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Admiraal R, Versluijs AB, Huitema ADR, Ebskamp L, Lacna A, de Kanter CTK, Bierings MB, Boelens JJ, Lindemans CA, Nierkens S. High-dose individualized antithymocyte globulin with therapeutic drug monitoring in high-risk cord blood transplant. Cytotherapy 2024; 26:599-605. [PMID: 38466262 DOI: 10.1016/j.jcyt.2024.02.015] [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: 05/03/2023] [Revised: 01/25/2024] [Accepted: 02/13/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND Graft-versus-host disease (GvHD) and rejection are main limitations of cord blood transplantation (CBT), more so in patients with severe inflammation or previous rejections. While rigorous T-cell depletion with antithymocyte globulin (ATG) is needed to prevent GvHD and rejection, overexposure to ATG leads to slow T-cell recovery after transplantation, especially in CBT. OBJECTIVE To evaluate high-dose, upfront ATG with individualized dosing and therapeutic drug monitoring (TDM) in pediatric CBT for patients at high risk for GvHD and rejection. STUDY DESIGN Heavily inflamed patients and patients with a recent history of rejection were eligible for individualized high-dose ATG with real-time TDM. The ATG dosing scheme was adjusted to target a post-CBT exposure of <10 AU*day/mL, while achieving a pre-CBT exposure of 60-120 AU*day/mL; exposure levels previously defined for optimal efficacy and safety in terms of reduced GvHD and rejection, respectively. Main outcomes of interest included efficacy (target exposure attainment) and safety (incidence of GvHD and rejection). Other outcomes of interest included T-cell recovery and survival. RESULTS Twenty-one patients were included ranging from 2 months to 18 years old, receiving an actual median cumulative dose of ATG of 13.3 mg/kg (range 6-30 mg/kg) starting at a median 15 days (range 12-17) prior to CBT. Dosing was adjusted in 14 patients (increased in 3 and decreased in 11 patients). Eighteen (86%) and 19 (91%) patients reached the target pre-CBT and post-CBT exposure, respectively. Cumulative incidence for acute GvHD was 34% (95% CI 23-45) and 5% (95% CI 0-10%) for grade 2-4 and grade 3-4, respectively; cumulative incidence of rejection was 9% (95% CI 2-16%). Overall survival was 75% (95% CI 65-85%). CONCLUSION Individualized high-dose ATG with TDM is feasible and safe for patients with hyperinflammation in a CBT setting. We observe high target ATG exposure attainment, good immune reconstitution (despite very high doses of ATG) and acceptable rates of GvHD and rejection.
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Affiliation(s)
- Rick Admiraal
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands; Department of Pediatrics, University Medical Center Utrecht, Utrecht, the Netherlands.
| | - A Birgitta Versluijs
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands; Department of Pediatrics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Alwin D R Huitema
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands; Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek Hospital, Netherlands Cancer Institute, Amsterdam, the Netherlands; Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Lysette Ebskamp
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Amelia Lacna
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - C T Klaartje de Kanter
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands; Department of Pharmacy, Curacao Medical Center, Willemstad, Curacao
| | - Marc B Bierings
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands; Department of Pediatrics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jaap Jan Boelens
- Transplantation and Cellular Therapies, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Caroline A Lindemans
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands; Department of Pediatrics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Stefan Nierkens
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands; Center for Translational Immunology, University Medical Center Utrecht, Utrecht, the Netherlands
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Barbarito G, Hiroshima L, Oppizzi L, Saini G, Kristovich K, Klein O, Hosszu K, Boehlke K, Gupta A, Mcavoy D, Shyr D, Boelens JJ, Bertaina A. Model-Based Antithymocyte Globulin in αβhaplo-Hematopoietic Stem Cell Transplantation Facilitates Engraftment, Expedites T Cell Recovery, and Mitigates the Risk of Acute Graft-versus-Host Disease. Transplant Cell Ther 2024:S2666-6367(24)00412-3. [PMID: 38768907 DOI: 10.1016/j.jtct.2024.05.015] [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: 02/08/2024] [Revised: 05/06/2024] [Accepted: 05/13/2024] [Indexed: 05/22/2024]
Abstract
In αβ T-cell/CD19 B-cell depleted hematopoietic stem cell transplantation (αβhaplo-HSCT) recipients, antithymocyte globulin (ATG; Thymoglobulin) is used for preventing graft rejection and graft-versus-host disease (GVHD). The optimal dosing remains to be established, however. Here we present the first comparative analysis of 3 different ATG dosing strategies and their impact on immune reconstitution and GVHD. Our study aimed to evaluate the effects of 3 distinct dosing strategies of ATG on engraftment success, αβ+ and γδ+ T cell immune reconstitution, and the incidence and severity of acute GVHD in recipients of αβhaplo-HSCT. This comparative analysis included 3 cohorts of pediatric patients with malignant (n = 36) or nonmalignant (n = 8) disease. Cohorts 1 and 2 were given fixed ATG doses, whereas cohort 3 received doses via a new nomogram, based on absolute lymphocyte count (ALC) and body weight (BW). Cohort 3 showed a 0% incidence of day 100 grade II-IV acute GVHD, compared to 48% in cohort 1 and 27% in cohort 2. Furthermore, cohort 3 (the ALC/BW-based cohort) had a significant increase in CD4+ and CD8+ naïve T cells by day 90 (P = .04 and .03, respectively). Additionally, we found that the reconstitution and maturation of γδ+ T cells post-HSCT was not impacted across all 3 cohorts. Cumulative ATG exposure in all cohorts was lower than previously reported in T cell-replete settings, with a lower pre-HSCT exposure (<40 AU*day/mL) correlating with engraftment failure (P = .007). Conversely, a post-HSCT ATG exposure of 10 to 15 AU*day/mL was optimal for improving day 100 CD4+ (P = .058) and CD8+ (P = .03) immune reconstitution without increasing the risk of relapse or nonrelapse mortality. This study represents the first comparative analysis of ATG exposure in αβhaplo-HSCT recipients. Our findings indicate that (1) a 1- to 2-fold ATG to ATLG bioequivalence is more effective than previously established standards, and (2) ATG exposure post-HSCT does not adversely affect γδ+ T cell immune reconstitution. Furthermore, a model-based ATG dosing strategy effectively reduces graft rejection and day 100 acute GVHD while also promoting early CD4+/CD8+ immune reconstitution. These insights suggest that further optimization, including more distal administration of higher ATG doses within an ALC/BW-based strategy, will yield even greater improvements in outcomes.
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Affiliation(s)
- Giulia Barbarito
- Division of Hematology, Oncology, Stem Cell Transplantation, and Regenerative Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Lyndsie Hiroshima
- Division of Hematology, Oncology, Stem Cell Transplantation, and Regenerative Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Linda Oppizzi
- Division of Hematology, Oncology, Stem Cell Transplantation, and Regenerative Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Gopin Saini
- Division of Hematology, Oncology, Stem Cell Transplantation, and Regenerative Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Karen Kristovich
- Division of Hematology, Oncology, Stem Cell Transplantation, and Regenerative Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Orly Klein
- Division of Hematology, Oncology, Stem Cell Transplantation, and Regenerative Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Kinga Hosszu
- MSK Kids, Transplantation and Cellular Therapy Service, Memorial Sloan Kettering Cancer Center, New York, New York; Immune Discovery and Monitoring Service, Department of Pediatrics and Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kylan Boehlke
- Division of Hematology, Oncology, Stem Cell Transplantation, and Regenerative Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Aditi Gupta
- Division of Hematology, Oncology, Stem Cell Transplantation, and Regenerative Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Devin Mcavoy
- MSK Kids, Transplantation and Cellular Therapy Service, Memorial Sloan Kettering Cancer Center, New York, New York; Immune Discovery and Monitoring Service, Department of Pediatrics and Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - David Shyr
- Division of Hematology, Oncology, Stem Cell Transplantation, and Regenerative Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Jaap Jan Boelens
- MSK Kids, Transplantation and Cellular Therapy Service, Memorial Sloan Kettering Cancer Center, New York, New York; Immune Discovery and Monitoring Service, Department of Pediatrics and Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Alice Bertaina
- Division of Hematology, Oncology, Stem Cell Transplantation, and Regenerative Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California.
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Justus JLP, Beltrame MP, de Azambuja AP, Schluga YC, Martins EA, Rocha MTL, Rodrigues AM, Loth G, Lima ACM, Bonfim C. Immune recovery and the role of recent thymic emigrated T lymphocytes after pediatric hematopoietic stem cell transplantation. Cytotherapy 2024:S1465-3249(24)00685-6. [PMID: 38762804 DOI: 10.1016/j.jcyt.2024.04.073] [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: 09/17/2023] [Revised: 04/23/2024] [Accepted: 04/26/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND AIMS Adequate re-establishment of thymopoiesis is critical for long-term immune reconstitution after hematopoietic cell transplantation (HCT), potentially impacting patient survival rates. This study aimed to evaluate immune reconstitution in pediatric HCT recipients by quantifying recent thymic emigrants (RTEs), specifically CD3+CD31+CD45RA+ cells. METHODS We conducted a retrospective analysis of 186 pediatric patients transplanted between 2013 and 2020, undergoing their first allogeneic HCT, who were alive in the first 100 days after transplantation with immune recovery evaluation at three time points: day 100, day 180 and day 360 after HCT. We analyzed the distribution of peripheral blood subsets of T, B and natural killer lymphocytes and assessed the impact of underlying disease, HCT type, stem cell source, recipient age, conditioning regimen, graft-versus-host disease (GVHD) occurrence and cytomegalovirus (CMV) reactivation on immune recovery. RESULTS At day 100, patients under 10 years exhibited higher RTE CD4+ and CD8+CD31+CD45RA+ counts compared with older patients (5.3 versus 2.2 cells/µL, P = 0.022 and 48 versus 72.8 cells/µL, P = 0.049, respectively). Patients with haploidentical HCT had lower RTE CD4+ counts compared with those with unrelated or related donors (2.4 versus 4.4 versus 7.9 cells/µL, P = 0.024). Administration of rabbit anti-thymocyte globulin negatively impacted RTE CD4+ production (median, 6.5 versus 2.4 cells/µL, P = 0.007). At day 180, the presence of GVHD had a negative influence on RTE production (11.7 versus 56.8 cells/µL, P < 0.001), particularly higher-grade acute GVHD (without, 56.8 cells/µL, grade 1-2, 28.1 cells/µL, grade 3-4, 6.0 cells/µL, P < 0.001). Patients with CMV reactivation had higher CD8+CD31+CD45RA+ compared with those without reactivation (median, 204.6 versus 100.2 cells/µL, P = 0.022). At day 360, no variables significantly affected RTE recovery. Overall survival at 5-year follow-up was 87.7%, with a median of 1170 days (range, 122-3316). Multivariate analysis showed that age >10 years (P = 0.038), negative CMV donor serology (P = 0.0029) and acute GVHD (P = 0.0026) had a negative impact on survival. CONCLUSIONS This study highlights variations in RTE production based on patient age, donor type and immunosuppression regimen employed.
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Affiliation(s)
- Julie Lillian Pimentel Justus
- Flow Cytometry Laboratory, Clinics Hospital, Federal University of Paraná, Curitiba, Brazil; Post-Graduation Program in Children and Adolescent Health, Clinics Hospital, Federal University of Parana, Curitiba, Brazil.
| | - Miriam P Beltrame
- Flow Cytometry Laboratory, Clinics Hospital, Federal University of Paraná, Curitiba, Brazil; Post-Graduation Program in Children and Adolescent Health, Clinics Hospital, Federal University of Parana, Curitiba, Brazil
| | - Ana Paula de Azambuja
- Flow Cytometry Laboratory, Clinics Hospital, Federal University of Paraná, Curitiba, Brazil
| | - Yara C Schluga
- Flow Cytometry Laboratory, Clinics Hospital, Federal University of Paraná, Curitiba, Brazil
| | - Edna A Martins
- Flow Cytometry Laboratory, Clinics Hospital, Federal University of Paraná, Curitiba, Brazil
| | | | - Adriana Mello Rodrigues
- Pediatric Blood and Marrow Transplantation Division, Clinics Hospital, Federal University of Paraná, Curitiba, Brazil
| | - Gisele Loth
- Pediatric Blood and Marrow Transplantation Division, Clinics Hospital, Federal University of Paraná, Curitiba, Brazil
| | | | - Carmem Bonfim
- Post-Graduation Program in Children and Adolescent Health, Clinics Hospital, Federal University of Parana, Curitiba, Brazil; Pediatric Blood and Marrow Transplantation Division, Hospital Pequeno Príncipe, Curitiba, Brazil
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4
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Cordón L, Chorão P, Martín-Herreros B, Montoro J, Balaguer A, Guerreiro M, Villalba M, Facal A, Asensi P, Solves P, Gómez I, Santiago M, Lamas B, Bataller A, Granados P, Sempere A, Sanz GF, Sanz MA, Sanz J. Immune reconstitution after single-unit umbilical cord blood transplantation using anti-thymoglobulin and myeloablative conditioning in adults with hematological malignancies. Ann Hematol 2024:10.1007/s00277-024-05758-0. [PMID: 38634914 DOI: 10.1007/s00277-024-05758-0] [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: 11/21/2023] [Accepted: 04/11/2024] [Indexed: 04/19/2024]
Abstract
This study aimed to investigate the kinetics of immune recovery following umbilical cord blood transplantation (UCBT) in adults who received a myeloablative conditioning (MAC) regimen and antithymocyte globulin (ATG). While the immune recovery kinetics has been extensively studied in pediatric UCBT recipients, limited data exist for adults. We conducted a comprehensive analysis of 221 consecutive adult patients who underwent UCBT with MAC and ATG at a single institution. Our objective was to evaluate the influence of patient, disease, and transplant factors, along with acute graft-versus-host disease (aGVHD), on immune reconstitution and overall survival. Our findings confirm a delayed recovery of T cells, while B and NK cell reconstitution exhibited rapid progress, with NK cell counts reaching normal levels within 3 months post-transplantation and B cells within 6 months. Within CD3+ T cells, CD8+ T cells also experienced a delayed recovery (12 months), but to a lesser extent compared to CD4+ T cells (18 months). Delayed immune recovery of T-cell subsets was associated with the development of aGVHD grade II-IV, older age, CMV negativity, and a female donor. Patients with lymphoproliferative diseases showed slower NK cell recovery. Our study demonstrates that adult patients undergoing MAC with ATG and receiving a single unit UCBT for hematologic malignancies experienced rapid reconstitution of NK and B cells. However, T cell recovery, particularly CD4+ T cells, was significantly delayed. To enhance T cell recovery, it may be crucial to consider UCB units with higher cellularity and optimize ATG doses in conditioning.
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Affiliation(s)
- Lourdes Cordón
- Hematology Research Group, Instituto de Investigación Sanitaria La Fe, Avenida Fernando Abril Martorell, 106, Valencia, 46026, Spain.
