevention of graft-versus-host disease in first complete remission undergoing 10/10 HLA-matched unrelated donor peripheral blood stem cell transplants: a multicentre, randomized controlled trial. Bone Marrow Transplant 2022; 57:1573-1580. [PMID: 35840747 PMCID: PMC9532243 DOI: 10.1038/s41409-022-01754-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 06/16/2022] [Accepted: 06/28/2022] [Indexed: 11/09/2022]
Abstract
The most widely used regimens of graft-versus-host disease (GVHD) prophylaxis in HLA-matched unrelated donor peripheral blood stem cell transplantation (MUD-PBSCT) are based on anti-thymocyte globulin (ATG) or post-transplant cyclophosphamide (PTCy). To improve the efficiency of GVHD prophylaxis, a novel regimen, composed of low-dose PTCy (20 mg/kg on day +3 and +4) and low-dose ATG (6 mg/kg), was evaluted in patients with hematological malignancies ungoing 10/10 HLA MUD-PBSCT in first remission (CR1). In our prospective, multicenter study, 104 patients were randomly assigned one-to-one to low-dose PTCy-ATG (n = 53) or standard-dose ATG (10 mg/kg, n = 51). Both the cumulative incidences (CIs) of grade II-IV acute GVHD (aGVHD) and chronic GVHD (cGVHD) at 2 years in low-dose PTCy-ATG cohort were significantly reduced (24.5% vs. 47.1%; P = 0.017; 14.1% vs. 33.3%; P = 0.013). The CI of non-relapse-mortality (NRM) was much lower (13.2% vs. 34.5%; P = 0.049) and GVHD-free, relapse-free survival (GRFS) was significantly improved at 2 years in low-dose PTCy-ATG arm (67.3% vs 42.3%; P = 0.032). The low-dose PTCy-ATG based GVHD prophylaxis is a promising strategy for patients in CR1 after 10/10 HLA MUD-PBSCT.
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Affiliation(s)
- Yingling Zu
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, 450000, Henan, China.,Academy of Medical Sciences, Zhengzhou University, Zhengzhou, 450000, Henan, China
| | - Zhen Li
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, 450000, Henan, China
| | - Ruirui Gui
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, 450000, Henan, China
| | - Yanyan Liu
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, 450000, Henan, China
| | - Yanli Zhang
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, 450000, Henan, China
| | - Fengkuan Yu
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, 450000, Henan, China
| | - Huifang Zhao
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, 450000, Henan, China
| | - Yuewen Fu
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, 450000, Henan, China
| | - Xinrong Zhan
- Department of Hematology, Central Hospital of Xinxiang, Xinxiang, 453000, Henan, China
| | - Zhongliang Wang
- Department of Hematology, Central Hospital of Xinxiang, Xinxiang, 453000, Henan, China
| | - Pengtao Xing
- Department of Hematology, Central Hospital of Xinxiang, Xinxiang, 453000, Henan, China
| | - Xianjing Wang
- Department of Hematology, The Third People's Hospital of Zhengzhou, Zhengzhou, 450000, Henan, China
| | - Huili Wang
- Department of Hematology, The Third People's Hospital of Zhengzhou, Zhengzhou, 450000, Henan, China
| | - Jian Zhou
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, 450000, Henan, China.
| | - Yongping Song
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, 450000, Henan, China. .,Department of Hematology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, China.