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto Carlos III, Madrid, Spain.
| | - Pedro Chorão
- Hematology Research Group, Instituto de Investigación Sanitaria La Fe, Avenida Fernando Abril Martorell, 106, Valencia, 46026, Spain
- Hematology Department, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Beatriz Martín-Herreros
- Hematology Research Group, Instituto de Investigación Sanitaria La Fe, Avenida Fernando Abril Martorell, 106, Valencia, 46026, Spain
| | - Juan Montoro
- Hematology Department, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Aitana Balaguer
- Hematology Research Group, Instituto de Investigación Sanitaria La Fe, Avenida Fernando Abril Martorell, 106, Valencia, 46026, Spain
- Hematology Department, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Manuel Guerreiro
- Hematology Research Group, Instituto de Investigación Sanitaria La Fe, Avenida Fernando Abril Martorell, 106, Valencia, 46026, Spain
- Hematology Department, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Marta Villalba
- Hematology Research Group, Instituto de Investigación Sanitaria La Fe, Avenida Fernando Abril Martorell, 106, Valencia, 46026, Spain
- Hematology Department, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Ana Facal
- Hematology Research Group, Instituto de Investigación Sanitaria La Fe, Avenida Fernando Abril Martorell, 106, Valencia, 46026, Spain
- Hematology Department, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Pedro Asensi
- Hematology Department, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Pilar Solves
- Hematology Department, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Inés Gómez
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto Carlos III, Madrid, Spain
- Hematology Department, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Marta Santiago
- Hematology Research Group, Instituto de Investigación Sanitaria La Fe, Avenida Fernando Abril Martorell, 106, Valencia, 46026, Spain
- Hematology Department, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Brais Lamas
- Hematology Department, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Ana Bataller
- Hematology Department, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Pablo Granados
- Hematology Department, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Amparo Sempere
- Hematology Research Group, Instituto de Investigación Sanitaria La Fe, Avenida Fernando Abril Martorell, 106, Valencia, 46026, Spain
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto Carlos III, Madrid, Spain
- Hematology Department, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Guillermo F Sanz
- Hematology Research Group, Instituto de Investigación Sanitaria La Fe, Avenida Fernando Abril Martorell, 106, Valencia, 46026, Spain
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto Carlos III, Madrid, Spain
- Hematology Department, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Miguel A Sanz
- Hematology Research Group, Instituto de Investigación Sanitaria La Fe, Avenida Fernando Abril Martorell, 106, Valencia, 46026, Spain
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto Carlos III, Madrid, Spain
- Hematology Department, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Jaime Sanz
- Hematology Research Group, Instituto de Investigación Sanitaria La Fe, Avenida Fernando Abril Martorell, 106, Valencia, 46026, Spain
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto Carlos III, Madrid, Spain
- Hematology Department, Hospital Universitario y Politécnico La Fe, Valencia, Spain
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Barriga F, Wietstruck A, Schulze-Schiappacasse C, Catalán P, Sotomayor C, Zúñiga P, Aguirre N, Vizcaya C, Le Corre N, Villarroel L. Individualized dose of anti-thymocyte globulin based on weight and pre-transplantation lymphocyte counts in pediatric patients: a single center experience. Bone Marrow Transplant 2024; 59:473-478. [PMID: 38253868 DOI: 10.1038/s41409-024-02206-5] [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: 05/15/2023] [Revised: 12/28/2023] [Accepted: 01/10/2024] [Indexed: 01/24/2024]
Abstract
Anti-thymocyte globulin (ATG) has become a standard in preventing GVHD in related and unrelated donor transplantation, but there is no consensus on the best administration schedule. The PARACHUTE trial reported excellent CD4 immune reconstitution (CD4 IR) using a dosing schedule based on the patient's weight and pre-conditioning absolute lymphocyte count (ALC). In 2015 we introduced the PARACHUTE dosing schedule for pediatric patients at our center. One hundred one patients were transplanted for malignant and non-malignant diseases. In this non-concurrent cohort CD4 IR+, defined by a single CD4 count >50/µL on day 90, was seen in 81% of patients. The incidence of grade II-IV and III to IV aGvHD was 26.6% and 15.3% and 5% for cGvHD with no severe cases. We found no difference in aGvHD between donor type and stem cell sources. Five-year EFS and OS were 77.5% and 83.5%. Grade III-IV GFRS was 75.2%. CD4 IR+ patients had better EFS (93.1% vs. 77.7%, p = 0.04) and lower non-relapse mortality (2.7% vs. 22.2%, p = 0.002). The PARACHUTE ATG dosing schedule individualized by weight and ALC results in good early immune reconstitution, low incidence of cGvHD, and favorable survival for patients with different disease groups, donor types, and stem cell sources.
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Affiliation(s)
- Francisco Barriga
- Section of Hematology, Oncology and Stem Cell Transplantation. Division of Pediatrics, Pontificia Universidad Católica de Chile, Santiago, Chile.
| | - Angelica Wietstruck
- Section of Hematology, Oncology and Stem Cell Transplantation. Division of Pediatrics, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Clara Schulze-Schiappacasse
- Department of Pediatric Infectious Diseases, Division of Pediatrics, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Paula Catalán
- Section of Hematology, Oncology and Stem Cell Transplantation. Division of Pediatrics, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Cristian Sotomayor
- Section of Hematology, Oncology and Stem Cell Transplantation. Division of Pediatrics, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Pamela Zúñiga
- Section of Hematology, Oncology and Stem Cell Transplantation. Division of Pediatrics, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Noemi Aguirre
- Section of Hematology, Oncology and Stem Cell Transplantation. Division of Pediatrics, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Cecilia Vizcaya
- Department of Pediatric Infectious Diseases, Division of Pediatrics, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Nicole Le Corre
- Department of Pediatric Infectious Diseases, Division of Pediatrics, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Luis Villarroel
- Department of Public Health, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
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6
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Lakkaraja M, Mauguen A, Boulad F, Cancio MI, Curran KJ, Harris AC, Kernan NA, Klein E, Kung AL, Oved J, Prockop S, Scaradavou A, Spitzer B, O'Reilly RJ, Boelens JJ. Impact of rabbit anti-thymocyte globulin (ATG) exposure on outcomes after ex vivo T-cell-depleted hematopoietic cell transplantation in pediatric and young adult patients. Cytotherapy 2024; 26:351-359. [PMID: 38349310 PMCID: PMC10997457 DOI: 10.1016/j.jcyt.2024.01.004] [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: 02/23/2023] [Revised: 11/03/2023] [Accepted: 01/24/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND AIMS Traditional weight-based dosing of rabbit anti-thymocyte globulin (rATG) used in allogeneic hematopoietic cell transplantation (HCT) to prevent graft-versus-host disease (GVHD) and graft rejection leads to variable exposures. High exposures induce delayed CD4+immune reconstitution (CD4+IR) and greater mortality. We sought to determine the impact of rATG exposure in children and young adults receiving various types of EX-VIVO T-cell-depleted (EX-VIVO-TCD) HCT. METHODS Patients receiving their first EX-VIVO-TCD HCT (CliniMACS CD34+, Isolex or soybean lectin agglutination), with removal of residual T cells by E-rosette depletion (E-) between 2008 and 2018 at Memorial Sloan Kettering Cancer Center were retrospectively analyzed. rATG exposure post-HCT was estimated (AU*d/L) using a validated population pharmacokinetic model. Previously defined rATG-exposures, <30, 30-55, ≥55 AU*d/L, were related with outcomes of interest. Cox proportional hazard and cause-specific models were used for analyses. RESULTS In total, 180 patients (median age 11 years; range 0.1-44 years) were included, malignant 124 (69%) and nonmalignant 56 (31%). Median post-HCT rATG exposure was 32 (0-104) AU*d/L. Exposure <30 AU*d/L was associated with a 3-fold greater probability of CD4+IR (P < 0.001); 2- to 4-fold lower risk of death (P = 0.002); and 3- to 4-fold lower risk of non-relapse mortality (NRM) (P = 0.02). Cumulative incidence of NRM was 8-fold lower in patients who attained CD4+IR compared with those who did not (P < 0.0001). There was no relation between rATG exposure and aGVHD (P = 0.33) or relapse (P = 0.23). Effect of rATG exposure on outcomes was similar in three EX-VIVO-TCD methods. CONCLUSIONS Individualizing rATG dosing to target a low rATG exposure post-HCT while maintaining total cumulative exposure may better predict CD4+IR, reduce NRM and increase overall survival, independent of the EX-VIVO-TCD method.
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Affiliation(s)
- Madhavi Lakkaraja
- Fred Hutchinson Cancer Center, Seattle, Washington, USA; Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
| | - Audrey Mauguen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Farid Boulad
- Department of Pediatrics, BMT Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Maria I Cancio
- Department of Pediatrics, BMT Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Pediatrics, Weill Cornell Medicine, New York, New York, USA
| | - Kevin J Curran
- Department of Pediatrics, BMT Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Pediatrics, Weill Cornell Medicine, New York, New York, USA
| | - Andrew C Harris
- Department of Pediatrics, BMT Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Pediatrics, Weill Cornell Medicine, New York, New York, USA
| | - Nancy A Kernan
- Department of Pediatrics, BMT Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Elizabeth Klein
- Department of Pediatrics, BMT Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Andrew L Kung
- Department of Pediatrics, BMT Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Joseph Oved
- Department of Pediatrics, BMT Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Pediatrics, Weill Cornell Medicine, New York, New York, USA
| | - Susan Prockop
- Dana Farber Cancer Institute, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Andromachi Scaradavou
- Department of Pediatrics, BMT Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Pediatrics, Weill Cornell Medicine, New York, New York, USA
| | - Barbara Spitzer
- Department of Pediatrics, BMT Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Pediatrics, Weill Cornell Medicine, New York, New York, USA
| | - Richard J O'Reilly
- Department of Pediatrics, BMT Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Pediatrics, Weill Cornell Medicine, New York, New York, USA
| | - Jaap Jan Boelens
- Department of Pediatrics, BMT Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Pediatrics, Weill Cornell Medicine, New York, New York, USA.
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7
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Glushkova S, Shelikhova L, Voronin K, Pershin D, Vedmedskaya V, Muzalevskii Y, Kazachenok A, Kurnikova E, Radygina S, Ilushina M, Khismatullina R, Maschan A, Maschan M. Impact of Natural Killer Cell-Associated Factors on Acute Leukemia Outcomes after Haploidentical Hematopoietic Stem Cell Transplantation with αβ T Cell Depletion in a Pediatric Cohort. Transplant Cell Ther 2024; 30:435.e1-435.e12. [PMID: 38278183 DOI: 10.1016/j.jtct.2024.01.070] [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: 11/02/2023] [Revised: 01/15/2024] [Accepted: 01/17/2024] [Indexed: 01/28/2024]
Abstract
The technique of αβ T cell depletion (αβTCD) is a well-established method of hematopoietic stem cell transplantation (HSCT) for children with acute leukemia owing to the low rates of graft-versus-host disease and nonrelapse mortality (NRM). The graft-versus-leukemia effect is generally ascribed to natural killer (NK) cells conserved within the graft. It is not known whether NK-related factors affect the outcome of αβTCD HSCT, however. The aim of this retrospective study was to explore the impact of NK alloreactivity (based on donor-recipient killer immunoglobulin-like receptor [KIR] mismatch), graft NK cell dose, and blood NK cell recovery on day +30 post-HSCT on the incidences of leukemia relapse and NRM. The pediatric acute leukemia cohort comprised 295 patients who underwent their first HSCT from a haploidentical donor in complete remission. During post hoc analysis, the total cohort was divided into subcohorts by diagnosis (acute lymphoblastic leukemia [ALL]/acute myeloid leukemia [AML]), NK alloreactivity prediction (KIR match/KIR mismatch), graft NK cell dose (less than versus greater than the median value), and blood NK cell recovery on day +30 post-HSCT (less than versus greater than the median value). We also investigated the influence of serotherapy (antithymocyte globulin [ATG] group) versus abatacept + tocilizumab combination [aba+toci] group) on relapse risk in the context of KIR mismatch. The risks of relapse and NRM were calculated by the cumulative risk method, and groups were compared using the Gray test. Multivariate analysis revealed no apparent impact of predicted NK alloreactivity or any other studied NK cell-related factors for the entire cohort. For patients with AML, a significantly higher relapse risk associated with high NK cell graft content on the background of no predicted KIR mismatch (P = .002) was shown. Multivariate analysis confirmed this finding (P = .018); on the other hand, for the KIR-mismatched patients, there was a trend toward a lower risk of relapse associated with high NK cell dose. The use of ATG was associated with a trend toward reduced relapse risk (P = .074) in the AML patients. There was no significant impact of NK-related factors in the ALL patients. Overall, the evaluated NK-related factors did not show a clear and straightforward correlation with the key outcomes of HSCT in our cohort of children with acute leukemia. In practice, the data support prioritization of KIR-mismatched donors for patients with AML. Importantly, a potential interaction of KIR ligand mismatch and NK cell content in the graft was identified. Indirect evidence suggests that additional cellular constituents of the graft could influence the function of NK cells after HSCT and affect their role as graft-versus-leukemia effectors.
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Affiliation(s)
- Svetlana Glushkova
- Laboratory of Transplantation Immunology and Immunotherapy, Dmitriy Rogachev National Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia.
| | - Larisa Shelikhova
- Department of Hematopoietic Stem Cell Transplantation, Dmitriy Rogachev National Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Kirill Voronin
- Department of Statistics, Dmitriy Rogachev National Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Dmitriy Pershin
- Laboratory of Transplantation Immunology and Immunotherapy, Dmitriy Rogachev National Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Viktoria Vedmedskaya
- Laboratory of Transplantation Immunology and Immunotherapy, Dmitriy Rogachev National Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Yakov Muzalevskii
- Department of Transfusion Medicine, Dmitriy Rogachev National Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Alexei Kazachenok
- Department of Transfusion Medicine, Dmitriy Rogachev National Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Elena Kurnikova
- Department of Transfusion Medicine, Dmitriy Rogachev National Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Svetlana Radygina
- Department of Hematopoietic Stem Cell Transplantation, Dmitriy Rogachev National Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Maria Ilushina
- Department of Hematopoietic Stem Cell Transplantation, Dmitriy Rogachev National Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Rimma Khismatullina
- Department of Hematopoietic Stem Cell Transplantation, Dmitriy Rogachev National Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Alexei Maschan
- Department of Hematopoietic Stem Cell Transplantation, Dmitriy Rogachev National Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Michael Maschan
- Department of Hematopoietic Stem Cell Transplantation, Dmitriy Rogachev National Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
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8
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Wang P, Qian X, Jiang W, Wang H, Wang Y, Zhou Y, Zhang Y, Huang Y, Zhai X. Cord Blood Transplantation for Very Early-Onset Inflammatory Bowel Disease Caused by Interleukin-10 Receptor Deficiency. J Clin Immunol 2024; 44:67. [PMID: 38372823 DOI: 10.1007/s10875-024-01669-x] [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: 11/06/2023] [Accepted: 02/06/2024] [Indexed: 02/20/2024]
Abstract
PURPOSE Interleukin-10 receptor (IL-10R) deficiency can result in life-threatening very early-onset inflammatory bowel disease (VEO-IBD). Umbilical cord blood transplantation (UCBT) is a curative therapy for patients with IL-10R deficiency. This study aimed to investigate the efficacy of UCBT in treating IL-10R deficiency and develop a predictive model based on pre-transplant factors. METHODS Eighty patients with IL-10R deficiency who underwent UCBT between July 2015 and April 2023 were retrospectively analyzed. Cox proportional hazards regression and random survival forest were used to develop a predictive model. RESULTS Median age at transplant was 13.0 months (interquartile range [IQR], 8.8-25.3 months). With a median follow-up time of 29.4 months (IQR, 3.2-57.1 months), the overall survival (OS) rate was 65.0% (95% confidence interval [CI], 55.3%-76.3%). The engraftment rate was 85% (95% CI, 77%-93%). The cumulative incidences of acute and chronic graft-versus-host disease were 48.2% (95% CI, 37.1%-59.4%) and 12.2% (95% CI, 4.7%-19.8%), respectively. VEO-IBD-associated clinical symptoms were resolved in all survivors. The multivariate analysis showed that IL-6 and stool occult blood were independent prognostic risk factors. The multivariate Cox proportional hazards regression model with stool occult blood, length- or height-for-age Z-score, medical history of sepsis, and cord blood total nucleated cells showed good discrimination ability, with a bootstrap concordance index of 0.767-0.775 in predicting OS. CONCLUSION Better inflammation control before transplantation and higher cord blood total nucleated cell levels can improve patient prognosis. The nomogram can successfully predict OS in patients with IL-10R deficiency undergoing UCBT.
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Affiliation(s)
- Ping Wang
- Department of Hematology/Oncology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China
| | - Xiaowen Qian
- Department of Hematology/Oncology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China
| | - Wenjin Jiang
- Department of Hematology/Oncology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China
| | - Hongsheng Wang
- Department of Hematology/Oncology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China
| | - Yuhuan Wang
- Department of Gastroenterology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China
| | - Ying Zhou
- Department of Gastroenterology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China
| | - Ye Zhang
- Department of Gastroenterology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China
| | - Ying Huang
- Department of Gastroenterology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China
| | - Xiaowen Zhai
- Department of Hematology/Oncology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China.
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9
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Eskandari SK, Revenich EGM, Pot DJ, de Boer F, Bierings M, van Spronsen FJ, van Hasselt PM, Lindemans CA, Lubout CMA. High-Dose ERT, Rituximab, and Early HSCT in an Infant with Wolman's Disease. N Engl J Med 2024; 390:623-629. [PMID: 38354141 DOI: 10.1056/nejmoa2313398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
Wolman's disease, a severe form of lysosomal acid lipase deficiency, leads to pathologic lipid accumulation in the liver and gut that, without treatment, is fatal in infancy. Although continued enzyme-replacement therapy (ERT) in combination with dietary fat restriction prolongs life, its therapeutic effect may wane over time. Allogeneic hematopoietic stem-cell transplantation (HSCT) offers a more definitive solution but carries a high risk of death. Here we describe an infant with Wolman's disease who received high-dose ERT, together with dietary fat restriction and rituximab-based B-cell depletion, as a bridge to early HSCT. At 32 months, the infant was independent of ERT and disease-free, with 100% donor chimerism in the peripheral blood.
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Affiliation(s)
- Siawosh K Eskandari
- From the Department of Metabolic Diseases, Beatrix Children's Hospital (S.K.E., F.B., F.J.S., C.M.A.L.), and the Department of Surgery (S.K.E.), University Medical Center (UMC) Groningen, Groningen, the Division of Pediatrics (E.G.M.R., M.B., P.M.H., C.A.L.) and the Department of Metabolic Diseases (P.M.H.), UMC Utrecht, and the Department of Stem Cell Transplantation, Princess Máxima Center for Pediatric Oncology (E.G.M.R., M.B., C.A.L.), Utrecht, and the Department of Pediatrics, Gelre Hospital, Apeldoorn (D.J.P.) - all in the Netherlands
| | - Elisabeth G M Revenich
- From the Department of Metabolic Diseases, Beatrix Children's Hospital (S.K.E., F.B., F.J.S., C.M.A.L.), and the Department of Surgery (S.K.E.), University Medical Center (UMC) Groningen, Groningen, the Division of Pediatrics (E.G.M.R., M.B., P.M.H., C.A.L.) and the Department of Metabolic Diseases (P.M.H.), UMC Utrecht, and the Department of Stem Cell Transplantation, Princess Máxima Center for Pediatric Oncology (E.G.M.R., M.B., C.A.L.), Utrecht, and the Department of Pediatrics, Gelre Hospital, Apeldoorn (D.J.P.) - all in the Netherlands
| | - Dirk J Pot
- From the Department of Metabolic Diseases, Beatrix Children's Hospital (S.K.E., F.B., F.J.S., C.M.A.L.), and the Department of Surgery (S.K.E.), University Medical Center (UMC) Groningen, Groningen, the Division of Pediatrics (E.G.M.R., M.B., P.M.H., C.A.L.) and the Department of Metabolic Diseases (P.M.H.), UMC Utrecht, and the Department of Stem Cell Transplantation, Princess Máxima Center for Pediatric Oncology (E.G.M.R., M.B., C.A.L.), Utrecht, and the Department of Pediatrics, Gelre Hospital, Apeldoorn (D.J.P.) - all in the Netherlands
| | - Foekje de Boer
- From the Department of Metabolic Diseases, Beatrix Children's Hospital (S.K.E., F.B., F.J.S., C.M.A.L.), and the Department of Surgery (S.K.E.), University Medical Center (UMC) Groningen, Groningen, the Division of Pediatrics (E.G.M.R., M.B., P.M.H., C.A.L.) and the Department of Metabolic Diseases (P.M.H.), UMC Utrecht, and the Department of Stem Cell Transplantation, Princess Máxima Center for Pediatric Oncology (E.G.M.R., M.B., C.A.L.), Utrecht, and the Department of Pediatrics, Gelre Hospital, Apeldoorn (D.J.P.) - all in the Netherlands
| | - Marc Bierings
- From the Department of Metabolic Diseases, Beatrix Children's Hospital (S.K.E., F.B., F.J.S., C.M.A.L.), and the Department of Surgery (S.K.E.), University Medical Center (UMC) Groningen, Groningen, the Division of Pediatrics (E.G.M.R., M.B., P.M.H., C.A.L.) and the Department of Metabolic Diseases (P.M.H.), UMC Utrecht, and the Department of Stem Cell Transplantation, Princess Máxima Center for Pediatric Oncology (E.G.M.R., M.B., C.A.L.), Utrecht, and the Department of Pediatrics, Gelre Hospital, Apeldoorn (D.J.P.) - all in the Netherlands
| | - Francjan J van Spronsen
- From the Department of Metabolic Diseases, Beatrix Children's Hospital (S.K.E., F.B., F.J.S., C.M.A.L.), and the Department of Surgery (S.K.E.), University Medical Center (UMC) Groningen, Groningen, the Division of Pediatrics (E.G.M.R., M.B., P.M.H., C.A.L.) and the Department of Metabolic Diseases (P.M.H.), UMC Utrecht, and the Department of Stem Cell Transplantation, Princess Máxima Center for Pediatric Oncology (E.G.M.R., M.B., C.A.L.), Utrecht, and the Department of Pediatrics, Gelre Hospital, Apeldoorn (D.J.P.) - all in the Netherlands
| | - Peter M van Hasselt
- From the Department of Metabolic Diseases, Beatrix Children's Hospital (S.K.E., F.B., F.J.S., C.M.A.L.), and the Department of Surgery (S.K.E.), University Medical Center (UMC) Groningen, Groningen, the Division of Pediatrics (E.G.M.R., M.B., P.M.H., C.A.L.) and the Department of Metabolic Diseases (P.M.H.), UMC Utrecht, and the Department of Stem Cell Transplantation, Princess Máxima Center for Pediatric Oncology (E.G.M.R., M.B., C.A.L.), Utrecht, and the Department of Pediatrics, Gelre Hospital, Apeldoorn (D.J.P.) - all in the Netherlands
| | - Caroline A Lindemans
- From the Department of Metabolic Diseases, Beatrix Children's Hospital (S.K.E., F.B., F.J.S., C.M.A.L.), and the Department of Surgery (S.K.E.), University Medical Center (UMC) Groningen, Groningen, the Division of Pediatrics (E.G.M.R., M.B., P.M.H., C.A.L.) and the Department of Metabolic Diseases (P.M.H.), UMC Utrecht, and the Department of Stem Cell Transplantation, Princess Máxima Center for Pediatric Oncology (E.G.M.R., M.B., C.A.L.), Utrecht, and the Department of Pediatrics, Gelre Hospital, Apeldoorn (D.J.P.) - all in the Netherlands
| | - Charlotte M A Lubout
- From the Department of Metabolic Diseases, Beatrix Children's Hospital (S.K.E., F.B., F.J.S., C.M.A.L.), and the Department of Surgery (S.K.E.), University Medical Center (UMC) Groningen, Groningen, the Division of Pediatrics (E.G.M.R., M.B., P.M.H., C.A.L.) and the Department of Metabolic Diseases (P.M.H.), UMC Utrecht, and the Department of Stem Cell Transplantation, Princess Máxima Center for Pediatric Oncology (E.G.M.R., M.B., C.A.L.), Utrecht, and the Department of Pediatrics, Gelre Hospital, Apeldoorn (D.J.P.) - all in the Netherlands
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10
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Satty AM, Klein E, Mauguen A, Kunvarjee B, Boelens JJ, Cancio M, Curran KJ, Kernan NA, Prockop SE, Scaradavou A, Spitzer B, Tamari R, Ruggiero J, Torok-Castanza J, Mehta PA, O'Reilly RJ, Boulad F. T-cell depleted allogeneic hematopoietic stem cell transplant for the treatment of Fanconi anemia and MDS/AML. Bone Marrow Transplant 2024; 59:23-33. [PMID: 37773270 DOI: 10.1038/s41409-023-02113-1] [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: 05/22/2023] [Revised: 09/11/2023] [Accepted: 09/19/2023] [Indexed: 10/01/2023]
Abstract
The only curative approach for myelodysplastic syndrome (MDS) or acute myeloid leukemia (AML) arising in patients with Fanconi anemia (FA) is allogeneic hematopoietic stem cell transplantation (HCT); however, HCT approaches are inconsistent and limited data on outcomes exist. We retrospectively evaluated outcomes of thirty patients with FA and MDS/AML who underwent first allogeneic HCT with a T-cell depleted (TCD) graft at our institution. Patients were transplanted on successive protocols with stepwise changes in cytoreduction and GVHD prophylaxis. All but two patients (93%) experienced durable hematopoietic engraftment. With median follow-up of 8.7 years, 5-year OS was 66.8% and DFS 53.8%. No significant differences in survival were found in patients with high-risk prognostic features (age ≥20 years, AML diagnosis, alternative donor graft) or when stratified by conditioning regimen. The 5-year cumulative incidences of relapse and NRM were 24.3% and 21.9%, respectively. NRM was higher in patients ≥20 years at HCT but did not otherwise differ. We herein demonstrate promising outcomes following allogeneic HCT for patients with FA and MDS/AML using TCD grafts, particularly in a cohort of high-risk patients with 50% ≥20 years and a majority receiving mismatched grafts. Future prospective studies are needed to compare this approach with other HCT platforms.
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Affiliation(s)
- Alexandra M Satty
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Elizabeth Klein
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Audrey Mauguen
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Binni Kunvarjee
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jaap Jan Boelens
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | - Maria Cancio
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | - Kevin J Curran
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | - Nancy A Kernan
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | - Susan E Prockop
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
- Dana Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA, USA
| | - Andromachi Scaradavou
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | - Barbara Spitzer
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | - Roni Tamari
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Julianne Ruggiero
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Parinda A Mehta
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Richard J O'Reilly
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | - Farid Boulad
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
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11
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Wang H, Wang N, Wang L, Du J, Li F, Shao Y, Peng B, Luan S, Wang L, Jin X, Gao C, Dou L, Liu D. Targeted dosing of anti-thymocyte globulin in adult unmanipulated haploidentical peripheral blood stem cell transplantation: A single-arm, phase 2 trial. Am J Hematol 2023; 98:1732-1741. [PMID: 37706580 DOI: 10.1002/ajh.27068] [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: 04/06/2023] [Revised: 07/14/2023] [Accepted: 08/09/2023] [Indexed: 09/15/2023]
Abstract
Anti-thymocyte globulin (ATG) is widely used in allogeneic hematopoietic stem cell transplantation to prevent severe graft-versus-host disease (GVHD) and graft failure. However, overexposure to ATG may increase cytomegalovirus (CMV), Epstein-Barr virus (EBV) reactivation, non-relapse mortality, and disease recurrence. To investigate the optimal dosing of ATG, we established a targeted dosing strategy based on ATG concentration monitoring for haploidentical peripheral blood stem cell transplantation (haplo-PBSCT). The aim of this phase 2 trial is to evaluate the safety and efficacy of the ATG-targeted dosing strategy in adult unmanipulated haplo-PBSCT. ATG was administered for 4 days (-5 days to -2 days) during conditioning. The ATG doses on -3 days and -2 days were adjusted by our dosing strategy to achieve the optimal ATG exposure. The primary endpoint was CMV reactivation on +180 days. Between December 2020 and January 2022, 66 haplo-PBSCT patients were enrolled and 63 of them were evaluable with a median follow-up of 632 days. The cumulative incidence of CMV reactivation was 36.7% and that of EBV was 58.7%. The 1-year disease-free survival was 82.5%, overall survival was 92.1%, and CD4+ T-cell reconstruction on +100 days was 76.8%. The most common severe regimen-associated toxicities (> grade 3) were infections (51.5%) and gastrointestinal toxicity (25.5%). A total of 102 haplo-PBSCT patients who received the conventional fixed ATG dose (cumulative 10 mg/kg) comprised historical control. The outcomes in historical control were inferior to those of phase 2 trial cohort (CMV reactivation: 70.8%, p < .001; EBV reactivation: 76.0%, p = .024; CD4 + T-cell reconstruction: 54.1%, p = .040). In conclusion, ATG-targeted dosing strategy reduced CMV/EBV reactivation and improved survival without increasing GVHD after haplo-PBSCT. These advantages may be associated with accelerated immune reconstitution.
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Affiliation(s)
- Haitao Wang
- Senior Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Nan Wang
- Medical School of Chinese PLA, Beijing, China
| | - Lili Wang
- Senior Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Jishan Du
- Medical School of Chinese PLA, Beijing, China
| | - Fei Li
- Senior Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | | | - Bo Peng
- Senior Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Songhua Luan
- Senior Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Lu Wang
- Senior Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xiangshu Jin
- Senior Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Chunji Gao
- Senior Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Liping Dou
- Senior Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Beijing, China
| | - Daihong Liu
- Senior Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Beijing, China
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12
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Liu X, Huang C, Cao X, Yang X, Li S, Jiang S, Lin W, Liu L, Ding X, Tang X, Miao L. A fully validated flow cytometry method to quantitatively analyze active rATG in human serum and its application in pharmacokinetic study for therapeutic drug monitoring. J Pharm Biomed Anal 2023; 234:115483. [PMID: 37454500 DOI: 10.1016/j.jpba.2023.115483] [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: 01/29/2023] [Revised: 05/14/2023] [Accepted: 05/23/2023] [Indexed: 07/18/2023]
Abstract
Rabbit anti-thymocyte globulin (rATG) has been widely used to prevent graft-versus-host disease (GvHD) after allogeneic hematopoietic stem cell transplantation (allo-HSCT). The therapeutic window of rATG is narrow, and it may increase the risk of relapse, viral reactivation, delayed immune reconstitution and GvHD when overexposed or underexposed. Therefore, a reliable method for detecting the rATG concentration in human serum by flow cytometry was established and fully validated for therapeutic drug monitoring. In this method, Jurkat T cells were used to capture active rATG in human serum, and PE-labeled donkey anti-rabbit IgG was used as a secondary antibody. The method showed good specificity, selectivity and excellent linearity at concentration of 0.00300-20.0 AU/mL. The intra- and interday precision values were all within 20% at four concentration levels for the analyte. The stock solutions of rATG showed no significant degradation after storage at ambient temperature for 8 h and at - 80 °C for 481 days. No significant degradation of rATG in serum was observed at ambient temperature for 6 h, during six freezethaw cycles and at - 80 °C for at least 373 days. This method was fully validated and successfully applied to monitor active rATG concentration in serum of patients with haploid-identical hematopoietic stem cell transplantation.
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Affiliation(s)
- Xiaoxue Liu
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Chenrong Huang
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xuanqi Cao
- National Clinical Research Center for Hematologic Diseases, The First Affiliated Hospital of Soochow University, Jiangsu, China
| | - Xiao Yang
- National Clinical Research Center for Hematologic Diseases, The First Affiliated Hospital of Soochow University, Jiangsu, China
| | - Sijia Li
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
| | | | - Wang Lin
- Suzhou Vocational Health College, Suzhou, China
| | - Linsheng Liu
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiaoliang Ding
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiaowen Tang
- National Clinical Research Center for Hematologic Diseases, The First Affiliated Hospital of Soochow University, Jiangsu, China.
| | - Liyan Miao
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China; Institute for Interdisciplinary Drug Research and Translational Sciences, Soochow University, Suzhou, China; College of Pharmaceutical Sciences, Soochow University, Suzhou, China.
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13
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Borrill R, Poulton K, Wynn R. Immunology of cord blood T-cells favors augmented disease response during clinical pediatric stem cell transplantation for acute leukemia. Front Pediatr 2023; 11:1232281. [PMID: 37780051 PMCID: PMC10534014 DOI: 10.3389/fped.2023.1232281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 08/22/2023] [Indexed: 10/03/2023] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) has been an important and efficacious treatment for acute leukemia in children for over 60 years. It works primarily through the graft-vs.-leukemia (GVL) effect, in which donor T-cells and other immune cells act to eliminate residual leukemia. Cord blood is an alternative source of stem cells for transplantation, with distinct biological and immunological characteristics. Retrospective clinical studies report superior relapse rates with cord blood transplantation (CBT), when compared to other stem cell sources, particularly for patients with high-risk leukemia. Xenograft models also support the superiority of cord blood T-cells in eradicating malignancy, when compared to those derived from peripheral blood. Conversely, CBT has historically been associated with an increased risk of transplant-related mortality (TRM) and morbidity, particularly from infection. Here we discuss clinical aspects of CBT, the unique immunology of cord blood T-cells, their role in the GVL effect and future methods to maximize their utility in cellular therapies for leukemia, honing and harnessing their antitumor properties whilst managing the risks of TRM.