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46
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Post-Transplantation Cyclophosphamide Versus Tacrolimus and Methotrexate Graft-Versus-Host Disease Prophylaxis for HLA-Matched Donor Transplantation. Transplant Cell Ther 2022; 28:695.e1-695.e10. [DOI: 10.1016/j.jtct.2022.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 07/21/2022] [Accepted: 07/21/2022] [Indexed: 11/24/2022]
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Lazzari L, Balaguer-Roselló A, Montoro J, Greco R, Hernani R, Lupo-Stanghellini MT, Villalba M, Giglio F, Facal A, Lorentino F, Guerreiro M, Bruno A, Pérez A, Xue E, Clerici D, Piemontese S, Piñana JL, Sanz MÁ, Solano C, de la Rubia J, Ciceri F, Peccatori J, Sanz J. Post-transplant cyclophosphamide and sirolimus based graft-versus-host disease prophylaxis after allogeneic stem cell transplantation for acute myeloid leukemia. Bone Marrow Transplant 2022; 57:1389-1398. [PMID: 35680995 PMCID: PMC9439951 DOI: 10.1038/s41409-022-01725-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 05/16/2022] [Accepted: 05/25/2022] [Indexed: 11/30/2022]
Abstract
Post-transplant cyclophosphamide (PTCy) has emerged as a promising graft-versus-host disease (GvHD) prophylaxis in allogeneic hematopoietic stem cell transplantation (allo-HSCT). However, no studies have reported the efficacy of a GvHD prophylaxis based on PTCy with sirolimus (Sir-PTCy) in patients with acute myeloid leukemia (AML). In this retrospective study, we analyze the use of sirolimus in combination with PTCy, with or without mycophenolate mofetil (MMF), on 242 consecutive adult patients with AML undergoing a myeloablative first allo-HSCT from different donor types, in three European centers between January 2017 and December 2020. Seventy-seven (32%) patients received allo-HSCT from HLA-matched sibling donor, 101 (42%) from HLA-matched and mismatched unrelated donor, and 64 (26%) from haploidentical donor. Except for neutrophil and platelet engraftment, which was slower in the haploidentical cohort, no significant differences were observed in major transplant outcomes according to donor type in univariate and multivariate analysis. GvHD prophylaxis with Sir-PTCy, with or without MMF, is safe and effective in patients with AML undergoing myeloablative allo-HSCT, resulting in low rates of transplant-related mortality, relapse/progression, and acute and chronic GvHD in all donor settings.
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Affiliation(s)
- Lorenzo Lazzari
- Hematology and Bone Marrow Transplantation Unit, IRCCS Ospedale San Raffaele, Milan, Italy.
| | | | - Juan Montoro
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Raffaella Greco
- Hematology and Bone Marrow Transplantation Unit, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Rafael Hernani
- Department of Hematology, Hospital Clínico Universitario, Valencia, Spain
| | | | - Marta Villalba
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Fabio Giglio
- Hematology and Bone Marrow Transplantation Unit, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Ana Facal
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Francesca Lorentino
- Hematology and Bone Marrow Transplantation Unit, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Manuel Guerreiro
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Alessandro Bruno
- Hematology and Bone Marrow Transplantation Unit, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Ariadna Pérez
- Department of Hematology, Hospital Clínico Universitario, Valencia, Spain
| | - Elisabetta Xue
- Hematology and Bone Marrow Transplantation Unit, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Daniela Clerici
- Hematology and Bone Marrow Transplantation Unit, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Simona Piemontese
- Hematology and Bone Marrow Transplantation Unit, IRCCS Ospedale San Raffaele, Milan, Italy
| | - José Luis Piñana
- Department of Hematology, Hospital Clínico Universitario, Valencia, Spain
| | - Miguel Ángel Sanz
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Carlos Solano
- Department of Hematology, Hospital Clínico Universitario, Valencia, Spain.,Department of Medicine, School of Medicine, University of Valencia, Valencia, Spain
| | - Javier de la Rubia
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Fabio Ciceri
- Hematology and Bone Marrow Transplantation Unit, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Jacopo Peccatori
- Hematology and Bone Marrow Transplantation Unit, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Jaime Sanz
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain.,Department of Medicine, School of Medicine, University of Valencia, Valencia, Spain
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Mehta RS, Saliba RM, Hayase E, Jenq RR, Abraham S, Rashid A, Rondon G, Al-Atrash G, Bashir Q, Hosing CM, Kebriaei P, Khouri I, Marin D, Nieto Y, Olson A, Oran B, Popat UR, Qazilbash MH, Ramdial J, Srour S, Champlin RE, Rezvani K, Shpall EJ, Alousi AM. Mycophenolate Mofetil: A Friend or a Foe with PTCy and Tacrolimus Prophylaxis in HLA-Matched donors? Transplant Cell Ther 2022; 28:500.e1-500.e10. [PMID: 35662592 DOI: 10.1016/j.jtct.2022.05.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 05/02/2022] [Accepted: 05/25/2022] [Indexed: 10/18/2022]
Abstract
Adapted from the haploidentical literature, post-transplantation cyclophosphamide (PTCy) is increasingly being used with HLA-matched donors, generally with a calcineurin inhibitor, such as tacrolimus (Tac) with or without mycophenolate mofetil (MMF). Owing to its immunosuppressive, potentially antitumor, and antimicrobial properties, MMF is an attractive drug; however, it remains unclear how much benefit is gained when used with PTCy/Tac. To assess that, we compared PTCy/Tac (n=242) to PTCy/Tac/MMF (n= 144) in recipients of HLA-matched donors. In multivariate analysis, the PTCy/Tac/MMF group had a significantly higher risk of grade II-IV acute graft-versus-host disease (GVHD; hazard ratio (HR) 2.1, 95% confidence interval (CI) 1.6-2.8, p<0.001), and steroid-refractory/dependent acute GVHD (HR 4.8, 95% CI 2.4-9.6, p<0.001), yet a significantly lower risk of relapse (HR 0.5, 95% CI, 0.3-0.9, p=0.009) and better progression-free survival (PFS; HR 0.7, 95% CI 0.5-0.9, p=0.04). There was no difference in the risk of grade III-IV acute GVHD, chronic GVHD, non-relapse mortality, or overall survival. MMF was associated with prolonged neutrophil engraftment by 2 days, and a higher risk of bacterial infections. In an exploratory stool microbiome analysis (n=16), we noted a higher relative abundance of β-glucuronidase-producing bacteria in the MMF group, which may have a role in the pathogenesis of MMF-related GVHD. Our data suggest that the addition of MMF to PTCy/Tac for HLA-matched donor HCT does not provide any advantage for GVHD prevention. Further studies are needed to decipher this mechanism, and understand its role with PTCy-based prophylaxis.