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Affiliation(s)
- Roisin Borrill
- Blood and Marrow Transplant Unit, Royal Manchester Children’s Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, School of Biological Sciences, Lydia Becker Institute of Immunology and Inflammation, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Kay Poulton
- Transplantation Laboratory, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Robert Wynn
- Blood and Marrow Transplant Unit, Royal Manchester Children’s Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
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14
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Troullioud Lucas AG, Boelens JJ, Prockop SE, Curran KJ, Bresters D, Kollen W, Versluys B, Bierings MB, Archer A, Davis E, Klein E, Kernan NA, Lindemans CA, Scaradavou A. Excellent leukemia control after second hematopoietic cell transplants with unrelated cord blood grafts for post-transplant relapse in pediatric patients. Front Oncol 2023; 13:1221782. [PMID: 37649924 PMCID: PMC10465242 DOI: 10.3389/fonc.2023.1221782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 07/24/2023] [Indexed: 09/01/2023] Open
Abstract
Background Patients with leukemia relapse after allogeneic hematopoietic cell transplant (HCT) have poor survival due to toxicity and disease progression. A second HCT often offers the only curative treatment. Methods We retrospectively reviewed our bi-institutional experience (MSKCC-USA; Utrecht-NL) with unrelated cord blood transplantation (CBT) for treatment of post-transplant relapse. Overall survival (OS) and event-free survival (EFS) were evaluated using the Kaplan-Meier method, treatment-related mortality (TRM) and relapse were evaluated using the competing risk method by Fine-Gray. Results Twenty-six patients age < 21 years received a second (n=24) or third (n=2) HCT with CB grafts during the period 2009-2021. Median age at first HCT (HCT1) was 11.5 (range: 0.9-17.7) years and all patients received myeloablative cytoreduction. Median time from HCT1 to relapse was 12.8 (range 5.5-189) months. At CBT, median patient age was 13.5 (range 1.4-19.1) years. Diagnoses were AML: 13; ALL: 4, MDS: 5, JMML: 2; CML: 1; mixed phenotype acute leukemia: 1. Sixteen patients (62%) were in advanced stage, either CR>2 or with active disease. Median time from HCT1 to CBT was 22.2 (range 7-63.2) months. All patients engrafted after CBT. Thirteen patients developed acute GvHD; 7 had grade III or IV. With a median survivor follow-up of 46.6 (range 17.4-155) months, 3-year OS was 69.2% (95% CI 53.6-89.5%) and 3-year EFS was 64.9% (95% CI 48.8-86.4%). Eight patients died, 3 of AML relapse and 5 due to toxicity (respiratory failure [n=4], GvHD [n=1]) at a median time of 7.7 (range 5.9-14.4) months after CBT. Cumulative incidence of TRM at 3 years was 19.2% (95% CI 4.1-34.4%). Notably, all TRM events occurred in patients transplanted up to 2015; no toxicity-related deaths were seen in the 16 patients who received CBT after 2015. Cumulative incidence of relapse was 15.9% (95% CI 1.6-30.2%) at 3 years, remarkably low for these very high-risk patients. Conclusions Survival was very encouraging following CB transplants in pediatric patients with recurrent leukemia after first HCT, and TRM has been low over the last decade. CBT needs to be strongly considered as a relatively safe salvage therapy option for post-transplant relapse.
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Affiliation(s)
- Alexandre G. Troullioud Lucas
- Department of Pediatrics, Transplantation and Cellular Therapies Service, MSK Kids, Memorial Sloan Kettering Cancer Center, New York, NY, United States
- Department of Stem Cell Transplantation, Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, United States
| | - Jaap Jan Boelens
- Department of Pediatrics, Transplantation and Cellular Therapies Service, MSK Kids, Memorial Sloan Kettering Cancer Center, New York, NY, United States
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, United States
| | - Susan E. Prockop
- Dana Farber/Boston Children’s Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, United States
| | - Kevin J. Curran
- Department of Pediatrics, Transplantation and Cellular Therapies Service, MSK Kids, Memorial Sloan Kettering Cancer Center, New York, NY, United States
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, United States
| | - Dorine Bresters
- Department of Stem Cell Transplantation, Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
- Division of Pediatrics, University Medical Center Utrecht, Utrecht, Netherlands
| | - Wouter Kollen
- Department of Stem Cell Transplantation, Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
- Division of Pediatrics, University Medical Center Utrecht, Utrecht, Netherlands
| | - Birgitta Versluys
- Department of Stem Cell Transplantation, Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
- Division of Pediatrics, University Medical Center Utrecht, Utrecht, Netherlands
| | - Marc B. Bierings
- Department of Stem Cell Transplantation, Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
- Division of Pediatrics, University Medical Center Utrecht, Utrecht, Netherlands
| | - Anne Archer
- Department of Pediatrics, Transplantation and Cellular Therapies Service, MSK Kids, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Eric Davis
- Department of Pediatrics, Transplantation and Cellular Therapies Service, MSK Kids, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Elizabeth Klein
- Department of Pediatrics, Transplantation and Cellular Therapies Service, MSK Kids, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Nancy A. Kernan
- Department of Pediatrics, Transplantation and Cellular Therapies Service, MSK Kids, Memorial Sloan Kettering Cancer Center, New York, NY, United States
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, United States
| | - Caroline A. Lindemans
- Department of Stem Cell Transplantation, Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
- Division of Pediatrics, University Medical Center Utrecht, Utrecht, Netherlands
| | - Andromachi Scaradavou
- Department of Pediatrics, Transplantation and Cellular Therapies Service, MSK Kids, Memorial Sloan Kettering Cancer Center, New York, NY, United States
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, United States
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15
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Zelikson V, Sabo R, Serrano M, Aqeel Y, Ward S, Al Juhaishi T, Aziz M, Krieger E, Simmons G, Roberts C, Reed J, Buck G, Toor A. Allogeneic haematopoietic cell transplants as dynamical systems: influence of early-term immune milieu on long-term T-cell recovery. Clin Transl Immunology 2023; 12:e1458. [PMID: 37457614 PMCID: PMC10345185 DOI: 10.1002/cti2.1458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 01/11/2023] [Accepted: 06/26/2023] [Indexed: 07/18/2023] Open
Abstract
Objectives Immune recovery following haematopoietic cell transplantation (HCT) functions as a dynamical system. Reducing the duration of intense immune suppression and augmenting antigen presentation has the potential to optimise T-cell reconstitution, potentially influencing long-term outcomes. Methods Based on donor-derived T-cell recovery, 26 patients were adaptively randomised between mycophenolate mofetil (MMF) administered for 30-day post-transplant with filgrastim for cytokine support (MMF30 arm, N = 11), or MMF given for 15 days with sargramostim (MMF15 arm, N = 15). All patients underwent in vivo T-cell depletion with 5.1 mg kg-1 antithymocyte globulin (administered over 3 days, Day -9 through to Day -7) and received reduced intensity 450 cGy total body irradiation (3 fractions on Day -1 and Day 0). Patients underwent HLA-matched related and unrelated donor haematopoietic cell transplantation (HCT). Results Clinical outcomes were equivalent between the two groups. The MMF15 arm demonstrated superior T-cell, as well as T-cell subset recovery and a trend towards superior T-cell receptor (TCR) diversity in the first month with this difference persisting through the first year. T-cell repertoire recovery was more rapid and sustained, as well as more diverse in the MMF15 arm. Conclusion The long-term superior immune recovery in the MMF15 arm, administered GMCSF, is consistent with a disproportionate impact of early interventions in HCT. Modifying the 'immune-milieu' following allogeneic HCT is feasible and may influence long-term T-cell recovery.
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Affiliation(s)
- Viktoriya Zelikson
- Department of Internal MedicineVirginia Commonwealth UniversityRichmondVAUSA
| | - Roy Sabo
- Department of BiostatisticsVirginia Commonwealth UniversityRichmondVAUSA
| | - Myrna Serrano
- Department of Microbiology and ImmunologyVirginia Commonwealth UniversityRichmondVAUSA
| | - Younus Aqeel
- Department of Internal MedicineVirginia Commonwealth UniversityRichmondVAUSA
| | - Savannah Ward
- Department of Internal MedicineVirginia Commonwealth UniversityRichmondVAUSA
| | - Taha Al Juhaishi
- Department of Internal MedicineVirginia Commonwealth UniversityRichmondVAUSA
| | - May Aziz
- Department of PharmacyVirginia Commonwealth UniversityRichmondVAUSA
| | - Elizabeth Krieger
- Department of PediatricsVirginia Commonwealth UniversityRichmondVAUSA
| | - Gary Simmons
- Department of Internal MedicineVirginia Commonwealth UniversityRichmondVAUSA
| | - Catherine Roberts
- Department of Internal MedicineVirginia Commonwealth UniversityRichmondVAUSA
| | - Jason Reed
- Department of PhysicsVirginia Commonwealth UniversityRichmondVAUSA
| | - Gregory Buck
- Department of BiostatisticsVirginia Commonwealth UniversityRichmondVAUSA
| | - Amir Toor
- Department of Internal MedicineVirginia Commonwealth UniversityRichmondVAUSA
- Lehigh Valley Topper Cancer InstituteAllentownPAUSA
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16
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Al-Antary ET, Caverly M, Buck S, Chandra S, Savaşan S. Delayed but successful T-cell immune reconstitution following umbilical cord blood transplantation conditioned with thymoglobulin alone in IL-7Rα-mutated SCID. Pediatr Blood Cancer 2023; 70:e30137. [PMID: 36518062 DOI: 10.1002/pbc.30137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 11/10/2022] [Accepted: 11/14/2022] [Indexed: 12/23/2022]
Affiliation(s)
- Eman T Al-Antary
- Division of Hematology/Oncology, Chidren's Hospital of Michigan, Detroit, Michigan, USA.,Department of Pediatrics, Central Michigan University College of Medicine, Mt Clemons, Michigan, USA.,Division of Hematology/Oncology, Pediatric Blood and Marrow Transplantation Program, Barbara Ann Karmanos Cancer Center, Children's Hospital of Michigan, Detroit, Michigan, USA
| | - Mary Caverly
- Division of Hematology/Oncology, Pediatric Blood and Marrow Transplantation Program, Barbara Ann Karmanos Cancer Center, Children's Hospital of Michigan, Detroit, Michigan, USA
| | - Steve Buck
- Division of Hematology/Oncology, Flow Cytometry Laboratory, Children's Hospital of Michigan, Detroit, Michigan, USA
| | - Sharat Chandra
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio, USA
| | - Süreyya Savaşan
- Division of Hematology/Oncology, Chidren's Hospital of Michigan, Detroit, Michigan, USA.,Department of Pediatrics, Central Michigan University College of Medicine, Mt Clemons, Michigan, USA.,Division of Hematology/Oncology, Pediatric Blood and Marrow Transplantation Program, Barbara Ann Karmanos Cancer Center, Children's Hospital of Michigan, Detroit, Michigan, USA.,Division of Hematology/Oncology, Flow Cytometry Laboratory, Children's Hospital of Michigan, Detroit, Michigan, USA
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17
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Forbes Satter LR, Martinez C. The earlier, the better: RAG-deficient transplants. Blood 2023; 141:686-687. [PMID: 36795451 DOI: 10.1182/blood.2022018715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
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18
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Klein OR, Bonfim C, Abraham A, Ruggeri A, Purtill D, Cohen S, Wynn R, Russell A, Sharma A, Ciccocioppo R, Prockop S, Boelens JJ, Bertaina A. Transplant for non-malignant disorders: an International Society for Cell & Gene Therapy Stem Cell Engineering Committee report on the role of alternative donors, stem cell sources and graft engineering. Cytotherapy 2023; 25:463-471. [PMID: 36710227 DOI: 10.1016/j.jcyt.2022.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 12/17/2022] [Accepted: 12/19/2022] [Indexed: 01/30/2023]
Abstract
Hematopoietic stem cell transplantation (HSCT) is curative for many non-malignant disorders. As HSCT and supportive care technologies improve, this life-saving treatment may be offered to more and more patients. With the development of new preparative regimens, expanded alternative donor availability, and graft manipulation techniques, there are many options when choosing the best regimen for patients. Herein the authors review transplant considerations, transplant goals, conditioning regimens, donor choice, and graft manipulation strategies for patients with non-malignant disorders undergoing HSCT.
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Affiliation(s)
- Orly R Klein
- Division of Hematology, Oncology and Stem Cell Transplant and Regenerative Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA.
| | - Carmem Bonfim
- Pediatric Blood and Marrow Transplantation Division and Pele Pequeno Principe Research Institute, Hospital Pequeno Principe, Curitiba, Brazil
| | - Allistair Abraham
- Center for Cancer and Immunology Research, Cell Enhancement and Technologies for Immunotherapy, Children's National Hospital, Washington, DC, USA
| | - Annalisa Ruggeri
- Istituto di Ricovero e Cura a Carattere Scientifico Ospedale San Raffaele, Milan, Italy
| | - Duncan Purtill
- Department of Hematology, Fiona Stanley Hospital, Perth, Australia
| | - Sandra Cohen
- Université de Montréal and Maisonneuve Rosemont Hospital, Montréal, Canada
| | - Robert Wynn
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Athena Russell
- Center for Cellular Immunotherapies, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Akshay Sharma
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Rachele Ciccocioppo
- Gastroenterology Unit, Department of Medicine, Azienda Ospedaliera Universitaria Integrata Policlinico G.B. Rossi and University of Verona, Verona, Italy
| | - Susan Prockop
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, USA
| | - Jaap Jan Boelens
- Stem Cell Transplantation and Cellular Therapies, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Pediatrics, Weill Cornell Medical College of Cornell University, New York, New York, USA
| | - Alice Bertaina
- Division of Hematology, Oncology and Stem Cell Transplant and Regenerative Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
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19
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Grasso AG, Simeone R, Maestro A, Zanon D, Maximova N. Pre-Transplant Total Lymphocyte Count Determines Anti-Thymocyte Globulin Exposure, Modifying Graft-versus-Host Disease Incidence and Post-Transplant Thymic Restoration: A Single-Center Retrospective Study. J Clin Med 2023; 12:jcm12020730. [PMID: 36675660 PMCID: PMC9860924 DOI: 10.3390/jcm12020730] [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: 11/25/2022] [Revised: 01/01/2023] [Accepted: 01/09/2023] [Indexed: 01/18/2023] Open
Abstract
The use of anti-thymocyte globulin (ATG) as part of conditioning to prevent graft-versus-host disease (GVHD) may severely impair immune reconstitution (IR). We analyzed relationships between ATG exposure, the recipient lymphocyte count, IR, and transplant outcome. We retrospectively reviewed patients aged ≤ 18 years who underwent allogeneic HSCT between April 2005 and April 2020. The outcomes of interest included the incidence of GVHD, overall survival (OS), and IR. IR was analyzed through thymic magnetic resonance imaging (MRI) and by quantifying T CD4+ and recent thymic emigrants (RTEs). The ATG-exposed group was split into a low ATG/lymphocyte ratio subgroup (ratio < 0.01) and a high ATG/lymphocyte ratio subgroup (ratio > 0.01). The low ratio subgroup had a higher incidence of GVHD (29 [59%] vs. 7 [16.6%]) but a better IR in both laboratory and MRI imaging assessments (p < 0.0001). The median thymic volume in the low ratio subgroup was significantly higher (14.7 cm3 vs. 4.5 cm3, p < 0.001). This was associated with a better OS and lower transplant-related mortality (TRM) (80.4% vs. 58.0%, p = 0.031) and (13.1% vs. 33.0%, p = 0.035). An individualized approach to ATG dosing allows for the obtainment of rapid thymic reconstitution and the best transplant-related outcomes.
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Affiliation(s)
- Antonio Giacomo Grasso
- Institute for Maternal and Child Health—IRCCS Burlo Garofolo, Via dell’Istria 65/1, 34137 Trieste, Italy
| | - Roberto Simeone
- Department of Transfusion Medicine, ASUGI, Piazza dell’Ospitale 1, 34125 Trieste, Italy
| | - Alessandra Maestro
- Institute for Maternal and Child Health—IRCCS Burlo Garofolo, Via dell’Istria 65/1, 34137 Trieste, Italy
| | - Davide Zanon
- Institute for Maternal and Child Health—IRCCS Burlo Garofolo, Via dell’Istria 65/1, 34137 Trieste, Italy
| | - Natalia Maximova
- Institute for Maternal and Child Health—IRCCS Burlo Garofolo, Via dell’Istria 65/1, 34137 Trieste, Italy
- Correspondence: ; Tel.: +39-040-378-5276-565; Fax: +39-040-378-5494
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20
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Gudauskaitė G, Kairienė I, Ivaškienė T, Rascon J, Mobasheri A. Therapeutic Perspectives for the Clinical Application of Umbilical Cord Hematopoietic and Mesenchymal Stem Cells: Overcoming Complications Arising After Allogeneic Hematopoietic Stem Cell Transplantation. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2023; 1409:111-126. [PMID: 35995905 DOI: 10.1007/5584_2022_726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
This review focuses on the therapeutic features of umbilical cord blood (UCB) cells as a source for allogeneic hematopoietic stem cell transplantation (aHSCT) in adult and child populations to treat malignant and nonmalignant hematologic diseases, genetic disorders, or pathologies of the immune system, when standard treatment (e.g., chemotherapy) is not effective or clinically contraindicated. In this article, we summarize the immunological properties and the advantages and disadvantages of using UCB stem cells and discuss a variety of treatment outcomes using different sources of stem cells from different donors both in adults and pediatric population. We also highlight the critical properties (total nucleated cell dose depending on HLA compatibility) of UCB cells that reach better survival rates, reveal the advantages of double versus single cord blood unit transplantation, and present recommendations from the most recent studies. Moreover, we summarize the mechanism of action and potential benefit of mesenchymal umbilical cord cells and indicate the most common posttransplantation complications.
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Affiliation(s)
- Greta Gudauskaitė
- State Research Institute Centre for Innovative Medicine, Vilnius, Lithuania
| | - Ignė Kairienė
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Tatjana Ivaškienė
- State Research Institute Centre for Innovative Medicine, Vilnius, Lithuania
| | - Jelena Rascon
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Ali Mobasheri
- State Research Institute Centre for Innovative Medicine, Vilnius, Lithuania.
- Research Unit of Medical Imaging, Physics and Technology, Faculty of Medicine, University of Oulu, Oulu, Finland.
- Department of Joint Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.
- World Health Organization Collaborating Centre for Public Health Aspects of Musculoskeletal Health and Aging, Université de Liège, Liège, Belgium.
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21
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Irie M, Niihori T, Nakano T, Suzuki T, Katayama S, Moriya K, Niizuma H, Suzuki N, Saito-Nanjo Y, Onuma M, Rikiishi T, Sato A, Hangai M, Hiwatari M, Ikeda J, Tanoshima R, Shiba N, Yuza Y, Yamamoto N, Hashii Y, Kato M, Takita J, Maeda M, Aoki Y, Imaizumi M, Sasahara Y. Reduced-intensity conditioning is effective for allogeneic hematopoietic stem cell transplantation in infants with MECOM-associated syndrome. Int J Hematol 2022; 117:598-606. [PMID: 36515795 PMCID: PMC10063491 DOI: 10.1007/s12185-022-03505-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 12/01/2022] [Accepted: 12/01/2022] [Indexed: 12/15/2022]
Abstract
Mutations in the MECOM encoding EVI1 are observed in infants who have radioulnar synostosis with amegakaryocytic thrombocytopenia. MECOM-associated syndrome was proposed based on clinical heterogeneity. Allogeneic hematopoietic stem cell transplantation (HSCT) is a curative treatment for progressive bone marrow failure. However, data regarding allogeneic HSCT for this rare disease are limited. We retrospectively assessed overall survival, conditioning regimen, regimen-related toxicities and long-term sequelae in six patients treated with allogeneic HSCT. All patients received a reduced-intensity conditioning (RIC) regimen consisting of fludarabine, cyclophosphamide or melphalan, and rabbit anti-thymocyte globulin and/or low-dose total body/thoracic-abdominal/total lymphoid irradiation, followed by allogeneic bone marrow or cord blood transplantation from unrelated donors between 4 and 18 months of age. All patients survived and achieved stable engraftment and complete chimerization with the donor type. Moreover, no patient experienced severe regimen-related toxicities, and only lower grades of acute graft-versus-host disease were observed. Three patients treated with low-dose irradiation had relatively short stature compared to three patients not treated with irradiation. Therefore, allogeneic HSCT with RIC is an effective and feasible treatment for infants with MECOM-associated syndrome. Future studies are needed to evaluate the use of low-dose irradiation to avoid risks of other long-term sequelae.
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Affiliation(s)
- Masahiro Irie
- Department of Pediatrics, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-Ku, Sendai, Miyagi, 980-8574, Japan
| | - Tetsuya Niihori
- Department of Medical Genetics, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Tomohiro Nakano
- Department of Pediatrics, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-Ku, Sendai, Miyagi, 980-8574, Japan
| | - Tasuku Suzuki
- Department of Pediatrics, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-Ku, Sendai, Miyagi, 980-8574, Japan
| | - Saori Katayama
- Department of Pediatrics, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-Ku, Sendai, Miyagi, 980-8574, Japan
| | - Kunihiko Moriya
- Department of Pediatrics, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-Ku, Sendai, Miyagi, 980-8574, Japan
| | - Hidetaka Niizuma
- Department of Pediatrics, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-Ku, Sendai, Miyagi, 980-8574, Japan
| | - Nobu Suzuki
- Department of Hematology and Oncology, Miyagi Children's Hospital, Miyagi, Japan
| | - Yuka Saito-Nanjo
- Department of Hematology and Oncology, Miyagi Children's Hospital, Miyagi, Japan
| | - Masaei Onuma
- Department of Hematology and Oncology, Miyagi Children's Hospital, Miyagi, Japan
| | - Takeshi Rikiishi
- Department of Hematology and Oncology, Miyagi Children's Hospital, Miyagi, Japan
| | - Atsushi Sato
- Department of Hematology and Oncology, Miyagi Children's Hospital, Miyagi, Japan
| | - Mayumi Hangai
- Department of Pediatrics, The University of Tokyo, Tokyo, Japan
| | - Mitsuteru Hiwatari
- Department of Pediatrics, The University of Tokyo, Tokyo, Japan.,Department of Pediatrics, School of Medicine, Teikyo University, Tokyo, Japan
| | - Junji Ikeda
- Department of Pediatrics, Yokohama City University Graduate School of Medicine, Kanagawa, Japan
| | - Reo Tanoshima
- Department of Pediatrics, Yokohama City University Graduate School of Medicine, Kanagawa, Japan
| | - Norio Shiba
- Department of Pediatrics, Yokohama City University Graduate School of Medicine, Kanagawa, Japan
| | - Yuki Yuza
- Department of Hematology and Oncology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Nobuyuki Yamamoto
- Department of Pediatrics, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Yoshiko Hashii
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan.,Department of Pediatrics, Osaka International Cancer Institute, Osaka, Japan
| | - Motohiro Kato
- Department of Pediatrics, The University of Tokyo, Tokyo, Japan.,Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
| | - Junko Takita
- Department of Pediatrics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Miho Maeda
- Department of Pediatrics, Nippon Medical School, Tokyo, Japan
| | - Yoko Aoki
- Department of Medical Genetics, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Masue Imaizumi
- Department of Hematology and Oncology, Miyagi Children's Hospital, Miyagi, Japan
| | - Yoji Sasahara
- Department of Pediatrics, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-Ku, Sendai, Miyagi, 980-8574, Japan.
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22
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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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23
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Outcome of human umbilical cord blood stem cell transplantation (CBT) for acute myeloid leukemia in patients achieving first complete remission after one versus two induction courses: a study from the Acute Leukemia Working Party of the European Society for Blood and Marrow Transplantation (EBMT). Bone Marrow Transplant 2022; 57:1514-1519. [PMID: 35773347 DOI: 10.1038/s41409-022-01742-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 06/09/2022] [Accepted: 06/13/2022] [Indexed: 11/09/2022]
Abstract
We compared transplantation outcomes of adult patients with AML that underwent cord blood transplantation (CBT) in CR1 following 1 versus 2 induction courses. Study included 325 patients, 243 (75%) with 1 and 82 (25%) with 2 induction courses. Engraftment was lower for patients achieving CR1 after 1 vs. 2 induction courses: 91% vs. 99% (p = 0.02). Incidence of acute GVHD was similar, 38% and 36% (p = 0.81), as was 2-year chronic GVHD at 23.4% and 27.5%, respectively (p = 0.65). Two-year non-relapse mortality (NRM), relapse incidence (RI), leukemia-free survival (LFS), overall survival (OS) and GVHD-free, relapse-free survival (GRFS) were not statistically different between patients achieving CR1 with 1 vs. 2 induction courses with 23% vs. 24% (p = 0.87), 25% vs. 30% (p = 0.4), 52% vs. 46% (p = 0.3), 59% vs. 50% (p = 0.2), and 44% vs. 41% (p = 0.66), respectively. Results were confirmed by multivariable analysis, NRM (hazard ratio (HR) = 1.1; 95% CI, 0.6-1.8, p = 0.7), RI (HR = 1.4; 95% CI, 0.9-2.3, p = 0.1), LFS (HR = 1.3; 95% CI, 0.9-1.8, p = 0.2), OS (HR = 1.3; 95% CI, 0.9-1.9, p = 0.1), and GRFS (HR = 1.1; 95% CI, 0.8-1.5, p = 0.5). Overall, outcomes of AML patients undergoing CBT in CR1 achieved after 1 or 2 induction courses are similar.
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24
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Fan ZY, Han TT, Zuo W, Zhao XS, Chang YJ, Lv M, Mo XD, Sun YQ, Zhang YY, Wang Y, Xu LP, Zhang XH, Liu KY, Huang XJ, Zhao XY. CMV infection combined with acute GVHD associated with poor CD8+ T-cell immune reconstitution and poor prognosis post-HLA-matched allo-HSCT. Clin Exp Immunol 2022; 208:332-339. [PMID: 35551362 PMCID: PMC9226149 DOI: 10.1093/cei/uxac047] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 04/30/2022] [Accepted: 05/07/2022] [Indexed: 11/14/2022] Open
Abstract
Cytomegalovirus (CMV) infection and acute graft-versus-host disease (aGVHD) are two major complications that contribute to a poor prognosis after hematopoietic stem cell transplantation (HSCT). Superior early immune reconstitution (IR) is associated with improved survival after HSCT. However, when all three factors, CMV infection, aGVHD, and IR, are concomitantly considered, the effects of the triple events on HSCT are still unknown and should be studied further. Thus we enrolled 185 patients who were diagnosed as hematological malignancies and treated with HLA-matched sibling transplantation (MST) between January 2010 and December 2014, of whom 83 were positive for CMV infection and 82 had aGVHD. Results showed that patients with both aGVHD and CMV infection had significantly higher non-relapse mortality (NRM), lower overall survival (OS), and delayed CD8+ T-cell IR. Multivariate analyses showed that both aGVHD combined with CMV infection and delayed CD8+ T-cell IR were independent risk factors for prognosis post-MST. Recurrent CMV infections are associated with poor CD8+ T-cell reconstitution. However, superior IR could protect against the negative effects of aGVHD and CMV infection on the transplant outcomes.
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Affiliation(s)
- Ze-Ying Fan
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Ting-Ting Han
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Wei Zuo
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Xiao-Su Zhao
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Ying-Jun Chang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Meng Lv
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Xiao-Dong Mo
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Yu-Qian Sun
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Yuan-Yuan Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Yu Wang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Lan-Ping Xu
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Xiao-Hui Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Kai-Yan Liu
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Xiao-Jun Huang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Xiang-Yu Zhao
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China.,Collaborative Innovation Center of Hematology, Beijing 100044, China
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25
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Dekker L, Sanders E, Lindemans CA, de Koning C, Nierkens S. Naive T Cells in Graft Versus Host Disease and Graft Versus Leukemia: Innocent or Guilty? Front Immunol 2022; 13:893545. [PMID: 35795679 PMCID: PMC9250980 DOI: 10.3389/fimmu.2022.893545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 05/18/2022] [Indexed: 11/13/2022] Open
Abstract
The outcome of allogeneic hematopoietic cell transplantation (allo-HCT) largely depends on the development and management of graft-versus-host disease (GvHD), infections, and the occurrence of relapse of malignancies. Recent studies showed a lower incidence of chronic GvHD and severe acute GvHD in patients receiving naive T cell depleted grafts compared to patients receiving complete T cell depleted grafts. On the other hand, the incidence of acute GvHD in patients receiving cord blood grafts containing only naive T cells is rather low, while potent graft-versus-leukemia (GvL) responses have been observed. These data suggest the significance of naive T cells as both drivers and regulators of allogeneic reactions. The naive T cell pool was previously thought to be a quiescent, homogenous pool of antigen-inexperienced cells. However, recent studies showed important differences in phenotype, differentiation status, location, and function within the naive T cell population. Therefore, the adequate recovery of these seemingly innocent T cells might be relevant in the imminent allogeneic reactions after allo-HCT. Here, an extensive review on naive T cells and their contribution to the development of GvHD and GvL responses after allo-HCT is provided. In addition, strategies specifically directed to stimulate adequate reconstitution of naive T cells while reducing the risk of GvHD are discussed. A better understanding of the relation between naive T cells and alloreactivity after allo-HCT could provide opportunities to improve GvHD prevention, while maintaining GvL effects to lower relapse risk.
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Affiliation(s)
- Linde Dekker
- Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
| | - Evy Sanders
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht, Netherlands
| | | | - Coco de Koning
- Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Stefan Nierkens
- Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht, Netherlands
- *Correspondence: Stefan Nierkens,
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26
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Viral infection in hematopoietic stem cell transplantation: an International Society for Cell & Gene Therapy Stem Cell Engineering Committee review on the role of cellular therapy in prevention and treatment. Cytotherapy 2022; 24:884-891. [PMID: 35705447 DOI: 10.1016/j.jcyt.2022.05.010] [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: 12/30/2021] [Revised: 04/13/2022] [Accepted: 05/22/2022] [Indexed: 11/20/2022]
Abstract
Despite recent advances in the field of HSCT, viral infections remain a frequent causeof morbidity and mortality among HSCT recipients. Adoptive transfer of viral specific T cells has been successfully used both as prophylaxis and treatment of viral infections in immunocompromised HSCT recipients. Increasingly, precise risk stratification of HSCT recipients with infectious complications should incorporate not only pretransplant clinical criteria, but milestones of immune reconstitution as well. These factors can better identify those at highest risk of morbidity and mortality and identify a population of HSCT recipients in whom adoptive therapy with viral specific T cells should be considered for either prophylaxis or second line treatment early after inadequate response to first line antiviral therapy. Broadening these approaches to improve outcomes for transplant recipients in countries with limited resources is a major challenge. While the principles of risk stratification can be applied, early detection of viral reactivation as well as treatment is challenging in regions where commercial PCR assays and antiviral agents are not readily available.
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27
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Miltiadous O, Waters NR, Andrlová H, Dai A, Nguyen CL, Burgos da Silva M, Lindner S, Slingerland J, Giardina P, Clurman A, Armijo GK, Gomes ALC, Lakkaraja M, Maslak P, Scordo M, Shouval R, Staffas A, O'Reilly R, Taur Y, Prockop S, Boelens JJ, Giralt S, Perales MA, Devlin SM, Peled JU, Markey KA, van den Brink MRM. Early intestinal microbial features are associated with CD4 T-cell recovery after allogeneic hematopoietic transplant. Blood 2022; 139:2758-2769. [PMID: 35061893 PMCID: PMC9074404 DOI: 10.1182/blood.2021014255] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/23/2021] [Indexed: 11/20/2022] Open
Abstract
Low intestinal microbial diversity is associated with poor outcomes after allogeneic hematopoietic cell transplantation (HCT). Using 16S rRNA sequencing of 2067 stool samples and flow cytometry data from 2370 peripheral blood samples drawn from 894 patients who underwent allogeneic HCT, we have linked features of the early post-HCT microbiome with subsequent immune cell recovery. We examined lymphocyte recovery and microbiota features in recipients of both unmodified and CD34-selected allografts. We observed that fecal microbial diversity was an independent predictor of CD4 T-cell count 3 months after HCT in recipients of a CD34-selected allograft, who are dependent on de novo lymphopoiesis for their immune recovery. In multivariate models using clinical factors and microbiota features, we consistently observed that increased fecal relative abundance of genus Staphylococcus during the early posttransplant period was associated with worse CD4 T-cell recovery. Our observations suggest that the intestinal bacteria, or the factors they produce, can affect early lymphopoiesis and the homeostasis of allograft-derived T cells after transplantation.