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Affiliation(s)
- Rohtesh S Mehta
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Rima M Saliba
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Eiko Hayase
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Robert R Jenq
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX; Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Susan Abraham
- Department of Anatomical Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Asif Rashid
- Department of Anatomical Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Gabriela Rondon
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Gheath Al-Atrash
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Qaiser Bashir
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Chitra M Hosing
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Partow Kebriaei
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Issa Khouri
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - David Marin
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Yago Nieto
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Amanda Olson
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Betul Oran
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Uday R Popat
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Muzaffar H Qazilbash
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jeremy Ramdial
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Samer Srour
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Richard E Champlin
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Katayoun Rezvani
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Elizabeth J Shpall
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Amin M Alousi
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX
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49
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Long-term outcomes in patients with relapsed/refractory acute myeloid leukemia and other high-risk myeloid malignancies after undergoing sequential conditioning regimen based on IDA-FLAG and high-dose melphalan. Bone Marrow Transplant 2022; 57:1304-1312. [DOI: 10.1038/s41409-022-01703-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 04/25/2022] [Accepted: 04/29/2022] [Indexed: 12/17/2022]
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50
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Hamilton BK, Cutler C, Divine C, Juckett M, LeMaistre C, Stewart S, Wilder J, Horowitz M, Khera N, Burns LJ. Are We Making PROGRESS in Preventing Graft-versus-Host Disease and Improving Clinical Outcomes? Impact of BMT CTN 1301 Study Results on Clinical Practice. Transplant Cell Ther 2022; 28:419-425. [PMID: 35550441 PMCID: PMC9364468 DOI: 10.1016/j.jtct.2022.05.002] [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: 03/04/2022] [Revised: 04/28/2022] [Accepted: 05/01/2022] [Indexed: 11/15/2022]
Abstract
The need for prospective randomized clinical trials investigating novel graft-versus-host disease (GVHD) prevention strategies that include other clinical outcomes impacted by GVHD has been highlighted as a priority for the field of hematopoietic cell transplantation. A recently completed study through the Blood and Marrow Transplant Clinical Trials Network (BMT CTN 1301) comparing CD34+ selection and post-transplantation cyclophosphamide with tacrolimus/methotrexate (Tac/MTX) for GVHD prevention demonstrated no significant differences in the primary endpoint of chronic GVHD relapse-free survival among the 3 approaches. The trial did not demonstrate a superior approach compared with Tac/MTX; however, it did highlight several challenges in determining the best and most relevant approaches to clinical trial design, particularly in the context of current and ongoing changes in real-world practices. Here we review the results of BMT CTN 1301 and their implications for clinical practice and future clinical trial design.
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Affiliation(s)
- Betty K Hamilton
- Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Corey Cutler
- Division of Stem Cell Transplantation and Cellular Therapy, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Clint Divine
- Division of Hematologic Malignancies and Cellular Therapeutics, University of Kansas Medical Center, Kansas City, Kansas
| | - Mark Juckett
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | | | - Susan Stewart
- Blood and Marrow Transplant Information Network, Highland Park, Illinois
| | - Jennifer Wilder
- Clinical Monitoring Research Program Directorate, Frederick National Laboratory for Cancer Research sponsored by the National Cancer Institute, Frederick, Maryland
| | - Mary Horowitz
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nandita Khera
- Division of Hematology and Oncology, Mayo Clinic Arizona, Phoenix, Arizona
| | - Linda J Burns
- Center for International Blood and Marrow Transplant Research, Milwaukee, Wisconsin
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