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Affiliation(s)
- Oriana Miltiadous
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Nicholas R Waters
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center (MSKCC), New York, NY
| | - Hana Andrlová
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center (MSKCC), New York, NY
| | - Anqi Dai
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center (MSKCC), New York, NY
| | - Chi L Nguyen
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center (MSKCC), New York, NY
| | - Marina Burgos da Silva
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center (MSKCC), New York, NY
| | - Sarah Lindner
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center (MSKCC), New York, NY
| | - John Slingerland
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center (MSKCC), New York, NY
| | - Paul Giardina
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center (MSKCC), New York, NY
| | - Annelie Clurman
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center (MSKCC), New York, NY
| | - Gabriel K Armijo
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center (MSKCC), New York, NY
| | - Antonio L C Gomes
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center (MSKCC), New York, NY
| | - Madhavi Lakkaraja
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Pediatrics, Weill Cornell Medicine, New York, NY
| | - Peter Maslak
- Immunology Laboratory Service, Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Michael Scordo
- Department of Medicine, Weill Cornell Medical College, New York, NY
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Roni Shouval
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Anna Staffas
- Sahlgrenska Center for Cancer Research, Department of Microbiology and Immunology, Institute of Biomedicine, University of Gothenburg, Sweden
- Clinical Genetics and Genomics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Richard O'Reilly
- Stem Cell Transplant and Cellular Therapy Service, Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Ying Taur
- Department of Medicine, Weill Cornell Medical College, New York, NY
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Susan Prockop
- Department of Pediatrics, Weill Cornell Medicine, New York, NY
- Stem Cell Transplant and Cellular Therapy Service, Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jaap Jan Boelens
- Department of Pediatrics, Weill Cornell Medicine, New York, NY
- Stem Cell Transplant and Cellular Therapy Service, Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Sergio Giralt
- Department of Medicine, Weill Cornell Medical College, New York, NY
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Miguel-Angel Perales
- Department of Medicine, Weill Cornell Medical College, New York, NY
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Sean M Devlin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jonathan U Peled
- Department of Medicine, Weill Cornell Medical College, New York, NY
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kate A Markey
- Department of Medicine, Weill Cornell Medical College, New York, NY
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Clinical Research Division, Fred Hutchinson Cancer Research Center (FHCRC), Seattle, WA; and
- Division of Medical Oncology, University of Washington, Seattle, WA
| | - Marcel R M van den Brink
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center (MSKCC), New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
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28
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Veldkamp SR, Jansen MHA, Swart JF, Lindemans CA. Case Report: Lessons Learned From Subsequent Autologous and Allogeneic Hematopoietic Stem Cell Transplantations in a Pediatric Patient With Relapsing Polychondritis. Front Immunol 2022; 13:812927. [PMID: 35359992 PMCID: PMC8960202 DOI: 10.3389/fimmu.2022.812927] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 02/17/2022] [Indexed: 12/29/2022] Open
Abstract
Background Autologous hematopoietic stem cell transplantation (autoHSCT) is increasingly being recognized as a treatment option for severe refractory autoimmune diseases (AD). However, efficacy is hampered by high relapse rates. In contrast, allogeneic HSCT (alloHSCT) has high potential to cure AD, but is associated with significant morbidity and mortality, and data in AD are limited. Experience with autoHSCT in relapsing polychondritis, a rare episodic inflammatory disorder characterized by destruction of cartilage, is scarce and alloHSCT has not been described before. Case Presentation Here, we present a case of a 9-year-old girl who was diagnosed with relapsing polychondritis, with severe airway involvement requiring a tracheostomy. The disease proved to be steroid-dependent and refractory to a wide array of disease-modifying anti-rheumatic drugs and biologicals. After an autoHSCT procedure, the disease became inactive for a short period of time, until the patient experienced a relapse after 31 days, accompanied by repopulation of effector/memory CD8+ T cells. Because of persistent inflammation and serious steroid toxicity, including severe osteoporosis, growth restriction, and excessive weight gain, the patient was offered an alloHSCT. She experienced transient antibody-mediated immune events post-alloHSCT, which subsided after rituximab. She ultimately developed a balanced immune reconstitution and is currently still in long-term disease remission, 8 years after alloHSCT. Conclusion This case adds to the few existing reports on autoHSCT in relapsing polychondritis and gives new insights in its pathogenesis, with a possible role for CD8+ T cells. Moreover, it is the first report of successful alloHSCT as a treatment for children with this severe autoimmune disease.
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Affiliation(s)
- Saskia R Veldkamp
- Center for Translational Immunology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands
| | - Marc H A Jansen
- Pediatric Rheumatology and Immunology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands
| | - Joost F Swart
- Pediatric Rheumatology and Immunology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands
| | - Caroline A Lindemans
- Pediatric Rheumatology and Immunology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands.,Blood and Bone Marrow Transplantation, Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
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29
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Bertaina A, Abraham A, Bonfim C, Cohen S, Purtill D, Ruggeri A, Weiss D, Wynn R, Boelens JJ, Prockop S. An ISCT Stem Cell Engineering Committee Position Statement on Immune Reconstitution: the importance of predictable and modifiable milestones of immune reconstitution to transplant outcomes. Cytotherapy 2022; 24:385-392. [PMID: 35331394 DOI: 10.1016/j.jcyt.2021.09.011] [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: 06/21/2021] [Revised: 09/14/2021] [Accepted: 09/18/2021] [Indexed: 11/19/2022]
Abstract
Allogeneic stem cell transplantation is a potentially curative therapy for some malignant and non-malignant disease. There have been substantial advances since the approaches first introduced in the 1970s, and the development of approaches to transplant with HLA incompatible or alternative donors has improved access to transplant for those without a fully matched donor. However, success is still limited by morbidity and mortality from toxicity and imperfect disease control. Here we review our emerging understanding of how reconstitution of effective immunity after allogeneic transplant can protect from these events and improve outcomes. We provide perspective on milestones of immune reconstitution that are easily measured and modifiable.
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Affiliation(s)
- Alice Bertaina
- Center for Cancer and Immunology Research, CETI, Children's National Hospital, Washington, District of Columbia, USA
| | - Allistair Abraham
- Division of Hematology, Oncology, Stem Cell Transplantation and Regenerative Medicine, Department of Pediatrics, Stanford University, Stanford, California, USA
| | - Carmem Bonfim
- Pediatric Bone Marrow Transplantation Division, Hospital Pequeno Principe, Curitiba, Brazil
| | - Sandra Cohen
- Université de Montréal and Maisonneuve Rosemont Hospital, Montréal, Québec, Canada
| | - Duncan Purtill
- Department of Haematology, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | | | | | - Robert Wynn
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Jaap Jan Boelens
- Stem Cell Transplantation and Cellular Therapies, Memorial Sloan Kettering Cancer Center, and Department of Pediatrics, Weill Cornell Medical College of Cornell University, New York, New York, USA
| | - Susan Prockop
- Stem Cell Transplant Program, Division of Hematology/Oncology Boston Children's Hospital and Department of Pediatric Oncology, Dana Farber Cancer Institute.
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30
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Wang H, Zhao Y, Fang S, Wang L, Peng B, Yang J, Wang N, Du J, Li F, Jin X, Luan S, Wu X, Dou L, Liu D. Optimal Active Anti-Thymocyte Globulin Exposure Associated with Minimum Risk of Virus Reactivation and Comparable Acute Graft-Versus-Host Disease Under Adult Myeloablative Haploidentical Peripheral Blood Stem Cell Transplantation. Transplant Cell Ther 2022; 28:332.e1-332.e10. [PMID: 35314377 DOI: 10.1016/j.jtct.2022.03.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 03/13/2022] [Accepted: 03/15/2022] [Indexed: 11/15/2022]
Abstract
Anti-thymocyte globulin (ATG) is often included in the conditioning regimen to prevent graft-versus-host disease (GVHD) in allogeneic hematopoietic cell transplantation (allo-HCT). However, the risk of virus reactivation increases significantly. We conducted a single-center prospective study to identify the optimal ATG exposure that ensures engraftment, effectively prevents acute GVHD, and reduces the risk of virus reactivation without increasing relapse of malignant diseases in haploidentical peripheral blood stem cell transplantation (haplo-PBSCT). From September 2018 to June 2020, 106 patients (median age, 32 years) with malignant hematological diseases who received haplo-PBSCT for the first time were enrolled. All patients received 10 mg/kg rabbit ATG (thymoglobulin) divided for 4 days (days -5 to -2). Pre-transplant, post-transplant, and total areas under the concentration-time curve (AUCs) of active ATG were calculated. Total AUC of active ATG was shown to be the best predictor for virus reactivation and acute GVHD of grades II to IV or grades III and IV. The optimal total AUC range of active ATG was 100 to 148.5 UE/mL/day. The median time was 14 versus 13 days (P = .184) for myeloid engraftment and 13 versus 13 days (P = .263) for platelet engraftment in the optimal and non-optimal AUC groups, respectively. The optimal AUC group showed a lower cumulative incidence of cytomegalovirus (CMV) reactivation and persistent CMV viremia than the non-optimal AUC group: 60.6% (95% confidence interval [CI], 48.3%-73.1%) versus 77.1% (95% CI, 64.5%-87.7%; P = .016) and 31.5% (95% CI, 21.2%-45.3%) versus 56.3% (95% CI, 42.9%-70.4%; P = .007), respectively. The cumulative incidence of persistent Epstein-Barr virus (EBV) viremia in the optimal AUC group was significantly lower than the non-optimal total AUC group: 33.1% (95% CI, 22.5%-46.8%) versus 52.6% (95% CI, 39.3%-67.2%; P = .048). However, there was no difference in EBV reactivation (P = .752). Similar outcomes were observed for grade II to IV and grade III and IV acute GVHD between the two groups: 48.6% (95% CI, 36.8%-62.0%) versus 37.0% (95% CI, 24.8%-52.5%; P = .113) and 10.4% (95% CI, 4.8%-21.7%) versus 4.2% (95% CI, 1.0%-15.6%; P = .234, respectively. Relapse, non-relapse mortality, and disease-free survival demonstrated no significant differences between the two groups. But, overall survival at 2 years tended to increase in the optimal AUC group: 75.7% (95% CI, 62.4%-84.8%) versus 57.8% (95% CI, 42.4%-70.4%; P = .061). These data support an optimal active ATG exposure of 110 to 148.5 UE/mL/day in haplo-PBSCT. Individualized dosing of ATG in allo-HCT might reduce the risk of virus reactivation and effectively prevent acute GVHD simultaneously.
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Affiliation(s)
- HaiTao Wang
- Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China; Chinese PLA General Hospital, Beijing, China
| | | | - Shu Fang
- Chinese PLA General Hospital, Beijing, China; School of Medicine, Nankai University, Tianjin, China
| | - LiLi Wang
- Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Bo Peng
- Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | | | - Nan Wang
- Chinese PLA General Hospital, Beijing, China
| | - JiShan Du
- Chinese PLA General Hospital, Beijing, China
| | - Fei Li
- Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - XiangShu Jin
- Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - SongHua Luan
- Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - XiaoXiong Wu
- Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - LiPing Dou
- Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China; Chinese PLA General Hospital, Beijing, China; The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China.
| | - DaiHong Liu
- Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China; Chinese PLA General Hospital, Beijing, China.
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31
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Meesters-Ensing J, Admiraal R, Ebskamp L, Lacna A, Boelens JJ, Lindemans CA, Nierkens S. Therapeutic Drug Monitoring of Anti-Thymocyte Globulin in Allogeneic Stem Cell Transplantation: Proof of Concept. Front Pharmacol 2022; 13:828094. [PMID: 35370695 PMCID: PMC8974913 DOI: 10.3389/fphar.2022.828094] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 02/25/2022] [Indexed: 01/08/2023] Open
Abstract
Anti-thymocyte globulin (ATG), a polyclonal antibody, is used in allogeneic hematopoietic cell transplantation (HCT) to prevent graft-vs.-host-disease (GvHD) and graft failure (GF). Overexposure to ATG leads to poor early T-cell recovery, which is associated with viral infections and poor survival. Patients with severe inflammation are at high risk for GF and GvHD, and may have active infections warranting swift T-cell recovery. As ATG exposure may be critical in these patients, individualized dosing combined with therapeutic drug monitoring (TDM) may improve outcomes. We describe the individualized dosing approach, an optimal sampling scheme, the assay to measure the active fraction of ATG, and the workflow to perform TDM. Using a previously published population pharmacokinetic (PK) model, we determine the dose to reach optimal exposures associated with low GvHD and rejection, and at the same time promote T-cell recovery. Based on an optimal sampling scheme, peak and trough samples are taken during the first 3 days of once-daily dosing. The fraction of ATG able to bind to T-cells (active ATG) is analyzed using a bio-assay in which Jurkat cells are co-cultured with patient’s plasma and the binding is quantified using flow cytometry. TDM is performed based on these ATG concentrations on the third day of dosing; subsequent doses can be adjusted based on the expected area under the curve. We show that individualized ATG dosing with TDM is feasible. This approach is unique in the setting of antibody treatment and may result in better immune reconstitution post-HCT and subsequently better survival chances.
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Affiliation(s)
| | - R. Admiraal
- Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
- Department of Pediatrics, University Medical Center Utrecht, Utrecht, Netherlands
- *Correspondence: R. Admiraal,
| | - L. Ebskamp
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht, Netherlands
| | - A. Lacna
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht, Netherlands
| | - J. J. Boelens
- Stem Cell Transplantation and Cellular Therapies, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - C. A. Lindemans
- Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
- Department of Pediatrics, University Medical Center Utrecht, Utrecht, Netherlands
| | - S. Nierkens
- Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht, Netherlands
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32
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van der Stoep MYEC, Oostenbrink LVE, Bredius RGM, Moes DJAR, Guchelaar HJ, Zwaveling J, Lankester AC. Therapeutic Drug Monitoring of Conditioning Agents in Pediatric Allogeneic Stem Cell Transplantation; Where do We Stand? Front Pharmacol 2022; 13:826004. [PMID: 35330826 PMCID: PMC8940165 DOI: 10.3389/fphar.2022.826004] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/18/2022] [Indexed: 11/13/2022] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) is an established curative treatment that has significantly improved clinical outcome of pediatric patients with malignant and non-malignant disorders. This is partly because of the use of safer and more effective combinations of chemo- and serotherapy prior to HSCT. Still, complications due to the toxicity of these conditioning regimens remains a major cause of transplant-related mortality (TRM). One of the most difficult challenges to further improve HSCT outcome is reducing toxicity while maintaining efficacy. The use of personalized dosing of the various components of the conditioning regimen by means of therapeutic drug monitoring (TDM) has been the topic of interest in the last decade. TDM could play an important role, especially in children who tend to show greater pharmacokinetic variability. However, TDM should only be performed when it has clear added value to improve clinical outcome or reduce toxicity. In this review, we provide an overview of the available evidence for the relationship between pharmacokinetic parameters and clinical outcome or toxicities of the most commonly used conditioning agents in pediatric HSCT.
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Affiliation(s)
- M. Y. Eileen C. van der Stoep
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, Netherlands
- *Correspondence: M. Y. Eileen C. van der Stoep,
| | - Lisa V. E. Oostenbrink
- Willem-Alexander Children’s Hospital, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Robbert G. M. Bredius
- Willem-Alexander Children’s Hospital, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Dirk Jan A. R. Moes
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, Netherlands
| | - Henk-Jan Guchelaar
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, Netherlands
| | - Juliette Zwaveling
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, Netherlands
| | - Arjan C. Lankester
- Willem-Alexander Children’s Hospital, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
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33
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Drozdov D, Petermann K, Dougoud S, Oberholzer S, Held L, Güngör T, Hauri-Hohl M. Dynamics of recent thymic emigrants in pediatric recipients of allogeneic hematopoetic stem cell transplantation. Bone Marrow Transplant 2022; 57:620-626. [PMID: 35140350 DOI: 10.1038/s41409-022-01594-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 01/11/2022] [Accepted: 01/19/2022] [Indexed: 11/09/2022]
Abstract
After allogeneic hematopoietic stem cell transplantation (allo-HSCT), the recurrence of recent thymic emigrants (RTE) and self-tolerant T cells indicate normalized thymic function. From 2008 to 2019, we retrospectively analyzed the RTE-reconstitution rate and the minimal time to reach normal age-specific first percentiles for CD31+CD45RA+CD4+T cells in 199 pediatric patients after allo-HSCT for various malignant and non-malignant diseases. The impact of clinically significant graft-versus-host disease (GvHD), age at transplantation, underlying disease and cumulative area under the curve of busulfan on RTE-reemergence was assessed in multivariable longitudinal analysis. RTE-reconstitution (coefficient -0.24, 95% CI -0.33 to -0.14, p < 0.001) was slowed down by GvHD and the time to reach P1 was significantly longer (Event Time Ratio 1.49, 95% CI 1.25 to 1.78, p < 0.001). Older age at transplantation was also associated with a slower RTE-reconstitution (coefficient -0.028, 95% CI -0.04 to -0.02, p < 0.001) and time to reach P1 was significantly longer (Event Time Ratio 1.03, 95% CI 1.02 to 1.05, p < 0.001). RTE-reconstitution velocity was not influenced by underlying disease or cumulative busulfan exposure. In summary, duration until thymic reactivation was independent of both conditioning intensity and underlying disease and was negatively influenced by older age and GvHD.
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Affiliation(s)
- Daniel Drozdov
- Division of Stem Cell Transplantation and Children's Research Center, University Children's Hospital Zurich, University of Zürich, Zürich, Switzerland. .,Division of Oncology-Hematology, Department of Pediatrics, Kantonsspital Aarau, Aarau, Switzerland.
| | - Katrin Petermann
- Epidemiology, Biostatistics, and Prevention Institute (EBPI), University of Zürich, Zürich, Switzerland.,Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Svetlana Dougoud
- Department of Cardiology, University Hospital Zürich, University of Zürich, Zürich, Switzerland
| | - Sibylle Oberholzer
- Division of Stem Cell Transplantation and Children's Research Center, University Children's Hospital Zurich, University of Zürich, Zürich, Switzerland
| | - Leonhard Held
- Epidemiology, Biostatistics, and Prevention Institute (EBPI), University of Zürich, Zürich, Switzerland
| | - Tayfun Güngör
- Division of Stem Cell Transplantation and Children's Research Center, University Children's Hospital Zurich, University of Zürich, Zürich, Switzerland
| | - Mathias Hauri-Hohl
- Division of Stem Cell Transplantation and Children's Research Center, University Children's Hospital Zurich, University of Zürich, Zürich, Switzerland
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34
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Admiraal R, Nierkens S, Bierings MB, Bredius RGM, van Vliet I, Jiang Y, Lopez-Yurda M, Versluijs AB, Zwaan CM, Lindemans CA, Boelens JJ. Individualised dosing of anti-thymocyte globulin in paediatric unrelated allogeneic haematopoietic stem-cell transplantation (PARACHUTE): a single-arm, phase 2 clinical trial. Lancet Haematol 2022; 9:e111-e120. [DOI: 10.1016/s2352-3026(21)00375-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/23/2021] [Accepted: 11/25/2021] [Indexed: 12/13/2022]
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35
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Individualized Dosage Optimization for Myeloablative Conditioning before Unrelated Cord Blood Transplantation in a Diamond–Blackfan Anemia Patient with Germline RPL11 Mutation: A Case Study. Processes (Basel) 2022. [DOI: 10.3390/pr10020201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/10/2022] Open
Abstract
Unrelated cord blood transplantation (CBT) for Diamond–Blackfan anemia (DBA), a systemic ribosomopathy affecting the disposition of conditioning agents, has resulted in outcomes inferior to those by transplantations from matched donors. We report the experience of the pharmacokinetics-guided myeloablative unrelated CBT in a DBA patient with a germline RPL11 mutation. The conditioning consisted of individualized dosing of fludarabine (based on weight and renal function with a target area under the curve (AUC) of 17.5 mg·h/L) and busulfan (based on therapeutic drug monitoring with a target AUC of 90 mg·h/L), as well as dosing and timing of thymoglobulin (based on body weight and pre-dose lymphocyte count to target pre-CBT AUC of 30.7 AU·day/mL and post-CBT AUC of 4.3 AU·day/mL, respectively). The pharmacokinetic measures resulted in a 27.5% reduction in busulfan and a 35% increase in fludarabine, as well as an over three-fold increase in thymoglobulin dosage with the start time changed to day-9 instead of day-2 compared to regular regimens. The transplantation resulted in rapid, complete, and sustained hematopoietic engraftment. The patient is now healthy over 3 years after CBT. A pharmacokinetics-guided individualized dosing strategy for conditioning might be a feasible option to improve the outcomes of DBA patients receiving unrelated myeloablative CBT.
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36
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The Role of γδ T Cells as a Line of Defense in Viral Infections after Allogeneic Stem Cell Transplantation: Opportunities and Challenges. Viruses 2022; 14:v14010117. [PMID: 35062321 PMCID: PMC8779492 DOI: 10.3390/v14010117] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 12/30/2021] [Accepted: 01/05/2022] [Indexed: 02/04/2023] Open
Abstract
In the complex interplay between inflammation and graft-versus-host disease (GVHD) after allogeneic stem cell transplantation (allo-HSCT), viral reactivations are often observed and cause substantial morbidity and mortality. As toxicity after allo-HSCT within the context of viral reactivations is mainly driven by αβ T cells, we describe that by delaying αβ T cell reconstitution through defined transplantation techniques, we can harvest the full potential of early reconstituting γδ T cells to control viral reactivations. We summarize evidence of how the γδ T cell repertoire is shaped by CMV and EBV reactivations after allo-HSCT, and their potential role in controlling the most important, but not all, viral reactivations. As most γδ T cells recognize their targets in an MHC-independent manner, γδ T cells not only have the potential to control viral reactivations but also to impact the underlying hematological malignancies. We also highlight the recently re-discovered ability to recognize classical HLA-molecules through a γδ T cell receptor, which also surprisingly do not associate with GVHD. Finally, we discuss the therapeutic potential of γδ T cells and their receptors within and outside the context of allo-HSCT, as well as the opportunities and challenges for developers and for payers.
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37
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Zhou X, Cai Y, Yang J, Tong Y, Qiu H, Huang C, Zhou K, Xu X, Niu J, Xia X, Zhang Y, Shen C, Wei Y, Song X, Wan L. Lower Absolute Lymphocyte Count Before Conditioning Predicts High Relapse Risk in Patients After Haploidentical Peripheral Blood Stem Cell Transplantation With Low Dose Anti-Thymocyte Globulin/Post-Transplant Cyclophosphamide for GvHD Prophylaxis. Cell Transplant 2022; 31:9636897221079739. [PMID: 35225024 PMCID: PMC8894976 DOI: 10.1177/09636897221079739] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Standard anti-thymocyte globulin (ATG) weight-based dosing often resulted in highly variable ATG exposure, which had profound effects on relapse and survival, especially in recipients with relatively low absolute lymphocyte count (ALC) before conditioning. Data regarding rabbit ATG pharmacokinetics and pharmacodynamics in the setting of HLA-haploidentical peripheral blood stem cell transplantation (haplo-PBSCT) is lacking. We conducted a retrospective study on 90 consecutive patients who underwent haplo-PBSCT with low dose rabbit ATG (5 mg/kg) plus low dose post-transplant cyclophosphamide (50 mg/kg) based regimen for graft-versus-host disease (GvHD) prophylaxis. We compared serum concentration of ATG and post-transplant results between patients with ALC<500/μl and ALC≥500/μl before conditioning. Patients with ALC<500/μl had higher ATG concentrations, delayed immune reconstitution, lower incidence of grade II-IV acute GvHD (0 vs. 19.42%, P = 0.043), higher risk of Epstein-Barr virus infection within 100 days post-transplant (47.78% vs. 22.22%, P = 0.020) and 1-year relapse rate (33.33% vs.11.59%, P = 0.041), and lower 1-year overall survival (OS) (52.38% vs.79.71%, P = 0.004), 1-year relapse free survival (RFS) (47.62% vs. 75.36% for RFS, P = 0.014), and 1-year GvHD free relapse-free survival (GRFS) (42.89% vs. 65.22%, P = 0.043). ALC<500/μl before conditioning was a significant poor risk factor for relapse, OS, RFS, and GRFS.
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Affiliation(s)
- Xiao Zhou
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Engineering Technology Research Center of Cell Therapy and Clinical Translation, Shanghai Science and Technology Committee (STCSM), Shanghai, China
| | - Yu Cai
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Engineering Technology Research Center of Cell Therapy and Clinical Translation, Shanghai Science and Technology Committee (STCSM), Shanghai, China
| | - Jun Yang
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Engineering Technology Research Center of Cell Therapy and Clinical Translation, Shanghai Science and Technology Committee (STCSM), Shanghai, China
| | - Yin Tong
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Engineering Technology Research Center of Cell Therapy and Clinical Translation, Shanghai Science and Technology Committee (STCSM), Shanghai, China
| | - Huiying Qiu
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Engineering Technology Research Center of Cell Therapy and Clinical Translation, Shanghai Science and Technology Committee (STCSM), Shanghai, China
| | - Chongmei Huang
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Engineering Technology Research Center of Cell Therapy and Clinical Translation, Shanghai Science and Technology Committee (STCSM), Shanghai, China
| | - Kun Zhou
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Engineering Technology Research Center of Cell Therapy and Clinical Translation, Shanghai Science and Technology Committee (STCSM), Shanghai, China
| | - Xiaowei Xu
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Engineering Technology Research Center of Cell Therapy and Clinical Translation, Shanghai Science and Technology Committee (STCSM), Shanghai, China
| | - Jiahua Niu
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Engineering Technology Research Center of Cell Therapy and Clinical Translation, Shanghai Science and Technology Committee (STCSM), Shanghai, China
| | - Xinxin Xia
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Engineering Technology Research Center of Cell Therapy and Clinical Translation, Shanghai Science and Technology Committee (STCSM), Shanghai, China
| | - Ying Zhang
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Engineering Technology Research Center of Cell Therapy and Clinical Translation, Shanghai Science and Technology Committee (STCSM), Shanghai, China
| | - Chang Shen
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Engineering Technology Research Center of Cell Therapy and Clinical Translation, Shanghai Science and Technology Committee (STCSM), Shanghai, China
| | - Yu Wei
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Engineering Technology Research Center of Cell Therapy and Clinical Translation, Shanghai Science and Technology Committee (STCSM), Shanghai, China
| | - Xianmin Song
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Engineering Technology Research Center of Cell Therapy and Clinical Translation, Shanghai Science and Technology Committee (STCSM), Shanghai, China
| | - Liping Wan
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Engineering Technology Research Center of Cell Therapy and Clinical Translation, Shanghai Science and Technology Committee (STCSM), Shanghai, China
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38
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B-cell depletion abrogates immune mediated cytopenia and rejection of cord blood transplantation in Hurler syndrome. Bone Marrow Transplant 2022; 57:38-42. [PMID: 34608276 PMCID: PMC8732280 DOI: 10.1038/s41409-021-01465-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 09/08/2021] [Indexed: 02/08/2023]
Abstract
Umbilical cord blood is the preferred donor cell source for children with Inherited Metabolic disorders undergoing Hematopoietic Cell Transplant (HCT), and its use has been associated with improved "engrafted survival" and higher donor chimerism compared to other cell sources. However, as in other pediatric cord blood transplants for non-malignant disease, immune-mediated cytopenia and primary graft failure limit its use, and the latter remains the commonest cause of death following cord blood transplant for non-malignant disease. We have previously shown an association between immune-mediated cytopenia and graft failure in inherited metabolic diseases suggesting that both immune-mediated cytopenia and graft failure could be mediated by antibodies from the residual recipient B cells. Since rituximab is effective in depletion of B cells and management of refractory immune-mediated cytopenia following HCT, we have added rituximab to the conditioning regimen. We studied 57 patients in 2 centers who received myeloablative conditioning for cord blood transplant in Hurler syndrome, and report a significant improvement in event-free survival with reduced incidence of graft failure and without any evidence of immune-mediated cytopenia in those patients that had received rituximab.
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39
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The impact of GVHD on outcomes after adult single cord blood transplantation in European and Japanese populations. Bone Marrow Transplant 2022; 57:57-64. [PMID: 34635798 DOI: 10.1038/s41409-021-01479-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 09/09/2021] [Accepted: 09/21/2021] [Indexed: 02/08/2023]
Abstract
The impact of GVHD and graft-versus-leukemia effect in unrelated cord blood transplantation (UCBT) is controversial. In the Eurocord/ALWP EBMT and JSTCT/JDCHCT collaborative study, we evaluated the impact of GVHD on UCBT outcomes in Japanese and European registries. A total of 3,690 adult patients with acute leukemia who received their first single UCBT were included. A multivariate analysis of overall survival (OS) revealed a positive impact of grade II acute GVHD compared with grade 0-I GVHD, in the Japanese cohort (hazard ratio (HR), 0.81; P = 0.001), and an adverse impact in the European cohort (HR, 1.37; P = 0.007). A negative impact of grade III-IV acute GVHD on OS was observed regardless of registries. In the analysis of relapse, a positive impact of grade II acutes GVHD compared with grade 0-I GVHD was observed only in the Japanese cohort, regardless of disease risk. The positive impact of limited chronic GVHD on OS was observed only in the Japanese cohort. In conclusion, a positive impact of mild GVHD after a single UCBT was observed only in the Japanese cohort. This could explain the ethnic difference in UCBT outcomes and might contribute to the preference usage of UCBT in Japan.
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40
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Combined Analysis of Early CD4 + T Cell Counts and CMV Serostatus May Improve CMV Risk Assessment after Allogeneic Hematopoietic Cell Transplantation. Cells 2021; 10:cells10123318. [PMID: 34943824 PMCID: PMC8699729 DOI: 10.3390/cells10123318] [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: 10/28/2021] [Revised: 11/14/2021] [Accepted: 11/19/2021] [Indexed: 11/26/2022] Open
Abstract
The incidence and severity of viral complications after cellular therapy are highly variable. Recent publications describe relevant interactions between the human Cytomegalovirus (CMV) and host immunity in recipients of allogeneic hematopoietic cell transplantation (HCT). Although immune monitoring is routinely performed in HCT patients, validated cut-off levels correlating with transplant outcomes such as survival or CMV reactivation are mostly limited to day +100, which is later than the median time for CMV reactivation in the absence of medical prophylaxis. To address this gap in early risk assessment, we applied an unsupervised machine learning technique based on clustering of day +30 CD4+ helper T cell count data, and identified relevant cut-off levels within the diverse spectrum of early CD4+ reconstitution. These clusters were stratified for CMV recipient serostatus to identify early risk groups that predict clinical HCT outcome. Indeed, the new risk groups predicted subsequent clinical events such as NRM, OS, and high CMV peak titers better than the most established predictor, i.e., the positive CMV recipient serostatus (R+). More specifically, patients from the R+/low CD4+ subgroup strongly associated with high CMV peak titers and increased 3-year NRM (subdistribution hazard ratio (SHR) 10.1, 95% CI 1.38–73.8, p = 0.023), while patients from the R-/very high CD4+ subgroup showed comparable NRM risks (SHR 9.57, 95% CI 1.12–81.9, p = 0.039) without such an association. In short, our study established novel cut-off levels for early CD4+ T cells via unsupervised learning and supports the integration of host cellular immunity into clinical risk-assessment after HCT in the context of CMV reactivation.
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Clofarabine-fludarabine-busulfan in HCT for pediatric leukemia: an effective, low toxicity, TBI-free conditioning regimen. Blood Adv 2021; 6:1719-1730. [PMID: 34781362 PMCID: PMC8941455 DOI: 10.1182/bloodadvances.2021005224] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 10/10/2021] [Indexed: 11/20/2022] Open
Abstract
CloFluBu-conditioning results in encouraging EFS for ALL and AML, with low TRM, limited incidence of aGvHD and GF, and no cases of VOD. Minimal residual disease status prior to transplantation impacted outcome due to increased relapse risk in both AML and ALL patients.
We prospectively studied clofarabine-fludarabine-busulfan (CloFluBu)-conditioning in allogeneic hematopoietic cell therapy (HCT) for lymphoid and myeloid malignancies and hypothesized that CloFluBu provides a less toxic alternative to conventional conditioning regimens, with adequate antileukemic activity. All patients receiving their first HCT, from 2011-2019, were included and received CloFluBu. The primary endpoint was event-free survival (EFS). Secondary endpoints were overall survival (OS), graft-versus-host disease (GvHD)-relapse-free survival (GRFS), treatment-related mortality (TRM), cumulative incidence of relapse (CIR), acute and chronic GvHD (aGvHD and cGvHD), and veno-occlusive disease (VOD). Cox proportional hazard and Fine and Gray competing-risk models were used for data analysis. One hundred fifty-five children were included: 60 acute lymphoid leukemia (ALL), 69 acute myeloid leukemia (AML), and 26 other malignancies (mostly MDS-EB). The median age was 9.7 (0.5 to 18.6) years. Estimated 2-year EFS was 72.0% ± 6.0 in ALL patients, and 62.4% ± 6.0 in AML patients. TRM in the whole cohort was 11.0% ± 2.6, incidence of aGvHD 3 to 4 at 6 months was 12.3% ± 2.7, extensive cGvHD at 2 years was 6.4% ± 2.1. Minimal residual disease-positivity prior to HCT was associated with higher CIR, both in ALL and AML. CloFluBu showed limited toxicity and encouraging EFS. CloFluBu is a potentially less toxic alternative to conventional conditioning regimens. Randomized prospective studies are needed.
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42
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Guidelines for Pediatric Unrelated Cord Blood Transplantation-Unique Considerations. Transplant Cell Ther 2021; 27:968-972. [PMID: 34571212 DOI: 10.1016/j.jtct.2021.09.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 09/19/2021] [Indexed: 11/24/2022]
Abstract
Cord blood (CB) is the stem cell source of choice for approximately 30% of pediatric patients undergoing hematopoietic cell transplantation. Cord blood is readily available and is a particularly appealing stem cell source for patients who lack appropriate HLA-matched related or unrelated donors. Pediatric cord blood transplant (CBT) recipients have low rates of disease relapse in the malignant setting and very low rates of chronic graft-versus-host disease (GVHD). In addition, CB has unique properties that make it the stem cell source of choice for some nonmalignant conditions such as metabolic disorders. This review provides evidence-based and experience-based pediatric-specific guidelines for CBT including considerations for infectious disease management, CB unit selection and infusion, conditioning regimen selection, and GVHD management. In addition, it covers unique bedside considerations for pediatric patients and CB banking. In concert with the other topic specific CB guidelines previously published in this series, it provides a comprehensive overview of the clinical management of pediatric CBT.
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43
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Paving the Way for Immunotherapy in Pediatric Acute Myeloid Leukemia: Current Knowledge and the Way Forward. Cancers (Basel) 2021; 13:cancers13174364. [PMID: 34503174 PMCID: PMC8431730 DOI: 10.3390/cancers13174364] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 08/22/2021] [Accepted: 08/26/2021] [Indexed: 11/17/2022] Open
Abstract
Simple Summary Immunotherapy may be an attractive treatment option to increase survival, and to reduce treatment-related side effects, for children with acute myeloid leukemia (AML). While immunotherapies have shown successes in many cancer types, the development and subsequent clinical implementation have proven difficult in pediatric AML. To expedite the development of immunotherapy, it will be crucial to understand which pediatric AML patients are likely to respond to immunotherapies. Emerging research in solid malignancies has shown that the number and phenotype of immune cells in the tumor microenvironment is predictive of response to several types of immunotherapies. Such a predictive model may also be applicable for AML and, thus, knowledge on the immune cells infiltrating the bone marrow environment is needed. Here, we discuss the current state of knowledge on these infiltrating immune cells in pediatric AML, as well as ongoing immunotherapy trials, and provide suggestions concerning the way forward. Abstract Immunotherapeutic agents may be an attractive option to further improve outcomes and to reduce treatment-related toxicity for pediatric AML. While improvements in outcome have been observed with immunotherapy in many cancer types, immunotherapy development and implementation into patient care for both adult and pediatric AML has been hampered by an incomplete understanding of the bone marrow environment and a paucity of tumor-specific antigens. Since only a minority of patients respond in most immunotherapy trials across different cancer types, it will be crucial to understand which children with AML are likely to respond to or may benefit from immunotherapies. Immune cell profiling efforts hold promise to answer this question, as illustrated by the development of predictive scores in solid cancers. Such information on the number and phenotype of immune cells during current treatment regimens will be pivotal to generate hypotheses on how and when to intervene with immunotherapy in pediatric AML. In this review, we discuss the current understanding of the number and phenotype of immune cells in the bone marrow in pediatric AML, ongoing immunotherapy trials and how comprehensive immune profiling efforts may pave the way for successful clinical trials (and, ultimately, implementation into patient care).
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Liu H, Pan W, Tang C, Tang Y, Wu H, Yoshimura A, Deng Y, He N, Li S. The methods and advances of adaptive immune receptors repertoire sequencing. Theranostics 2021; 11:8945-8963. [PMID: 34522220 PMCID: PMC8419057 DOI: 10.7150/thno.61390] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 06/09/2021] [Indexed: 12/13/2022] Open
Abstract
The adaptive immune response is a powerful tool, capable of recognizing, binding to, and neutralizing a vast number of internal and external threats via T or B lymphatic receptors with widespread sets of antigen specificities. The emergence of high-throughput sequencing technology and bioinformatics provides opportunities for research in the fields of life sciences and medicine. The analysis and annotation for immune repertoire data can reveal biologically meaningful information, including immune prediction, target antigens, and effective evaluation. Continuous improvements of the immunological repertoire sequencing methods and analysis tools will help to minimize the experimental and calculation errors and realize the immunological information to meet the clinical requirements. That said, the clinical application of adaptive immune repertoire sequencing requires appropriate experimental methods and standard analytical tools. At the population cell level, we can acquire the overview of cell groups, but the information about a single cell is not obtained accurately. The information that is ignored may be crucial for understanding the heterogeneity of each cell, gene expression and drug response. The combination of high-throughput sequencing and single-cell technology allows us to obtain single-cell information with low-cost and high-throughput. In this review, we summarized the current methods and progress in this area.
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Affiliation(s)
- Hongmei Liu
- Hunan Key Laboratory of Biomedical Nanomaterials and Devices, Hunan University of Technology, Zhuzhou 412007, China
| | - Wenjing Pan
- Hunan Key Laboratory of Biomedical Nanomaterials and Devices, Hunan University of Technology, Zhuzhou 412007, China
| | - Congli Tang
- State Key Laboratory of Bioelectronics, Southeast University, Nanjing 210096, China
| | - Yujie Tang
- State Key Laboratory of Bioelectronics, Southeast University, Nanjing 210096, China
| | - Haijing Wu
- Department of Dermatology, Second Xiangya Hospital, Central South University, Hu-nan Key Laboratory of Medical Epigenomics, Changsha, Hunan, China
| | - Akihiko Yoshimura
- Department of Microbiology and Immunology, Keio University School of Medicine, Tokyo, Japan
| | - Yan Deng
- Hunan Key Laboratory of Biomedical Nanomaterials and Devices, Hunan University of Technology, Zhuzhou 412007, China
| | - Nongyue He
- Hunan Key Laboratory of Biomedical Nanomaterials and Devices, Hunan University of Technology, Zhuzhou 412007, China
- State Key Laboratory of Bioelectronics, Southeast University, Nanjing 210096, China
| | - Song Li
- Hunan Key Laboratory of Biomedical Nanomaterials and Devices, Hunan University of Technology, Zhuzhou 412007, China
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Olson AL, Politikos I, Brunstein C, Milano F, Barker J, Hill JA. Guidelines for Infection Prophylaxis, Monitoring and Therapy in Cord Blood Transplantation. Transplant Cell Ther 2021; 27:359-362. [PMID: 33965172 DOI: 10.1016/j.jtct.2021.01.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 01/27/2021] [Indexed: 12/14/2022]
Abstract
As an alternative stem cell source, cord blood (CB) has many advantages. However, delayed engraftment, lack of transferred immunity, and a significant incidence of acute graft-versus-host disease renders CB transplant (CBT) recipients at high risk of infectious complications. This guidance written by CBT and infectious disease experts outlines evidence-based recommendations for the prevention and treatment of opportunistic infections in adult patients undergoing CBT. Topics addressed include bacterial, fungal, viral, pneumocystis jirovcii and toxoplasmosis prophylaxis, suggested PCR monitoring for viruses, therapy for the most commonly encountered infections after CBT. We review key concepts including the recent important role of letermovir in the prevention of CMV reactivation. In instances where there is a paucity of data, practice recommendations are provided, including the duration of antimicrobial prophylaxis.
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Affiliation(s)
- Amanda L Olson
- The University of Texas MD Anderson Cancer Center, Houston, Texas.
| | | | | | - Fillipo Milano
- The Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Juliet Barker
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Joshua A Hill
- The Fred Hutchinson Cancer Research Center, Seattle, Washington
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Metheny L, Politikos I, Ballen KK, Rezvani AR, Milano F, Barker JN, Brunstein CG. Guidelines for Adult Patient Selection and Conditioning Regimens in Cord Blood Transplant Recipients with Hematologic Malignancies and Aplastic Anemia. Transplant Cell Ther 2021; 27:286-291. [PMID: 33836867 DOI: 10.1016/j.jtct.2020.11.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 11/10/2020] [Indexed: 11/16/2022]
Abstract
For cord blood transplantation (CBT), appropriate patient and conditioning regimen selection is necessary to achieve long-term disease-free survival. This review aims to provide comprehensive guidelines on these issues using evidence from the literature and experience at dedicated CBT centers. Topics include patient and disease characteristics that make CBT a good or poor choice and a review of outcomes in commonly used conditioning regimens in CBT. This is accompanied with recommendations on regimen intensity based on disease, organ function, and patient performance status and age. In addition, the use of antithymocyte globulin in CBT is discussed, as is the choice of conditioning in aplastic anemia patients who have access to acceptable CB units.
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Affiliation(s)
- Leland Metheny
- Stem Cell Transplant Program, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, Ohio.
| | - Ioannis Politikos
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Karen K Ballen
- University of Virginia Cancer Center, Charlottesville, Virginia
| | - Andrew R Rezvani
- Division of Blood & Marrow Transplantation, Stanford University, Stanford, California
| | - Filippo Milano
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Juliet N Barker
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Claudio G Brunstein
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
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CD4+ T-cell reconstitution predicts survival outcomes after acute graft-versus-host-disease: a dual-center validation. Blood 2021; 137:848-855. [PMID: 33150379 DOI: 10.1182/blood.2020007905] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 10/04/2020] [Indexed: 11/20/2022] Open
Abstract
Acute graft-versus-host-Disease (aGVHD) is a major cause of morbidity and mortality after allogeneic hematopoietic cell transplantation (HCT). We previously showed that early CD4+ T-cell immune reconstitution (IR; CD4+ IR) predicts survival after HCT. Here, we studied the relation between CD4+ IR and survival in patients developing aGVHD. Pediatric patients undergoing first allogeneic HCT at University Medical Center Utrecht (UMC)/Princess Máxima Center (PMC) or Memorial Sloan Kettering Cancer Center (MSK) were included. Primary outcomes were nonrelapse mortality (NRM) and overall survival (OS), stratified for aGVHD and CD4+ IR, defined as ≥50 CD4+ T cells per μL within 100 days after HCT or before aGVHD onset. Multivariate and time-to-event Cox proportional hazards models were applied, and 591 patients (UMC/PMC, n = 276; MSK, n = 315) were included. NRM in patients with grade 3 to 4 aGVHD with or without CD4+ IR within 100 days after HCT was 30% vs 80% (P = .02) at UMC/PMC and 5% vs 67% (P = .02) at MSK. This was associated with lower OS without CD4+ IR (UMC/PMC, 61% vs 20%; P = .04; MSK, 75% vs 33%; P = .12). Inadequate CD4+ IR before aGVHD onset was associated with significantly higher NRM (74% vs 12%; P < .001) and inferior OS (24% vs 78%; P < .001). In this retrospective analysis, we demonstrate that early CD4+ IR, a simple and robust marker predictive of outcomes after HCT, is associated with survival after moderate to severe aGVHD. This association must be confirmed prospectively but suggests strategies to improve T-cell recovery after HCT may influence survival in patients developing aGVHD.
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Allogeneic Stem Cell Transplantation Platforms With Ex Vivo and In Vivo Immune Manipulations: Count and Adjust. Hemasphere 2021; 5:e580. [PMID: 34095763 PMCID: PMC8171366 DOI: 10.1097/hs9.0000000000000580] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 04/14/2021] [Indexed: 01/16/2023] Open
Abstract
Various allogeneic (allo) stem cell transplantation platforms have been developed over the last 2 decades. In this review we focus on the impact of in vivo and ex vivo graft manipulation on immune reconstitution and clinical outcome. Strategies include anti-thymocyte globulin- and post-transplantation cyclophosphamide-based regimens, as well as graft engineering, such as CD34 selection and CD19/αβT cell depletion. Differences in duration of immune suppression, reconstituting immune repertoires, and associated graft-versus-leukemia effects and toxicities mediated through viral reactivations are highlighted. In addition, we discuss the impact of different reconstituting repertoires on donor lymphocyte infusions and post allo pharmacological interventions to enhance tumor control. We advocate for precisely counting all graft ingredients and therapeutic drug monitoring during conditioning in the peripheral blood, and for adjusting dosing accordingly on an individual basis. In addition, we propose novel trial designs to better assess the impact of variations in transplantation platforms in order to better learn from our diversity of “counts” and potential “adjustments.” This will, in the future, allow daily clinical practice, strategic choices, and future trial designs to be based on data guided decisions, rather than relying on dogma and habits.
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Cho HW, Ju HY, Hyun JK, Lee JW, Sung KW, Koo HH, Lim DH, Yoo KH. Conditioning with 10 Gy Total Body Irradiation, Cyclophosphamide, and Fludarabine without ATG Is Associated with Improved Outcome of Cord Blood Transplantation in Children with Acute Leukemia. J Korean Med Sci 2021; 36:e128. [PMID: 34002548 PMCID: PMC8129619 DOI: 10.3346/jkms.2021.36.e128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 04/07/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The optimal conditioning regimen in cord blood transplantation (CBT) needs to be determined. This study aimed to identify the impact of conditioning regimen on the outcome of CBT in children with acute leukemia. METHODS Medical records of patients with acute leukemia who received CBT were retrospectively reviewed. RESULTS A total of 71 patients were allocated into 2 groups; patients who received total body irradiation 10 Gy, cyclophosphamide 120 mg/kg, and fludarabine 75 mg/m² were named as TCF group (n = 18), while the non-TCF group (n = 53) included patients conditioned with regimens other than the TCF regimen. All patients in the TCF group were successfully engrafted, while 22.6% in the non-TCF group (n = 12) failed to achieve donor-origin hematopoiesis (P = 0.028). The incidence of cytomegalovirus diseases was 5.6% in the TCF group and 30.2% in the non-TCF group (P = 0.029). The 5-year overall survival rates of the TCF and non-TCF groups were 77.8% and 44.2%, respectively (P = 0.017). CONCLUSION Patients conditioned with the TCF regimen achieved better engraftment and survival rates, less suffering from cytomegalovirus disease. Our data suggest that the TCF regimen is a preferred option for CBT in children with acute leukemia.
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Affiliation(s)
- Hee Won Cho
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hee Young Ju
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ju Kyung Hyun
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji Won Lee
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ki Woong Sung
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hong Hoe Koo
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Stem Cell & Regenerative Medicine Institute, Samsung Medical Center, Seoul, Korea
- Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Sungkyunkwan University, Seoul, Korea
| | - Do Hoon Lim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Keon Hee Yoo
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Stem Cell & Regenerative Medicine Institute, Samsung Medical Center, Seoul, Korea
- Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Sungkyunkwan University, Seoul, Korea.
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Robust CD4+ T-cell recovery in adults transplanted with cord blood and no antithymocyte globulin. Blood Adv 2021; 4:191-202. [PMID: 31935291 DOI: 10.1182/bloodadvances.2019000836] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 11/18/2019] [Indexed: 11/20/2022] Open
Abstract
Quality of immune reconstitution after cord blood transplantation (CBT) without antithymocyte globulin (ATG) in adults is not established. We analyzed immune recovery in 106 engrafted adult CBT recipients (median age 50 years [range 22-70]) transplanted for hematologic malignancies with cyclosporine/mycophenolate mofetil immunoprophylaxis and no ATG. Patients were treated predominantly for acute leukemia (66%), and almost all (96%) underwent myeloablation. Recovery of CD4+ T cells was faster than CD8+ T cells with median CD4+ T-cell counts exceeding 200/mm3 at 4 months. Early post-CBT, effector memory (EM), and central memory cells were the most common CD4+ subsets, whereas effector and EM were the most common CD8+ T-cell subsets. Naive T-cell subsets increased gradually after 6 to 9 months post-CBT. A higher engrafting CB unit infused viable CD3+ cell dose was associated with improved CD4+ and CD4+CD45RA+ T-cell recovery. Cytomegalovirus reactivation by day 60 was associated with an expansion of total, EM, and effector CD8+ T cells, but lower CD4+ T-cell counts. Acute graft-versus-host disease (aGVHD) did not significantly compromise T-cell reconstitution. In serial landmark analyses, higher CD4+ T-cell counts and phytohemagglutinin responses were associated with reduced overall mortality. In contrast, CD8+ T-cell counts were not significant. Recovery of natural killer and B cells was prompt, reaching medians of 252/mm3 and 150/mm3 by 4 months, respectively, although B-cell recovery was delayed by aGVHD. Neither subset was significantly associated with mortality. ATG-free adult CBT is associated with robust thymus-independent CD4+ T-cell recovery, and CD4+ recovery reduced mortality risk.
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